Robert B. Stanley

Value of Computed Tomography in Management of Acute Laryngeal Injury

Blunt trauma to the larynx is an uncommon injury that results in a wide spectrum of damage to the endolaryngeal soft tissues as well as underlying cartilaginous skeleton. Recognition of these injuries is essential if long-term problems with compromised airway and voice quality are to be avoided. Although minor soft-tissue injuries do not mandate surgery, severe soft-tissue damage or cartilaginous fracture-dislocations require exploration and repair. Treatment is less clearly defined for the injured larynx with moderate damage. Frequently, the degree of soft-tissue injury is used to judge the likelihood of damage to the thyroid and cricoid cartilages. Computed tomography (CT) is an excellent noninvasive technique for examining the laryngeal skeleton. Laryngeal CT may be successfully used to determine the need for open exploration and repair in selected cases of blunt trauma to the larynx when clinical findings are equivocal for cartilaginous damage.

Management of external penetrating injuries into the hypopharyngeal- cervical esophageal funnel

OBJECTIVE To compare outcomes related to observation versus exploration for the hypopharynx and the cervical esophagus as the site of proven external penetrating injuries. METHODS The records of 70 patients (47 with hypopharyngeal and 23 with cervical esophageal wounds) were retrospectively reviewed. RESULTS No patient, observed or explored, who sustained a penetration into the hypopharynx above the level of the tips of the arytenoid cartilages of the larynx developed a complication. However, 22% of the patients with a hypopharyngeal injury below this level and 39% of patients with a cervical esophageal injury developed either a deep neck infection that required drainage or a postsurgical salivary fistula. CONCLUSIONS Overall, the consequences of an external penetrating injury become more serious in the descending levels of the funnel formed by the hypopharynx and cervical esophagus. Injuries located in the upper portion of the hypopharynx can be routinely managed without surgical intervention. Neck exploration and adequate drainage of the deep neck spaces are, however, mandatory for all penetrating injuries into the cervical esophagus and most injuries into the lower portion of the hypopharynx.

Management of complications of frontal sinus and frontal bone fractures

Complications related to untreated and treated fractures of the frontal calvarium, frontal sinus, and anterior skull base are, fortunately, uncommon. However, when they do occur, disturbing alterations in appearance and life-threatening infections may result, alone or in combination. Extensive reconstructive procedures may be required to restore defects that affect the contour of the forehead or position of the globe. These procedures should not be undertaken until all infection in the frontal and ethmoid sinuses and the frontal bone have been controlled and the chance of recurrent infection in the sinus reduced to a minimum. A rational approach to the management of the injured frontal sinus, based on an understanding of the pathophysiology of drainage system dysfunction, is mandatory for these goals to be achieved. Patients must be made aware that have a life-long risk of additional problems, even with appropriate managment of their initial complications.

Buttress fixation with plates

The skeletal unit of the middle third of the face is formed by a system of horizontal and vertical buttresses. Fracture dislocations involving these buttresses can alter facial height, width, and posteroanterior projection, as well as lead to malocclusion. Treatment must restore the exact three-dimensional relationship of each component of the buttress system to the skeletal unit as a whole. This is best achieved through extended access approaches that allow for direct visualization of the fracture lines. Stability of the buttress reconstruction is improved if rigid internal fixation devices (plates and screws) are used to hold the reduced fracture fragments in alignment, and the need for prolonged maxillomandibular fixation may be eliminated. However, rigid fixation is much more technique-sensitive and non-forgiving than interosseous wire fixation. If used inappropriately, rigid fixation will produce an unacceptably high rate of iatrogenic complications, including malocclusion, that will require revision surgery.

Intraoperative computed tomography to facilitate repair of orbitozygomatic fractures

Present-day management of complex orbitozygomatic and large orbital blow-out fractures involves wide exposure to allow for direct inspection of fracture reduction and implant placement. This usually means multiple incisions, and thus prolonged surgical time and expense. Even then, it is not possible to uniformly predict accurate postoperative results. We describe the use of intraoperative computed tomography to immediately evaluate the accuracy of the repairs, thus allowing for revisions, if necessary, at the time of the initial procedure. As the surgical team gains experience with intraoperative scanning, the benefits that should be realized include elimination of the need for wide exposure of all fracture sites, shortened surgical time and expense, and fewer return visits to the operating room for secondary revision procedures.