Purpose: to increase the reliability of diagnosis in the acute period of traumatic brain injury. The method consists in the fact that laboratory studies of secretions from the nasal cavity or ear canals and capillary blood are carried out for the content of sugar and erythrocytes, and then the ratio of the amount of sugar to the number of red blood cells in the secretions and capillary blood is determined. If these ratios are equal, it is concluded that there is no liquorrhea, but if the ratio in the discharge is greater, it is concluded that there is liquorrhea. 1 tab.
The invention relates to surgery, namely to neurosurgery and surgery of combined head injuries. Until now, most clinicians for the diagnosis of early liquorrhea in traumatic brain injury use the "double spot" method (A. A. Shlykov Features of the clinic and surgical methods of treating parabasal craniocerebral wounds // Craniocerebral trauma. M. 1962, p. 172 179). The method consists in identifying around a blood stain on linen or a napkin, left by a bloody fluid flowing from the nasal cavity or auditory canals, depending on the localization of damage to the base of the skull, a lighter rim formed by the cerebrospinal fluid due to its greater penetrating ability due to its lower specific gravity. However, this method is not reliable enough: a double spot is formed only when the ratio of blood and cerebrospinal fluid in the test fluid is 1 1, 1 1.5 and higher, which is confirmed by our own laboratory studies. This limits its use in the diagnosis of liquorrhea in patients with combined fractures of the bones of the middle zone of the face and the base of the skull, when there is a fairly pronounced bleeding and, accordingly, the amount of blood in the flowing fluid increases. Closest to the proposed is a method for the diagnosis of late liquorrhea based on the analysis of light transparent nasal discharge and sugar content. Unlike the secretion of the mucous membrane, in the presence of rhinitis, the cerebrospinal fluid contains sugar (2.5-4.16 mmol / l). The secret of the nasal mucosa does not contain sugar. However, if the secret contains an admixture of blood, this test will also give a positive result, since there is a fairly large amount of sugar in the blood (3.33 5.55 mmol). This makes the diagnosis of liquorrhea by this method in the acute period of injury impossible due to the presence, as a rule, of bleeding of varying severity. The aim of the invention is to increase the reliability of diagnosis in the acute period of traumatic brain injury. The proposed method for the diagnosis of liquorrhea in traumatic brain injury consists, as in the prototype, in the study of the discharge flowing from the nasal cavity or auditory canals, depending on the localization of damage to the base of the skull, for sugar content. However, unlike the prototype, in this case, the content of erythrocytes is determined in the secretions, as well as the content of sugar and erythrocytes in capillary blood. As a rule, the investigated nasal discharge, in addition to cerebrospinal fluid and blood, contains other components, for example, mucous secretions. This leads to the fact that the cerebrospinal fluid and blood in the discharge are diluted and a comparison of the absolute values of sugar in the discharge and capillary blood would lead to unreliable results. Therefore, in the proposed method take for comparison the ratio of sugar to the number of erythrocytes, respectively, in the secretions and capillary blood. If liquorrhea is absent, then the ratio of the amount of sugar to the number of erythrocytes in the outflowing fluid and capillary blood should be the same, even if mucous secretion is added to the outflowing fluid from the nose, which does not contain either sugar or erythrocytes. If the ratio of the amount of sugar to the number of erythrocytes of fluid from the nasal cavity or ear canal is greater than in capillary blood, then we can talk about the presence of liquorrhea. The method is simple; the research does not require the presence of rare and expensive equipment. The study can be performed in a clinical laboratory of any medical institution. The method is quite reliable. In experimental studies, without the use of highly accurate dosimeters and counters, the method made it possible to detect the presence of an impurity of cerebrospinal fluid in blood at a ratio of 1 to 20, respectively. In laboratory studies, the orthotoluidine method for determining glucose and counting the number of erythrocytes in the Goryaev chamber were used. Clinical example. Patient I. 1975, and / b 5998, 09/18/91 hit by a car. Delivered from the site of injury to the Emergency Medical Aid Association in Cheboksary in serious condition, unconscious, placed in the intensive care unit. At the initial examination, the diagnosis was made: concomitant injury, severe brain contusion, multiple fractures of the bones of the midface with displacement of fragments, contusions of the trunk and extremities. Several radiographs of the skull were taken. The grave condition of the victim prevented the X-ray examination in the necessary settings, and the photographs taken turned out to be uninformative. The victim had moderate nosebleeds. The double spot symptom is negative. But given the presence of multiple fractures of the bones of the midface zone, it was suggested that there was a fracture of the skull base in the anterior cranial fossa. A comparative study of fluid flowing from the nose and capillary blood was carried out according to the proposed method (results in the table). This method made it possible to identify the presence of nasoliquorrhea already in the first hours after the injury, to confirm the assumption of the presence of a skull base fracture. This made it possible to choose a more rational tactics for treating the victim and avoid the occurrence of such complications as meningitis. The patient was discharged from the hospital in satisfactory condition for outpatient treatment after 32 days. The table shows examples of the results of the examination of patients who were inpatient treatment at the Association of Emergency Medical Services in Cheboksary in 1991-1992, using the proposed and known methods. The table shows that the proposed method allows you to diagnose liquorrhea in the early stages of the development of traumatic disease. So, in example 1 (case history N 4605), the ratio of the amount of sugar to the number of red blood cells in nasal discharge is not equal, which made it possible to conclude that there was liquorrhea in the very first hours of the patient's admission to the hospital, which was confirmed by later X-ray studies, while time, as the "double spot" method gave an erroneous result. In all cases of diagnostics according to the proposed method, a reliable diagnosis was established, which was confirmed by later studies, and made it possible to start the necessary treatment in a timely manner (examples 1 to 6), while using analog methods, relatively reliable results can be obtained only for 2 to 10 days, which increases the risk of complications due to untimely measures taken.
Claim
A method for diagnosing liquorrhea in traumatic brain injury by analyzing discharge from the nasal cavity or from the ear canals and determining the sugar content in them, characterized in that it additionally determines the content of sugar and erythrocytes in capillary blood and the content of erythrocytes in secretions from the nasal cavity and auditory canals, and with the inequality of the ratio of the amount of sugar to the number of erythrocytes in the secretions and capillary blood, liquorrhea is diagnosed.
Similar patents:
The invention relates to medicine, namely to the field of internal diseases, in particular to pulmonology, allergology, and can be used in the examination of patients with bronchial asthma both in clinical and in outpatient settings, including dispensary observation
The invention relates to medicine, mainly to cardiology, and will find application in the choice of treatment tactics and secondary prevention of arterial hypertension. total glycogenolytic activity before and after administration of a specific beta-adrenoagonist alupenta and with an increase in sugars by 200% and higher, cAMP by 10% and higher, total glycogenolytic activity by 100% and higher predict individual sensitivity and beta-adrenergic blockers in patients with arterial hypertension with C : Page 1 Abstract: Page 1 Formula: Page 1 Page 2 Page 3 Description: Page 3 Page 4 PA4A / PA4F - Termination of the USSR inventor's certificate for an invention on the territory of the Russian Federation and the grant of a Russian patent Federation for an invention for the remaining term Number and year of publication of the bulletin: 39-1992 (73) Patentee: V.N. CHERNYSHOV
Fractures of the upper jaw in children are rare and severe damage (Fig. 148). They arise as a result of severe multiple trauma and therefore are often combined with fractures of the lower jaw. Fractures of the base of the skull and concussions are almost always associated with fractures of the upper jaw. The severity of the injury determines the presence of the child in the first days after it in the intensive care unit. This can delay specialized care, which contributes to the development of complications, the main of which should be considered the penetration of infection into the cranial cavity and the development of traumatic osteomyelitis.
Line of weakness in the upper jaw. a - type Form I; b - type Form II; c - type Form III.
Such damage occurs as a result of a fall from a height, with a transport injury. This type of trauma in children has become much more common. Injuries to the midface can be combined not only with craniocerebral trauma, fractures of the base of the skull, but also with fractures of the lower jaw, external nose, orbit, zygomatic bone and arch.
Fractures of the upper jaw are open, as there are ruptures of the mucous membrane of the mouth, nose, maxillary sinuses. The more pronounced the displacement of the fragments, the greater the size of the breaks.
§ Le Fort I (lower level fracture) - the fracture line of the upper jaw runs horizontally over the alveolar process of the jaw from the base of the piriform foramen to the pterygoid process of the main bone. In this case, the bottom of the maxillary sinus usually breaks off and the base of the nasal septum breaks.
§ Le Fort II (fracture at the middle level) - the fracture line passes transversely through the nasal dorsum, medial wall, bottom and lower orbital edge and then continues along the zygomatic-maxillary suture to the pterygoid process of the main bone. This fracture is often referred to as a suborbital or pyramidal fracture, as it causes a maxillofacial separation when the upper jaw, along with the nasal bones, is detached from the zygomatic bones and the base of the skull.
§ Le Fort III (upper level fracture) - the fracture line passes transversely through the nasal dorsum, medial wall, bottom and outer wall of the orbit, through the upper-outer edge of the orbit, and then through the zygomatic arch and the pterygoid process of the main bone. This fracture is often referred to as a subbasal fracture, since it results in a complete craniofacial separation, i.e. separation of the upper jaw along with the bones of the nose and zygomatic bones from the base of the skull. Fractures according to Le Fort I I I, as a rule, are accompanied by traumatic brain injury and often a fracture of the base of the skull, i.e. open traumatic brain injury.
The main symptoms typical for a fracture of the upper jaw:
1. Damage (bruises, hematomas, wounds) of the soft tissues of the head and face.
2. Severe swelling of the eyelids of both eyes, hemorrhage in the tissue around the eyes and in the conjunctiva (a symptom of glasses).
3. Bleeding from the nose, mouth and ears. Liquorrhea (double spot symptom).
4. Elongation and flattening of the middle part of the face.
5. Anesthesia or paresthesia in the upper lip, wing of the nose and infraorbital region. Diplopia or double vision.
6. Pain, crepitus and "step symptom" on palpation in the region of the bridge of the nose, along the inferior orbital edge and the upper outer edge of the orbit, as well as along the zygomatic arch and in the region of the zygomatic-alveolar ridge.
7. Violation of occlusion, ruptures of the mucous membrane (usually along the midline of the palate), submucosal hemorrhages along the transitional fold, revealed during examination of the oral cavity.
8. The mobility of the upper jaw (as a reliable sign of fracture) determined by palpation and the symptom of "cracked pot" with percussion of the teeth of the upper jaw. However, with impacted fractures of the upper jaw, its mobility may not be determined.
9. The clinical picture of fractures in / h depends on the presence of concomitant pathology (concomitant injury). In case of fractures of the upper jaw (especially with fractures according to Le Fort II-III), the clinic of open or closed traumatic brain injury is determined: damage to the bones of the cranial vault; fracture of the bones of the base of the skull with liquorrhea through the nose or from the external auditory canals; nausea, vomiting, dizziness; retrograde amnesia; dysfunction of the cranial nerves; bradycardia; other neurological symptoms, etc.
Signs of a skull base fracture:
1. Increased discharge of fluid from the nose when the head is tilted forward.
2. A clean handkerchief moistened with blood remains soft, and moistened with cerebrospinal fluid - more rigid, as if starched.
3. If there is cerebrospinal fluid in the blood, then a red blood stain with a light halo along the periphery of the cerebrospinal fluid is formed on the napkin (a symptom of a "double spot").
4. Blood in the cerebrospinal fluid during lumbar puncture.
Diagnosis can be difficult due to rapidly developing massive edema. In these cases, X-ray examination is decisive. In case of traumatic injuries, the military unit produces Ro-grams in the following projections:
1) chin-nasal;
2) semi-axial or axial;
3) lateral (overview) Ro-gram of the skull;
Orthopantomogram is also used, for the study of the anterior parts of the jaw - panoramic Ro-graphy, for assessing the condition of the alveolar ridge and teeth in the fracture zone - intraoral contact Ro-grams or bite, Ro-grams of the hard palate with bite.
Early diagnosis and timely reposition of fragments are important factors in the prevention of bronchopulmonary insufficiency, prevent the aggravation of the course of traumatic brain injury, shock, help stop bleeding and spread infection.
Mandibular fractures prevail in boys over 7 years old and are mainly caused by household trauma and unorganized sports leisure. Fracture is facilitated by the position and anatomical shape of the lower jaw. In terms of localization, single fractures of the lower jaw body are in the first place (Fig. 2), in the second - fractures of the condylar or condylar processes (reflected), then double and multiple. Longitudinal branch fractures and fractures
If fractures occur as a green-branch, subperiosteal, or incomplete, there are no typical signs of a fracture. Intensively increasing edema, hematomas, especially in the area of the bottom of the mouth, disrupt articulation, cause salivation, pain. It is difficult to establish the typical signs of a fracture of the lower jaw (malocclusion, function, mobility of fragments). When examining a child, you must carefully choose and carry out pain relief.
With single complete fractures of the lower jaw body, the displacement of the fragments is due to its direction, the function of the masticatory muscles and the size of the fragments. The severity of the displacement increases with the distance of the fracture line from the central incisors. Violation of the integrity of the mucous membrane, mobility or complete dislocation of the teeth in the fracture line are observed in almost all cases.
Fig. 2 Traumatic linear fracture n / h without displacement between 22 and 23 teeth
Fig. 2-a Weber bus Port bus Vankevich bus
Rice. 2 - b standard Vasiliev's bus Vasiliev's bus fixes the fracture n / h.
Fractures in the area of the jaw angle are less common; they may not have violations of the integrity of the mucous membrane and displacement of fragments. Hematoma and collateral edema in such children are less pronounced, but the function of the lower jaw is impaired. Disocclusion is observed in the area of the molars on the side of the injury. Displacement of fragments is possible when the fracture line is located behind the masseter muscle.
Double fracture of the lower jaw is accompanied by displacement of fragments. This can create conditions for disturbed external respiration, lead to dislocation asphyxia (the root of the tongue sinks), which is dangerous especially in young children, when restless behavior, crying, crying simultaneously contribute to laryngospasm or increased mucus exudation and obstruction of the trachea with it. The bite is broken, the mucous membrane is traumatized over a considerable length, massive bleeding.
Fractures of the lower jaw in more than half of children are accompanied by craniocerebral trauma of varying severity. It is with fractures of the lower jaw that craniocerebral trauma remains undiagnosed, and its consequences appear at puberty and their cause remains unknown.
Injuries to the condylar process, which are often found in children, include a single fracture of the condylar process when the force is applied from the opposite side or the injury occurs in the chin area.
Subperiosteal fractures of this localization are very common, do not have a pronounced clinical picture and if they are not diagnosed in a timely manner, then at the end of the first week the child develops sharp pain and swelling in the skin area below the ear tragus, sometimes infiltration, restriction of movement of the lower jaw, deviation.
With a bilateral complete fracture of this localization, disocclusion is noted as a result of the posterior displacement of the lower jaw, and contact between the teeth of the upper and lower jaws is only on the last teeth; clinically pronounced sagittal fissure (open bite). In children, with this type of fracture, dislocation of the head of the lower jaw can occur and shift anteriorly, posteriorly, inward and outward. The types of fractures of the condylar process are diverse. Fractures of the condylar process are often combined with damage to the soft tissue structures of the temporomandibular joint.
The clinical picture of injury to one condylar process characterized by pain, limited opening of the mouth, impaired occlusion; lateral shift of the lower jaw, lack of movement of the temporomandibular joint. Palpation clearly expressed restriction and pain during lateral movements of the jaw in the direction opposite to the injured one. Bilateral damage is characterized by open bite disocclusion with posterior displacement of the jaw and restriction of its movement. Possible deformation of the posterior edge of the branch (determined by palpation). The mobility of the heads (by palpation) is not expressed.
Dislocation of the temporomandibular joint. The immediate cause of such a dislocation may be an injury or an excessively wide opening of the mouth during screaming, vomiting, tooth extraction or other medical manipulations. Congenital or acquired imperfection of the ligaments and joint capsule contributes to dislocation.
Distinguish between traumatic and habitual dislocations, although a strict distinction between them is not always possible. Dislocation can be complete or incomplete (subluxation), unilateral or bilateral. Depending on the direction in which the head of the lower jaw has shifted, anterior, lateral and posterior dislocations are distinguished. In children, anterior dislocation is most often observed. The most difficult is the posterior dislocation, which can occur in children with a fracture of the base of the skull.
With anterior dislocation the mouth is wide open, the child cannot close it on its own. Palpation reveals the exit of the heads of the lower jaw from the fossa and their forward displacement. Dislocation of the lower jaw is manifested by the displacement of the head from the glenoid fossa without an independent excursion into it.
With dislocations, there is a stretching of the ligamentous apparatus and a displacement of the disc. This happens with asthenic general development of the child and is considered as TMJ dysfunction; it is also observed with imbalances in the growth of joint elements (soft tissue and bone).
With bilateral dislocations, patients complain of the inability to close their mouth, chew, swallow, talk. Outwardly, the lower jaw is displaced downward, the cheeks are stretched, salivation is noted; in the area of the glenoid fossa - retraction.
For dislocations of the temporomandibular joint, the most characteristic is disocclusion of the type of open bite, displacement of the lower jaw forward without range of motion; pain is mild.
Pathological fractures. Unlike a traumatic fracture, this is a violation of the integrity of the bone, altered by some previous pathological process. The most common cause of such jaw fractures is bone neoplasms, less often chronic osteomyelitis.
An image of the temporomandibular joint can be obtained when placing the patient's head for pictures of the Schüller pyramids.
Zygomatic bone fractures are not isolated. The powerful zygomatic bone, as a rule, does not break, but penetrates into the maxillary sinus, destroying its anterior wall. This type of damage is considered as a combined or multiple zygomatic-jaw fracture. The fracture is regarded as open, since the bone fragments freely communicate with the external environment through the maxillary sinus. Fractures of the zygomatic arch are most often closed. An absolute sign of such damage is a violation of the movements of the lower jaw due to a mechanical obstacle created by fragments of the arc for the movements of the coronoid process.
Maxillary fractures are always open , since in this case there is a violation of the integrity of the oral mucosa.Nowadays, the definition is often used: fractures of the middle zone of the face, limiting it from above by a line drawn through the upper edges of the orbits, and from below - by the line of closure of the dentition. The bones of the middle zone of the face have an arched structure, characterized by the alternation of buttresses (thickening of the compact substance) with places of weak resistance.Classification of fractures of the upper jaw: ... Le Fort I (lower level fracture) - the fracture line of the upper jaw runs horizontally over the alveolar process of the jaw from the base of the piriform foramen to the pterygoid process of the main bone. In this case, the bottom of the maxillary sinus usually breaks off and the base of the nasal septum breaks.... Le Fort II (fracture at the middle level) - the fracture line passes transversely through the nasal dorsum, medial wall, bottom and lower orbital edge and then continues along the zygomatic-maxillary suture to the pterygoid process of the main bone. This fracture is often referred to as a suborbital or pyramidal fracture, as it causes a maxillofacial separation when the upper jaw, along with the nasal bones, is detached from the zygomatic bones and the base of the skull.... Le Fort I I I (upper level fracture) - the fracture line passes transversely through the nasal dorsum, medial wall, bottom and outer wall of the orbit, through the upper-outer edge of the orbit, and then through the zygomatic arch and the pterygoid process of the main bone. This fracture is often referred to as a subbasal fracture, since it results in a complete craniofacial separation, i.e. separation of the upper jaw along with the bones of the nose and zygomatic bones from the base of the skull. Fractures according to Le Fort I I I, as a rule, are accompanied by traumatic brain injury and often a fracture of the base of the skull, i.e. open traumatic brain injury.Fractures of the upper jaw can be one- and two-sided. Bilateral fractures are symmetrical and asymmetrical. In case of unilateral fractures of the upper jaw, the fracture line, in addition, runs sagitally, along the palatine suture.
The displacement of bone fragments in fractures of the upper jaw depends on: ... on the strength and direction of the blow;... from the mass of the fragments themselves;... from the traction force of the masticatory (pterygoid) muscles.Usually, the upper jaw is displaced below and posteriorly so that an open bite is formed (due to closing only in the area of the chewing teeth), an oblique bite or false progeny.Clinic of fractures of the upper jaw. Locally, you can identify the following main symptoms characteristic of a fracture of the upper jaw:1. Damage (bruises, bruises, wounds) of the soft tissues of the head and face.2. Severe swelling of the eyelids of both eyes, hemorrhage in the tissue around the eyes and in the conjunctiva (a symptom of glasses).3. Bleeding from the nose, mouth and ears. Liquorrhea (double spot symptom).4. Elongation and flattening of the middle part of the face.5. Anesthesia or paresthesia in the upper lip, wing of the nose and infraorbital region. Diplopia or double vision.6. Pain, crepitus and "step symptom" on palpation in the region of the bridge of the nose, along the inferior orbital edge and the upper outer edge of the orbit, as well as along the zygomatic arch and in the region of the zygomatic-alveolar ridge.7. Violation of occlusion, ruptures of the mucous membrane (usually along the midline of the palate), submucosal hemorrhages along the transitional fold, revealed during examination of the oral cavity.8. The mobility of the upper jaw (as a reliable sign of fracture) determined by palpation and the symptom of "cracked pot" with percussion of the teeth of the upper jaw. However, with impacted fractures of the upper jaw, its mobility may not be determined.9. The clinical picture of upper fractures also depends on the presence of concomitant pathology (concomitant injury). With fractures of the upper jaw (especially with fractures according to Le Fort II-III), the clinic of open or closed traumatic brain injury is determined: damage to the bones of the cranial vault; fracture of the bones of the base of the skull with liquorrhea through the nose or from the external auditory canals; nausea, vomiting, dizziness; retrograde amnesia; dysfunction of the cranial nerves; bradycardia; other neurological symptoms, etc.Signs confirming the presence of a fracture of the base of the skull: 1. Increased discharge of fluid from the nose when the head is tilted forward.2. A clean handkerchief moistened with cerebrospinal fluid remains soft, and moistened with nasal discharge - more rigid, as if starched.3. If there is cerebrospinal fluid in the blood, then a red blood stain with a light halo along the periphery of the cerebrospinal fluid is formed on the napkin (“double spot” symptom).4. Blood in the cerebrospinal fluid during lumbar puncture.X-ray examination. Most often, x-rays are taken of the paranasal sinuses and zygomatic bones in a straight naso-chin (semi-axial) projection with an open mouth. Radiography of the midface in the axial projection, radiography of the bones of the facial skeleton in the frontal naso-frontal projection and orthopantomogram are quite informative. In case of fractures of the upper jaw, a violation of the integrity of the bone tissue is determined at the junction of the upper jaw with other bones of the facial skeleton, as well as the darkening of the maxillary sinuses due to hemosinus. Computed tomography of the head also makes it possible to diagnose tissue damage in both the facial and cerebral skull, especially in difficult cases.
When examining patients with injuries of the maxillofacial region, clinical and instrumental diagnostic methods are used. The latter are used to confirm or clarify the diagnosis.
1. General clinical examination methods.
These include complaints, history, examination, and palpation.
1.1. Complaints.
Complaints can be specific in nature, inherent in patients with fractures of one or another jaw, and can also be common for trauma to various bones of the facial skeleton and soft tissues.
Typical complaints are: a change in the configuration of the face due to swelling of soft tissues, a change in skin color in this area, bleeding from the mouth, nose or ears, spontaneous pain in a particular jaw, aggravated by trying to open the mouth, closing teeth and chewing food, loss of teeth ...
Sometimes patients complain of visual impairment, changes in skin sensitivity (decrease or perversion), especially in the infraorbital, zygomatic regions, lower lip and chin. Often, patients report headache, dizziness, nausea and vomiting, fever and general unwell.
Complaints of pain when opening the mouth and chewing food occurs in patients when there is a violation of the integrity of the bone tissue (its fracture). In this case, there is a displacement of fragments, their friction against each other, irritation of the nerve endings in the periosteum and surrounding tissues. In addition, pain can occur if traumatic arthritis develops and without a fracture of the mandible.
Swelling of soft tissues worries the patient due to traumatic edema, blood soaking of soft tissues from damaged vessels due to the formation of a hematoma. With a late visit of the patient to the doctor (after three or more days), tissue swelling may be the result of an acute purulent inflammatory process that has developed (festering hematoma, traumatic osteomyelitis, etc.).
Discoloration of the skin of the face occurs due to rupture of blood vessels and blood soaking of loose tissue and skin or the formation of a subcutaneous or deeper hematoma. Bleeding from the mouth or nose with a fractured jaw occurs when the mucous membrane covering the broken bone is torn. Bleeding from the ear is usually observed with a ruptured tympanic membrane in case of injury to the lower wall of the external auditory canal with a fracture of the condylar process, fracture of the temporal bone pyramid, etc. This may be a sign of a fracture of the skull base.
Complaints about the inability to properly close the teeth (malocclusion) occur in the event of displacement of the fragments during the fracture of the lower (more often) or upper jaws. The reasons for the displacement of fragments are: traction of the chewing muscles that attach to the fragments of the jaws, the weight of the fragment and the muscles that attach to it, as well as the kinetic energy of the impact that affects the bone.
Often, as a result of trauma, a dislocation or fracture of the tooth occurs, then the patient is worried about the absence of a tooth (complete dislocation) or part of it (fracture of the crown, root), as well as pain in the area of this tooth.
Visual impairment (double vision, strabismus, decreased visual acuity) is possible in patients with a fracture of the upper jaw in the upper or, less often, of the middle type. These symptoms can be observed in patients with combined injuries of the maxillofacial region and traumatic brain injury.
Violation of the sensitivity of the skin in the infraorbital, zygomatic regions, numbness of the skin of the lower lip and chin is often noted by the victims, which is associated with infringement or rupture of the branches of the trigeminal nerve.
Headache, dizziness, nausea, sleep disturbance, lethargy, amnesia can be signs of a concussion or brain injury, or the formation of intracranial hematomas.
1.2. Anamnesis.
Anamnesis of a patient with damage to the tissues of the maxillofacial region is of great importance. A medical history completed by a doctor is quite often the fundamental and defining legal document in the event of conflict situations and the need for a forensic medical examination.
In clinical practice, the basic history data should contain answers to at least three of the following questions:
Where did the injury (location) occur?
Causes of damage (who is to blame)?
When did the injury occur (when did it happen)?
The location of the injury plays a role in determining the legal responsibility of a given entity. So, if the injury occurred at work or within one hour before the start and after the end of work, sick leave is paid from the first day of incapacity for work. Such an injury is called a work injury. In addition, in the event of injury during production, the organization will be obliged to pay all the costs of the victim for the necessary medical and rehabilitation services. In the event of disability, an employee of the organization, through whose fault and on the territory of which the injury occurred during working hours, has the right to additional payments to the existing pension coverage rates (additional payment for injury).
Non-work (household) injury occurs outside the working hours of the victim. Currently, a law has been adopted according to which payment for days of incapacity for work in the event of a domestic injury, as in the case of an industrial injury, is made from the first day of the injury. However, payment for medicines and rehabilitation measures is carried out at the expense of the patient. It should be noted that the costs of treating a patient are carried out from budget funds, as well as compulsory and voluntary health insurance. Disability due to an injury sustained while intoxicated is not covered by the state.
The cause of the damage (who is to blame?) Is most often established from the words of the patient, sometimes - on the basis of testimony and a written statement. Quite often, among patients with trauma of the maxillofacial region, there are persons who, for one reason or another, hide the cause (culprit) of the injury. A doctor is not an investigator. However, he must explain to the patient that his story about the reasons that led to the development of the disease will be recorded in the document - the history of the disease and, if there is a need for a legal investigation of the conflict in the future, it will be the main witness testimony. Sometimes patients during the period of treatment can change the anamnestic data regarding the cause of the injury. In this case, the first entry in the medical history can play a decisive role in determining the legal opinion, about which the doctor must warn the patient. Moreover, the payment for medical, diagnostic and rehabilitation measures, sometimes quite lengthy (one month or more), is carried out at the expense of the guilty party.
The time elapsed since the injury (when did it happen?) Can play a decisive role in the choice of a method of treatment or in determining the subsequent tactics of patient management. So, for example, if the victim goes to a medical institution in the first hours or days after the injury, the initial surgical treatment of the wound is performed at the most favorable time and ends with the imposition of blind sutures, while any methods of osteosynthesis can be chosen, etc.
When the victim addresses the patient at a later date from the moment of injury (two or more days), the choice of osteosynthesis methods narrows, the complex of antimicrobial and anti-inflammatory drugs increases, the indications for the extraction of teeth in the fracture gap expand.
Late terms of treatment, and, consequently, late terms of immobilization, can potentially lead to the development of various complications, such as: traumatic osteomyelitis and sinusitis, delayed consolidation, pseudarthrosis, etc. the outcome of the injury.
Medical history can help identify signs that indicate a concussion or contusion of the brain or other traumatic brain injury. Symptoms such as nausea, vomiting, loss of consciousness immediately following an injury should be evaluated by a physician as objective signs of a concussion or brain injury.
It should be noted that this symptomatology can also be present in patients with trauma to the maxillofacial region at the time of severe alcohol intoxication, but without concussion. In this case, examination data by a neuropathologist can help in making a differential diagnosis.
If a traumatic brain injury is suspected in a patient with damage to the soft and bone tissues of the face, the dentist must consult him with a neurologist to confirm his assumption. Before consulting the victim with a specialist, it is recommended to carry out temporary types of immobilization of fragments, since late manifestation of signs of traumatic brain injury with all the ensuing consequences (nausea, vomiting, etc.), up to death, is possible. The doctor does not have the right to let a free person with a suspected concomitant craniocerebral injury go home. It is necessary to call a specialist to the patient or send him to another clinic by ambulance accompanied by medical staff, because all patients with traumatic brain injury, regardless of its severity, are subject to immediate hospitalization.
Often, it is not possible to find out the complaints and collect anamnesis from the victim with concomitant trauma of the maxillofacial region (finding the patient unconscious or in a state of strong alcoholic intoxication). In this situation, partial or complete information about the circumstances of the injury can be obtained from the accompanying medical personnel or relatives.
1.3. Inspection and palpation.
When examining the victim's face as a result of trauma, one usually draws attention to the swelling of soft tissues in one or another section of the maxillofacial region due to the development of traumatic edema and hematoma. These phenomena develop following the release of biologically active substances (histamine, serotonin, bradykinin) from the destroyed tissues, which increase the permeability of the capillary walls and contribute to the rapid growth of edema. It reaches a maximum at the end of the third day from the moment of injury, and its severity depends on the volume of damaged tissues and the localization of tissue damage (for example, with a fracture of the upper jaw, edema is most pronounced).
The skin over the edematous tissues in the first hours has a normal color. It may show scratches, abrasions or wounds. At a later date from the moment of injury, the skin gradually acquires a bluish or purple color, which indicates
damage to a large vessel and hemorrhage in the subcutaneous tissue - the formation of a hematoma (Fig. 1). After 3 - 4 days, the outflowing blood due to the conversion of hemoglobin to hemosiderin stains the tissues in green, yellow-green and yellow colors. Usually, 3-5 days from the moment of injury, if appropriate treatment is not carried out, an inflammatory infiltrate may form, followed by the development of an abscess or phlegmon in case of tissue infection, while the skin over the swelling becomes pink or red, shines.
A displacement of the chin away from the midline can be observed with a fracture of the lower jaw.
Swelling of the tissues of the middle zone of the face, which determines its moon-like shape, as well as the "symptom of glasses" (hemorrhage in the upper and lower eyelids and conjunctiva) are characteristic of a fracture of the upper jaw, as well as the base of the skull.
Bleeding from the nose 1 - 2 days after the fracture can mask the outflow of cerebrospinal fluid (cerebrospinal fluid) from the cranial cavity with a fracture of its base, rupture of the dura mater and nasal mucosa. The liquor is poorly coagulated, therefore, with liquorrhea, an ascending infection and the development of an inflammatory process in the brain are possible. It is quite difficult to identify liquorrhea, therefore, a number of techniques are used to determine it. In the early period after the injury, the patient's head is tilted forward (down) and a napkin or filter paper is brought to the nose, on which a few drops of blood fall. After a few minutes, the blood coagulates, forming a stain, which is surrounded by a light yellow ring in the presence of cerebrospinal fluid mixed with blood. This is the so-called medical napkin or double stain symptom. In the later period after the injury (5 or more days), when the patient's head is tilted forward, when straining or squeezing large veins of the neck with fingers, one can observe the release of transparent cerebrospinal fluid from the nose in the form of drops or a thin stream. This secret is applied to a handkerchief, and if, after the handkerchief dries, it remains soft, this liquid is liquor, and if the handkerchief becomes starched (hard), then it will be mucous discharge from the nose (a symptom of a handkerchief).
Rice. 1. Hematomas in the infraorbital and chin regions, abrasions in the upper and lower lips.
Latent cerebrospinal fluid is also determined using biochemical fluid analysis. It is known that the cerebrospinal fluid contains 10 - 50 mg /% sugar and 20 - 33 mg /% protein, and the secretion of the nasal mucosa does not contain sugar and no more than 1% protein. For biochemical analysis, mucous discharge from the nose is collected and a study is carried out for the content of sugar and protein. This test is not acceptable if CSF is mixed with blood.
A test for latent cerebrospinal fluid can be performed using indifferent dyes: 1 ml of 1% urnin solution is injected endolumbally, then cotton swabs are inserted into the external auditory canals and both nostrils of the patient, and if they turn pink after an hour, then we can talk about latent cerebrospinal fluid.
Bleeding from the patient's ear can be observed with a fracture of the jaws, as well as a fracture of the base of the skull.
When palpating soft tissues, traumatic edema or inflammatory infiltration in the area of fracture localization is determined in the case of the development of, as a rule, traumatic osteomyelitis.
Sometimes in the soft tissues of the infraorbital region, when trying to collect the skin in a fold, crepitus is felt, which is caused by air emphysema, which occurs when the wall of the airway sinus is fractured.
Sensitivity of the skin in the upper and lower lips, chin, infraorbital, zygomatic and temporal regions may be impaired. This usually occurs due to injury to the infraorbital and zygomatic nerves - with a fracture of the upper jaw, or the mandibular - with damage to the lower jaw. The sensitivity of the skin can be determined by alternately touching the sharp and blunt ends of the injection needle.
When palpating the bones of the face, a certain sequence must be followed. So, the upper jaw is palpated in the glabella region, then the inner, upper, outer and lower edges of the orbit (the place where the fracture gap passes), the zygomatic arch and the bone. If there is a violation of the anatomical integrity of the bone in these areas in the form of steps or depressions and pain, one can assume the presence of a fracture of the upper jaw or zygomatic bone and arch.
The lower jaw is palpated along its base, where bone discontinuity is most often detected. Further, the posterior edge of the branch and the condylar process are palpated. It is important to determine the degree of mobility (amplitude) of the head of the condylar process, for which the index fingers of both hands are placed on the skin in the region of the heads or inserted into the external auditory canals and pressed against the anterior wall. Next, the patient is asked to move the lower jaw up and down and left and right. In this case, the amplitude of movement of the head on the side of the fracture will be reduced (sometimes quite significantly).
An important diagnostic sign of a jaw fracture is a positive stress symptom, which is characterized by the occurrence of pain in the area of the fracture when pressing on the distant parts of the jaw. Usually, in the area of the lower jaw, the symptom of loading is determined by pressing on the chin, the outer surface of the corners of the lower jaw (towards each other) and the lower surface of the corner of the lower jaw upward (Fig. 2).
Displacement of fragments and trauma to the periosteum in this case lead to the occurrence of a painful reaction at the site of localization of the fracture. The patient shows a volitional point on the face with a finger.
It should be noted that the symptom of loading can sometimes be positive in traumatic arthritis of the temporomandibular joint, which should be taken into account when conducting differential diagnostics.
To carry out the symptom of loading in the upper jaw, the second and third fingers of the right hand are pressed on the hooks of the pterygoid processes or on the last molars. At the same time, the patient notes pain in the upper jaw area.
Rice. 2. Symptom of stress. Variants of pressure on the lower jaw with a finger to determine the location of the fracture.
M.V. Shvyrkov suggested that pinpoint palpation of the mandible should be performed to identify the direction of the fracture line of the lower jaw prior to radiography. To do this, with the index finger of the hand, every 0.5 cm, light pressure is applied to the base of the lower jaw, moving it from a painless point towards a painful one, which is marked on the skin with paint. Then the finger is moved up 1 cm, the search for the painful point is repeated and marked with paint. The third point is found 1 cm higher than the second. These three points are connected by a line and thereby find the projection of the fracture line onto the skin.
Regional lymph nodes are examined in patients with jaw fractures according to the generally accepted technique.
Next, they begin to examine the vestibule of the mouth. Lips and cheeks are spread as much as possible and the ratio of the dentition is determined with closed jaws, that is, the bite. In the event of a jaw fracture, it is disturbed due to the displacement of the resulting fragments.
In case of unilateral fractures of the lower jaw, the displacement of fragments obeys the following rule: a larger fragment goes down and moves towards the fracture, a smaller fragment - up and inward (Fig. 3). It mainly depends on the traction of the masticatory muscles, the own weight of the fragment and the position of the plane of the fracture gap.
In case of tooth injury (dislocation, fracture), the position of their crown becomes displaced in relation to the occlusal plane, a crown or part of it may be missing, or a complete dislocation of the tooth occurs.
Percussion of the teeth adjacent to the fracture gap is painful due to the development of traumatic periodontitis. However, sometimes percussion of a tooth located anterior to the fracture line is painless, which is a diagnostic sign of damage n. alveolaris inferior.
On the gum in the area of the fracture, swelling of the mucous membrane and hematoma are possible, extending to the arch of the vestibule of the mouth. Sometimes there is a laceration, a violation of the sensitivity of the mucous membrane of the lip and gums.
Opening the mouth in full is usually difficult, since the fragments are displaced and pain occurs in the area of the fracture. In the oral cavity, it is sometimes possible to see the cancellous bone of the alveolar part of the posterior fragment of the lower jaw in case of significant displacement of the fragments.
Hemorrhage in the tissues of the sublingual region, which is observed only in violation of the integrity of the bone, is a valuable diagnostic sign of a fracture of the lower jaw.
Rice. 3. Displacement of fragments with a unilateral fracture in the area of the body of the lower jaw.
Hemorrhage into the mucous membrane of the hard palate, displacement of the soft palate back and touching the tongue of the soft palate to the root of the tongue, as well as narrowing of the throat, testifies in favor of a fracture of the upper jaw.
Direct evidence of a jaw fracture is the detection of the mobility of the fragments. To do this, the alleged fragments are fixed with the fingers of the right and left hands and they are carefully displaced (wiggled) in several directions (Fig. 4). In the event of a fracture, there is a change in the size of the gap between the teeth located in the fracture gap.
To determine the mobility of fragments in case of a fracture of the alveolar process of the upper jaw, the fragments are swayed with two fingers superimposed on its vestibular and palatal surfaces.
Rice. 4. Determination of the mobility of fragments of the lower jaw using the fingers of two hands (symptom of mobility of fragments).
2. Instrumental examination methods.
They are used to clarify or verify the clinical diagnosis, prognosis of the disease, assess the effectiveness of treatment and rehabilitation, as well as to conduct research.
These include: radiography, orthopantomography, computed tomography, masticiography, gnatodynamometry, myography, thermovisiography, rheography.
2.1. Radiography.
This is the most informative and widely used research method for damage to the maxillofacial region. In some cases, radiography can be dominant in the diagnosis. Most often, extraoral images are taken using dental or universal X-ray machines.
When laying the head for radiography, it is customary to focus on conditional planes (Fig. 5), of which the following are the main ones: sagittal (runs from front to back along the sagittal suture and divides the head into two symmetrical halves), frontal (located perpendicular to the sagittal plane, passes vertically through the external auditory openings and divides the head into anterior and posterior parts) and horizontal (perpendicular to the sagittal and frontal planes, passes through the external auditory openings and the lower edges of the entrance to the orbit, divides the head into upper and lower sections).
For radiography of the lower jaw, various layouts are used. When using the dental apparatus (I.A.Shekhter, Yu.I. Vorobiev, M.V.
1). Radiography of the angle and ramus of the lower jaw: on the roentgenogram, the branch of the lower jaw with its elements is well defined: the condylar and coronoid processes, the angle of the jaw, molars and premolars.
2) X-ray of the body of the lower jaw: on the roentgenogram, the body of the lower jaw is well defined within the canine-molars.
3) Chin X-ray: on the roentgenogram, the bone tissue of the chin of the lower jaw is determined in the range from canine to canine.
4) Temporomandibular joint radiography: sections of the temporomandibular joint are visible on the roentgenogram.
Rice. 5. Planes of the skull: 1- median sagittal plane; 2 - the plane of the physiological horizontal; 3 - frontal plane (plane of the ear vertical).
When using a universal X-ray apparatus (V.M.Sokolov, 1971; A.N.Kishkovsky et al., 1987), these styling will be as follows: For the study of the lower jaw
1) X-ray of the skull in the nasal projection: the image clearly shows the entire lower jaw in frontal projection, on which the image of the cervical spine is layered, in addition, the bones of the cranial vault, the pyramids of the temporal bones are clearly visible, the upper jaw, the entrance to the orbit, the walls of the nasal cavity, the lower parts of the maxillary sinuses are clearly visible.
2) X-ray of the lower jaw in an oblique projection: the picture clearly shows the angle and branch of the lower jaw, lower molars. Sometimes the zygomatic arch of the adjacent side is projected into the notch of the lower jaw. This projection is recommended in case of a fracture of the lower jaw in the area of its branches and body, sometimes - in case of a fracture of the zygomatic arch of the corresponding side.
For examining the upper jaw, zygomatic bones and nose.
1) X-ray of the skull in the anterior semi-axial (chin) projection: on the picture the facial skeleton is well defined (the orbit, zygomatic bones and arches, the nasal cavity, the boundaries of the maxillary sinus, the contours of the lower jaw are satisfactorily determined). This projection is recommended for diagnosing fractures of the upper jaw, zygomatic bone and arch.
2) X-ray of the zygomatic bone in tangential projection: the picture clearly shows the body of the zygomatic bone, the zygomatic arch, the anterior wall of the maxillary sinus. This projection is recommended when diagnosing a fracture of the zygomatic bone and zygomatic arch.
3) X-ray of the Turkish saddle(a snapshot of the skull in a lateral projection): the bones of the vault and base of the skull, the Turkish saddle, the pituitary fossa, the facial skeleton (upper and lower jaws in the lateral projection) are well defined in the image. The projection is recommended when diagnosing an upper jaw fracture.
4) Radiography of the wings of the sphenoid bone and the superior orbital fissures: in the picture, the wings of the main bone, the upper orbital fissures are well defined. This projection is recommended when diagnosing an upper jaw fracture.
5) X-ray of the eye sockets in the naso-chin projection: the picture clearly shows the structure of the walls of the orbit, the small and large wing of the sphenoid bone, the upper orbital fissures. This projection is recommended when diagnosing a fracture of the upper jaw in the upper and middle types.
2.2. Pantomography.
With this method, two halves of the lower jaw can be displayed simultaneously on one radiograph. The bone structures of the upper jaw are less visualized (Fig. 6). This research method makes it possible to fairly accurately diagnose fractures of the lower jaw in the area of the condylar process, branches, body and chin.
2.3. Computed tomography of the bones of the face (CT).
CT is a rather promising method in the diagnosis of damage to the bone structures of the maxillofacial region. CT can provide especially valuable information in cases of fractures of the upper jaw, sphenoid and ethmoid bones, orbital walls, zygomatic bone, that is, in areas that are not always well detected on conventional radiographs. In addition, CT diagnostics can reveal soft tissue injuries, such as muscle rupture, the presence and location of hematoma, the location of the wound channel, which cannot be determined using conventional radiography.
2.4. Electroodontodiagnostics (EDI).
The method allows you to judge the viability of the tooth pulp. The EDI values of the pulp of healthy teeth are 2 - 6 μA. With necrosis of the entire pulp, they increase (100 or more μA).
Rice. 6. Orthopantomogram
It is especially important to know about the viability of the pulp of the tooth located in the fracture gap. If the pulp has died as a result of damage, and the tooth must be preserved, then in the near future the pulp is removed and the canal is filled in order to prevent the development of inflammatory complications. It should be noted that during the initial study, the sensitivity of the pulp of the teeth in the fracture gap decreases. However, the results of a dynamic study of EDI (2-3 weeks after injury) may testify in favor of the restoration of its viability, which makes it possible to refuse to open the tooth cavity early after the injury.
2.5. Electromyography.
The method allows registering the electric potential in skeletal muscles, judging their bioelectric activity and functional capabilities, objectively assessing the degree of impairment and restoration of the function of the chewing muscles. In case of damage to the jaws, the amplitude of the potentials of the masticatory muscles decreases in comparison with the norm by 50% or more, which is the basis for additional therapy.
2.6. Mechanical arthrography.
The method allows you to record the total effect of rotational-sliding movements of the articular heads of the temporomandibular joints during chewing. The apparatus is used. Persin (1980), with the help of which mechano-arthrographic curves of the temporomandibular joints are simultaneously recorded at rest and during various movements of the lower jaw. Thus, in the dynamics of the study, it is possible to judge about the restoration of the functional ability of the lower jaw after its fracture in the area of the temporomandibular joint.
2.7. Gnathodynamometry.
Gnatodynamometric study allows to assess the strength of the masticatory muscles, the strength of the fusion of fragments and, indirectly, the degree of intensity of the regeneration processes. A gnathodynamometer is used with areas that perceive the pressure of the teeth, which are inserted into the patient's mouth and offer to close the teeth as tightly as possible. The gnatodynamometer can also be used as a training device.
2.8. Masticatiography.
It is a method of graphic representation on a kymograph of the chewing movements of the lower jaw during a meal from the moment it is introduced into the oral cavity until the moment it is swallowed (chewing period).
The chewing period consists of 5 phases: the state of rest, the introduction of food into the mouth, the beginning of the chewing function (adaptation), the main chewing function, the formation of a food lump and swallowing. All these phases are recorded by the recorder in the form of a curve (Fig. 7). A patient with a fracture of the lower jaw is given the same size pieces of food of increasing density, depending on the duration of the fracture or the method of treatment performed. Chewing lasts until food is swallowed or is limited to a certain length of time. By the nature of the curve obtained, the restoration of the phases of the chewing function in dynamics is judged.
2.9. Chewing test according to Gelman to determine the chewing power.
Methodology: the examinee is given 5 g of almonds to chew for 50 seconds. Almonds do not dissolve in saliva, but stick together with it. The chewed almonds are collected in a tray, washed, dried and sieved through a sieve with a hole of 2.4 mm. If all almonds are sieved, then the effectiveness of the chewing apparatus is taken as 100%. The amount of residue after screening shows the percentage of loss in chewing efficiency.
The Rubinov chewing test differs in that the patient is offered almonds weighing 800 mg, which he chews on one side until the swallowing reflex appears.
With a delayed period of consolidation, an increase in particle size and an increase in the time of chewing before swallowing are noted.
2.10. Ultrasound osteometry.
This is a method for studying bone tissue, based on determining the state of the mineralized bone matrix by recording the speed of ultrasound passing through it. The higher the rate of passage of ultrasound through the bone tissue, the greater its density, which depends on its mineral composition. The speed of propagation of ultrasound in the bone tissue fluctuates in the range of 1600 - 4750 m / s and depends on the type of bone site and the individual characteristics of the patient. The positive dynamics of an increase in the speed of ultrasound transmission indicates an active restoration of the structure of bone tissue and its mineralization. In the event of a violation of the reparative process, these indicators do not change.
Rice. 7. The masticiogram of the chewing period is normal: resting phase (1), the phase of introducing food into the mouth (2), the phase of the initial chewing function (3), the phase of the main chewing function (4), the phase of food lump formation and swallowing (5).
Liquorrhea is caused by rupture of the basal dura mater and arachnoid in combination with a fracture of the base of the skull in the anterior or middle cranial fossa. It occurs in about 2-3% of all head injuries and about 10% of all basal skull fractures. 80% are due to trauma, most of the remaining 20% are due to interventions (eg, endonasal procedures). The severity of the primary head injury is not associated with the formation of CSF fistulas, which can occur even in patients without loss of consciousness or without focal neurological symptoms.
Although most fistulas are closed with conservative therapy, some of them persist, requiring surgical treatment.
a) Symptoms and clinic of cerebrospinal fluid fistula... About 98% of all fistulas occur within the first three months after injury, most within the first 24 to 48 hours. However, rhinorrhea has been reported to develop even decades after injury. Delayed otorrhea is rare.
Meningitis develops in 10-85% of all CSF fistulas. The main pathogens are bacterial strains from the nasal cavity (pneumococcus, Haemophilus influenzae). In some cases, recurrent episodes of meningitis are the only clinical signs.
Pneumocephalus occurs in about a third of all cases. Usually, the amount of intracranial air is small and does not cause any problems. Tension pneumocephalus, however, is life-threatening and requires immediate surgery. This is due to a "valve" mechanism leading to an increase in intracranial air volume and a rapid progression of cerebral compression.
Clinical manifestation of liquorrhea: discharge of clear fluid from the nose (arrow).b) Physical examination... CSF fistula should be suspected if a patient complains of clear nasal discharge following a traumatic brain injury. The examination should begin with a thorough history taking. Special attention should be paid to any trauma, endonasal ENT procedures and episodes of fever in combination with impaired consciousness or stiff neck muscles.
In acute cases, bilateral paraorbital hematomas indicate a possible fracture of the anterior skull base (raccoon eyes). With a fracture of the temporal bone, a retroauricular hematoma (Battle symptom) can form.
A deficiency of cranial nerves also suggests a skull base fracture. Particular attention should be paid to the olfactory and vestibular-cochlear systems. Unilateral or bilateral anosmia indicates damage to the olfactory nerve, usually in frontal-basal fractures and is often accompanied by liquorrhea, but is not a necessary symptom. On the other hand, a normal sense of smell does not exclude CSF fistulas. Loss of vestibular or cochlear function can be caused by a fracture of the temporal bone, which in turn can cause ipsilateral facial nerve palsy.
Proving the presence of a fistula, however, can be difficult. If the discharge is profuse and transparent, the diagnosis is simple. But minor and intermittent liquorrhea can lead to serious diagnostic difficulties. If the liquor mixes with blood, the double spot symptom may be checked. To distinguish liquorrhea from "simple" rhinitis, you can use a glucose test. With a negative result, liquorrhea is excluded, since the cerebrospinal fluid, as a rule, contains 30% of the concentration of glucose in the blood. More specific (and more expensive) is the test for B 2 -transferrin, a substance absent in normal secretions from the ear canal and nasal cavity.
c) Fistula detection. The clinical localization of the anterior fistula is ambiguous in 10% of cases when rhinorrhea is observed on the opposite side. A conventional X-ray of the skull can reveal a bone defect, fracture, intracranial air and foreign bodies, which should serve as a basis for further studies, but data on the presence and location of a fistula are usually insufficient. CT with thin slices (1.5 mm) in the axial and / or coronal plane is superior to MRI and is the method of choice for detecting basal skull fractures.
In addition to trauma as the main cause of liquorrhea, the differential diagnosis includes tumors that destroy the base of the skull and latent encephalocele.
Intrathecal administration of contrast agents (CT cisternography) can only localize active fistulas. Other methods include radionuclide cisternography and lumbar dye injection (fluorescein, methylene blue). At our facility, we use intrathecal fluorescein in combination with nasal endoscopy in the ENT department.
Diagnostic algorithm for suspected CSF fistula.
G) . There are no prospective randomized trials comparing surgical and non-surgical treatment of traumatic liquorrhea. In various studies, ascending meningitis is described in 10-85% of such cases, mainly depending on the duration of observation. Given this, in each case, a thorough analysis of the effectiveness of conservative and surgical treatment should be performed. Based on personal experience of observing more than 200 cases, we have identified diagnostic measures and indications for surgery.
1. Conservative treatment... Conservative treatment includes bed rest in a semi-sitting position, repeated lumbar punctures, or prolonged lumbar drainage. In our clinic, only long-term lumbar drainage (100-200 ml / day) is carried out for seven days with rhinorrhea persisting for more than 24 hours. If the fistula does not disappear after this, surgery is usually indicated. In otorrhea, observation is carried out for seven days without special treatment, since such fistulas usually disappear within a few days.
2. CSF fistula surgery... The main goal of the surgery is to close the fistula, seal and prevent ascending meningitis. Other complications such as mucocele or piocele, chronic sinusitis, subdural empyema, and brain abscess need to be prevented. Cosmetic aspects also play a role if the trauma has caused an external deformation of the skull.
Discussions are still underway about the timing of the operation, the best surgical access, as well as materials for closing liquorrhea and possible bone defects.
Terms and access... All the surgical goals mentioned above can only be achieved with clear diagnosis and precise surgical planning, which usually take time. In addition, delayed intervention for intracranial procedures has been shown to be superior to immediate surgery in terms of outcome.
CSF fistulas caused by traumatic lesions of the anterior part of the skull base are desirable from the very beginning with the involvement of specialists. Neurosurgeons, maxillofacial surgeons, ENT doctors and sometimes ophthalmologists are involved in the diagnosis, timing of the necessary intervention, and in deciding on the surgical approach.
The benefits of extracranial access are lower mortality and morbidity. The main disadvantage is the inability to address adjacent brain damage. We use extracranial approaches only for small lesions (usually less than 1 cm in diameter) in the medial anterior skull base (endoscopic approach) and fistulas located in the sella turcica (paranasal approach). Operations are usually performed by an ENT surgeon with neurosurgical assistance.
With the transcranial approach, the need for brain retraction to fully visualize the entire anterior skull base carries a significant risk of damage to the olfactory nerves and frontal lobes. However, complex or large fractures of the anterior skull base with associated liquorrhea are still best treated with traditional transcranial intradural approaches, which provide complete visualization of the area of injury.
We strongly advocate delaying surgery until the patient has recovered to some extent (at least less than 5 points, no infection and hemodynamic stability) and there are no signs of cerebral edema on preoperative CT (ventricular, basal cisterna).
To minimize brain retraction, preoperative CSF drainage or intraoperative puncture of the lateral ventricle can be performed. If the operation is delayed for the indicated reasons, the maxillofacial surgeon will be able to simultaneously safely repair concomitant fractures of the facial bones.
We usually use the intradural approach first. Tears in the dura mater should be sutured whenever possible. If this is not possible, various methods of closing the dura mater defect are used (periosteal flap, rotated flap based on the temporal muscle, free flap from the temporal muscle, fascia lata of the thigh, etc.). Based on our experience of 34 reoperations, we do not believe that pedicle flaps are superior to free flaps. In our opinion, in order to prevent recurrent fistulas, it is more important that the flap is large enough to cover the defect more than 2 cm from its edge.
Large bone defects (> 2 cm) should be covered with hard materials to avoid recurrence of liquorrhea. For this purpose, various materials can be used (inverted temporalis muscle + bone, free split bone flap of the cranial vault, titanium meshes). Our department mainly uses titanium microgrids.
Antibiotic prophylaxis... So far, there has been no clear evidence of the effectiveness of prophylactic antibiotic use in patients with CSF fistulas. We usually use the second generation of cephalosporins from admission until the third day after the cessation of liquorrhea.
Bilateral paraorbital hematomas indicate a frontal-basal skull fracture.
Buttle's symptom in a patient with a fracture of the temporal bone pyramid.
A-B Skull x-ray and axial CT of a patient with severe pneumocephalus after a mild head injury, note the almost completely air-filled ventricles (arrow).
A-G. Extracranial endoscopic CSF fistula closure (51 years post-injury) in a 59-year-old woman. A. Sagittal MRI shows a protrusion of the brain (arrow) through the base of the skull into the nasal cavity and a fracture of the sphenoid bone.
B. Endoscopic view of hernia of the brain (arrow).
B. The closure of liquorrhea is carried out with a free muscle flap and fibrin glue (arrow).
D. Resected fragment of a hernia of the brain.
Transcranial access to the large defect (arrow) and fistula located on the right side of the anterior cranial fossa.
Loading ...