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ORIGINAL ARTICLE
Year : 2022  |  Volume : 25  |  Issue : 3  |  Page : 342-348

Association of frontal and maxillary bone fractures and concomitant craniocerebral injuries in patients presenting with head trauma


1 Department of Otolaryngology, Alaaddin Keykubat University, School of Medicine, Alanya, Antalya, Turkey
2 Department of Radiology, Alaaddin Keykubat University, School of Medicine, Alanya, Antalya, Turkey

Date of Submission06-Jun-2021
Date of Acceptance30-Nov-2021
Date of Web Publication16-Mar-2022

Correspondence Address:
Dr. G Orhan Kubat
Department of Otolaryngology, Alaaddin Keykubat University, School of Medicine, 07425, Alanya, Antalya
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_1582_21

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   Abstract 


Background: Maxillofacial fractures and craniocerebral injuries are common in patients with head trauma. These are injuries with high mortality and morbidity. Therefore, patients with head trauma should be evaluated early with a multidisciplinary approach. Aim: The association between frontal and maxillary bone fractures and concurrent craniocerebral injuries were investigated in patients presenting with head trauma in this study. The data of the patients were analyzed retrospectively. Methods and Material: Age and gender distributions were evaluated in frontal and maxillary fractures. Concomitant craniocerebral injuries were investigated. Craniocerebral injuries were grouped as pneumocephalus, extra-axial, intra-axial injuries and brain edema. Craniocerebral injuries in frontal and maxillary fractures were compared statistically. Results: Frontal bone and maxillary bone fractures were detected in 24% and 95% of the patients. Coexistence of pneumocephalus and intra-axial injuries in frontal bone fracture was statistically significant. The association of frontal posterior wall fractures with pneumocephalus and parenchymal contusion was found to be statistically significant. In addition, the association of craniocerebral injuries were evaluated and statistically significant ones were determined. Conclusion: The presence of maxillofacial fractures in patients presenting with head trauma increases mortality and morbidity. Craniocerebral injuries can be life-threatening and delay the treatment of facial fractures. Upper facial bone fractures are significantly more common in craniocerebral injuries.

Keywords: Computed tomography, frontal bone, head injuries, maxillofacial injuries, post-traumatic subarachnoid hemorrhage


How to cite this article:
Kubat G O, Sahin C, Ozen O. Association of frontal and maxillary bone fractures and concomitant craniocerebral injuries in patients presenting with head trauma. Niger J Clin Pract 2022;25:342-8

How to cite this URL:
Kubat G O, Sahin C, Ozen O. Association of frontal and maxillary bone fractures and concomitant craniocerebral injuries in patients presenting with head trauma. Niger J Clin Pract [serial online] 2022 [cited 2022 Aug 19];25:342-8. Available from: https://www.njcponline.com/text.asp?2022/25/3/342/339718




   Introduction Top


Maxillofacial traumas are a public health problem with high morbidity and mortality, affecting the general population and accompanying many serious injuries.[1] According to the data of the National Trauma Database (NTDB) 16,834 patients were diagnosed with facial fractures from 2002 to 2014.[2]

Craniomaxillofacial fractures are more common at younger ages and in men.[1] The most common etiological causes of craniomaxillofacial trauma differ in developed and developing countries. The etiology includes falls, sports accidents, assaults and traffic accidents. The predominant etiological factor is assault in developed countries, and traffic accidents in developing countries.[3]

Patients with craniofacial fractures have a higher risk of concurrent traumatic intracranial injuries.[4] The incidence of traumatic craniocerebral injuries is approximately 1.6 million annually, and it has been reported to occur in 12-45.5% of facial bone fractures.[5]

Since frontal bone fractures occur as a result of high-energy trauma, concomitant craniocerebral injuries can be very serious and life-threatening.[6] Traumatic intracranial hematoma is the major cause of mortality and morbidity in patients with head trauma.[4] Therefore, early diagnosis of intracranial pathologies is very important.

Thin-section, high-resolution computed tomography (CT) is recommended for the assessment of patients presenting with maxillofacial trauma.[7],[8] Magnetic resonance imaging (MRI) provides more detailed information about soft tissue and blood vessels, but it is not suitable in the acute phase because it takes longer to capture.[9]

Intracranial lesions are quickly diagnosed in head and maxillofacial traumas, and it is also used in the detection of lesions such as cerebral edema, ischemia and herniation that may develop during follow-up with CT.[10] Its sensitivity is high in detecting intra-axial injuries, extra-axial hemorrhages, and bone fractures, and in investigating the mass effect and ventricular volume. Except for hemorrhage, low sensitivity is a disadvantage in detecting cortical contusion and diffuse axonal injury, early hypoxic ischemic encephalopathy.[11]

The purpose of this study is to assess the association of frontal and maxillary bone fractures with intracranial complications in patients presenting with head trauma.


   Subjects and Methods Top


One hundred patients were selected from among the patients who were admitted to the emergency department with head trauma between 2018 and 2019 for this study. The presence of intracranial pathologies in patients with frontal and maxillary bone fractures were assessed retrospectively. The age and gender of the patients, localization of the frontal and maxillary bone fractures, and associated intracranial pathologies were assessed.

Fractures of frontal sinus were included in frontal bone fractures. Frontal bone fractures were classified as anterior-posterior wall fractures, displaced/non-displaced fractures. Maxillary bone fractures were classified as displaced/non-displaced fractures. Facial and craniocerebral injuries were diagnosed based on head CT.

Intracranial pathologies were grouped as pneumocephalus, extra-axial [subdural hematoma (SDH), epidural hematoma (EDH), subarachnoid hemorrhage (SAH), intraventricular hemorrhage (IVC)], intra-axial [parenchymal contusion (PC), parenchymal hematoma (PH), diffuse axonal injury (DAI)] and brain edema. In addition, sphenoid, parietal, occipital and temporal bone fractures were also investigated.

All data collection and analysis were carried out with the approval of the research ethics committee of Alaaddin Keykubat University (date: 26/10/2018, no: 3-16). The study protocol conforms to the ethical guidelines of the 1975 Declaration of Helsinki as reflected in approval by the ethics committee. Informed consent was obtained for experimentation with human subjects.

Statistical analysis

Statistical analysis was performed using SPSS, version 27.0. Descriptive data were expressed as means, standard deviation, median lowest, highest, frequency and ratio values. The Kolmogorov-Smirnov test was used for measure the distribution of variables Mann-Whitney's test was used in the analysis of quantitative independent data. Chi-square test was used in the analysis of qualitative independent data, and Fischer test was used when Chi-square test conditions were not met. The values of the patients were compared with the Pearson correlation analysis. For each test, a P value of 0.05 or less was accepted as statistically significant.


   Results Top


In our study, the male/female ratio was 4.3 (81% male, 19% female) and the mean age was 40.1 ± 16.6 [Table 1]. 25% of the patients were in the 2nd decade, while 12% were in the 6th decade and above. Demographic data are given in [Table 1].
Table 1: Demographic data of patients

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The age and gender distribution of patients with frontal bone fractures did not differ statistically (p > 0.05). In the frontal bone fracture group, the maxillary bone fracture rate was significantly higher than in the group without frontal bone fractures (p < 0.05) [Table 2].
Table 2: The age and gender distribution of patients with frontal bone fractures. Association of frontal bone fracture with maxillay bone fracture and intracranial pathologies

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When the correlations of frontal bone and maxillary bone fractures with intracranial pathologies were examined, the association of frontal bone fractures with pneumocephalus and intra-axial injuries were statistically significant (p < 0.05). Association of frontal bone fracture with intracranial pathologies are shown in [Table 2].

The age and gender distribution of patients with maxillary bone fractures did not differ statistically (p > 0.05). In the maxillary bone fracture group, the frontal sinus anterior wall fracture rate was significantly higher than in the group without maxillary bone fractures (p < 0.05) [Table 2].

When investigated the association of maxillary bone fractures and intracranial pathologies, it was seen that there was no statistically significant difference between maxillary bone fractures and intracranial pathologies (p > 0.05) [Table 3].
Table 3: The age and gender distribution of patients with maxillary bone fractures. Association of maxillary bone fracture with frontal bone fracture and intracranial pathologies

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Of the 22 patients with frontal sinus anterior wall fractures, 4 had pneumocephalus, 1 had extra-axial, 8 had intra-axial, and 10 had brain edema. Of the 9 patients with frontal sinus posterior wall fractures, 4 had pneumocephalus, 1 had extra-axial, 7 had intra-axial, and 6 had brain edema. Of the 3 patients with displaced frontal bone fractures, 1 had pneumocephalus, 1 had intra-axial and 1 had brain edema. Statistical evaluation could not be made in all groups due to insufficient data.

When anterior-posterior wall fractures and concomitant craniocerebral injuries were examined, the relation of posterior wall fractures with pneumocephalus and PC was found to be statistically significant (p < 0.001). When the association of displaced and non-displaced fractures with craniocerebral injuries was investigated, displaced frontal bone fractures and PC were found to be statistically significant (p < 0.001) [Table 4].
Table 4: Correlations of frontal bone fractures with pneumocephalus and parenchymal contusion

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Considering the association of intracranial pathologies among themselves, the association of pneumocephalus with SAH, PC, PH and edema; association of SDH with SAH, EDH and PH; association of SAH with PC and PH; association of PH with SAH, PC and edema; and association of PC with SAH, PH and edema were statistically significant (p < 0.05). Association of frontal, parietal, sphenoid, occipital and temporal bone fractures was not statistically significant.


   Discussion Top


Traumatic head injuries are often associated with maxillofacial fractures. The presence of maxillofacial fractures is an important parameter since they increase mortality and morbidity in traumatic head injuries. Head injuries are more common in young male patients.[12] In our study, the male/female ratio was 4.3, and the mean age was 40.1 SD16.6. In a study in Turkey determined that trauma in males was significantly higher than in women (16.7%- 83.3%).[13] The results were compatible with other literature.

In a study, it was found that 6.2-12.14% of adult patients with head trauma had fractures in the cranial bones.[14] Cranial bones are seen as frontal, parietal, occipital and sphenoid bone fractures. In these bones, frontal bone fractures usually occur as a result of high-energy trauma, and concurrent central system damage is common (73%).[15]

Intracranial injuries were identified as concomitant injuries to head and facial trauma. Pathologies such as CSF leak, cranial base fractures, brain contusion or laceration, pneumocephalus and intracranial hemorrhage can be seen as central nervous system damage.[14],[16] According to an investigation, intracranial hemorrhage was detected 16.4% of the patients with craniofacial fracture.[17]

Fractures of cranial bones, extra-axial and intra-axial injuries caused by trauma constitute primary central nervous system lesions while ischemic and hypoxic brain injuries, cerebral edema and herniation constitute secondary central nervous system lesions.[18] Extra-axial injuries are EDH, SDH, SAH and intraventricular hemorrhage. Intra-axial injuries include DAI, cortical contusion, intraparenchymal hemorrhage, and vascular lesions.[18]

In this study intracranial injuries categorized as pneumocephalus, extra-axial (EDH, SDH, SAH and IVH), intra-axial (DAI, PC, PH) injury and brain edema. In our study brain edema is the most intracranial injury (28%).

The incidence of head trauma in the upper maxillofacial region increases from 41.2% to 82.2%. While the comorbidity ratio of head trauma in single-region fractures is 28.7% to 79.9%, this rate increases to 65.5% to 88.7% in fractures of two or more regions.[16] Additionally, the study of Isık et al. showed the head trauma was significantly higher in patients with multiple facial fractures.[13]

In a study by Tung et al., it was stated that the maxilla was the most commonly fractured bone (45%) in patients presenting with trauma.[19] In our study, 95% maxillary bone fracture was found in accordance with the literature. 24% frontal bone, 7% temporal bone, 6% sphenoid bone, 1% parietal bone and 1% occipital bone fractures were found. Both frontal and maxillary bone fractures were detected in 19% of patients. Association of cranial bones were not statistically significant due to the lack of sufficient data; it is thought that significant results may be obtained in studies to be conducted with more data. The rates of brain trauma and intracranial damage are highest in frontal, orbital and maxillary bone fractures.[16],[20]

Frontal bone fractures are accompanied by neurological damage (39-76%), loss of consciousness (72%), fractures in other cranial bones (87-93%), or orbital trauma (26-59%).[8],[21] Studies found that injuries such as traumatic pneumocephalus, parenchymal contusion, subdural hematoma, intracranial hemorrhage showed a statistically significant increase, especially in frontal bone fractures and upper facial bone fractures.[22],[23],[24],[25] Işık et al. emphasized that the risk of head injury increases significantly in patients with frontal sinus fractures.[13] It was found that 20% of craniofacial trauma co-exited with a craniocerebral injury.[20]

In our study, the rate of concomitant craniocerebral injury to frontal and maxillary bone fracture was determined as 39%. This study examined the correlations of intracranial injuries with frontal and maxillary bone fractures, and a statistically significant association was found between frontal bone fractures and pneumocephalus and intra-axial injuries (p < 0.05). There was no significant association with maxillary bone fractures and concomitant craniocerebral injuries (p > 0.05).

It was found that 20.21% of cranial bone fractures also had a fracture in the cranial base.[14] The cranial base is anatomically grouped as anterior, middle and posterior, and fractures are often seen in the anterior part. The posterior tabula part of the frontal sinus belongs to the anterior cranial base. Posterior tabula fractures are fractures with high morbidity due to their close proximity with intracranial formations.[15],[26] They are frequently associated with dural, orbital and intracranial damage.[9] In posterior tabular fractures, it has been reported that 25-33% pneumocephalus, 13-25% CSF leak, and 10% extradural hematoma are observed due to dural injury.[27]

In our study, 9% frontal sinus posterior tabula fractures were detected. When the correlation between posterior tabula fractures and intracranial pathologies was examined, a statistically significant correlation was found with pneumocephalus and parenchymal contusion (p < 0.001). No statistically significant relationship could be shown in anterior tabula fractures.

A study found that 54% of frontal sinus posterior wall fractures were non-displaced and non-segmental while 46% were displaced and/or segmental fractures.[15] In our study, when frontal and maxillary bone fractures were classified as displaced and non-displaced, a statistically significant relationship was found between displaced frontal bone fractures and parenchymal contusion (p < 0.001).

Craniocerebral injuries can be seen isolated or combined in patients presenting with head trauma.[19] Our study examined the association of pneumocephalus, extra-axial injuries, intra-axial injuries and brain edema.

It was shown that cerebral damage accompanying maxillofacial trauma was most commonly in the form of intracranial hematoma (subdural, subarachnoid, parenchymal, epidural) followed by contusion, pneumocephalus, edema, concussion, traumatic brain injury and hypoxia. It was stated that approximately 50% of patients with cranial base fractures had vascular injuries, and most of these injuries were silent and showed no clinical symptoms. However, vascular damage can lead to neurological sequelae and death.[28] Subarachnoid hemorrhage, parenchymal hemorrhage and brain edema was associated with higher mortality compared to epidural hemorrhage and diffuse axonal injury.[29]

Post-traumatic brain edema accounts for 10-20% of traumatic brain injuries. Massive brain edema and intracranial hypertension is the most common secondary lesion. Epidural hematoma was seen in 0.2-12% of patients who had severe head trauma. Cerebral contusion and cortical contusion are brain surface damage, and have been observed in 43% of patients with head trauma.[18]

In our study, the most common cerebral damage was intraparenchymal edema (28%) while the least common was diffuse axonal injury (1%) and epidural hematoma (1%). Parenchymal contusion (22%) and pneumocephalus (10%) were the second and third most common damages, respectively. IVC and DAI were excluded from the assessment due to insufficient data. Since the lack of correlation results from the insufficient number, we suggest that studies should be conducted with larger number of cases.


   Conclusion Top


The determination of prevalence of head trauma associated with maxillofacial fractures is useful in clinical approach to the patient, diagnosis and follow-up. Comorbidity of maxillofacial fractures in most of the patients presenting with head trauma is a risk factor for mortality and morbidity.

Intracranial injuries are part of the group categorized as accompanying injuries to head trauma. The risks are higher in upper facial fractures, multiple maxillofacial fractures, and fractures that are anatomically adjacent to craniocerebral structures. Craniocerebral injuries can be life threatening and intracranial injuries are more severe than facial fractures. They may cause of delay the treatment of facial fractures.

In this study, we aimed to examine the association of frontal and maxillary bone fractures with intracranial injuries, and we found that the association of frontal bone fractures with pneumocephalus and parenchymal contusion was statistically significant. The association of intracranial injuries was also examined, and we showed that the injuries could be isolated or multiple.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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