Traumatic maxillofacial injury.ppt

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  • Tripod fractures consist of fractures through: Zygomatic arch Zygomaticofrontal suture Inferior orbital rim and floor Picture: Diagram of a tripod fracture. Note the disruption of both the lateral orbital rim and the orbital floor, as well as the zygomatic arch.
  • Traumatic maxillofacial injury.ppt

    1. 1. Traumatic maxillofacial and skull base injury: Is antibiotics prophylaxis indicated ?! 4FI Intern 陳晉瑋 / VS 韓吟宜 <ul><li>A Systematic Review of Prophylactic Antibiotics in the Surgical </li></ul><ul><li>Treatment of Maxillofacial Fractures ~~ J Oral Maxillofac Surg 64:1664-1668, 2006 </li></ul><ul><li>A ntibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures (Review) ~~ The Cochrane Library 2007, </li></ul><ul><li>Issue 2 </li></ul>
    2. 2. Content <ul><li>First part: </li></ul><ul><ul><li>Antibiotics prophylaxis for preventing infection in maxillofacial fracture </li></ul></ul><ul><li>Second part: </li></ul><ul><ul><li>Antibiotic prophylaxis for preventing meningitis in basilar skull fracture </li></ul></ul>
    3. 3. Epidemiology <ul><li>Etiology </li></ul><ul><ul><li>Car accidents 73 (30.8%), motorcycle accidents 55 (23.2%), </li></ul></ul><ul><ul><li>altercations 23 (9.7%), sports 15 (6.3%) </li></ul></ul><ul><li>Location </li></ul><ul><ul><li>173 (72.9%) mandibular, </li></ul></ul><ul><ul><li>57 (24.0%) zygomatico-orbital . </li></ul></ul><ul><ul><li>33 (13.9%) maxillary </li></ul></ul><ul><li>Distribution of mandibular fractures </li></ul><ul><ul><li>32% condylar , 29.3% symphyseal-parasymphyseal, 20% </li></ul></ul><ul><ul><li>angle, 12.5% body, 3.1% ramus, 1.9% dentoalveolar </li></ul></ul><ul><li>Distribution of maxillary fractures </li></ul><ul><ul><li>Le Fort II 18 (54.6%) , Le Fort I 8 (24.2%), Le Fort III 4 </li></ul></ul><ul><ul><li>(12.1%), alveolar 3 (9.1%). </li></ul></ul>
    4. 7. Zygomaticomaxillary complex (Tripod Fractures) <ul><li>Tripod fractures consist of fractures through: </li></ul><ul><ul><li>Zygomatic arch (zygomaticotemporal) </li></ul></ul><ul><ul><li>Zygomaticofrontal </li></ul></ul><ul><ul><li>Zygomaticosphenoid </li></ul></ul><ul><ul><li>Zygomaticomaxillary </li></ul></ul>
    5. 8. Etiology and pattern of zygomatic complex fractures J Natl Med Assoc. 2005 Jul;97(7):992-6 <ul><li>76.1% were males and 23.9% females. Most (46.3%) patients were aged 21-30 years </li></ul><ul><li>Road traffic accidents (82.1%) caused the most injuries (p < 0.05). </li></ul><ul><li>The most frequently associated maxillofacial fracture was mandibular (21.0%). </li></ul><ul><li>The commonest clinical feature was subconjunctival ecchymosis (63.4%), while the commonest radiologic findings were fractures at the zygomatico-frontal and zygomatico-maxillary sutures (38.8%). </li></ul>
    6. 9. C omminuted
    7. 10. Le Fort Fractures <ul><li>Definition: </li></ul><ul><ul><li>A separation of all or a portion of the maxilla from the skull base </li></ul></ul><ul><ul><li>Posterior maxillary sinus with the pterygoid plates of the sphenoid must be disrupted </li></ul></ul><ul><li>Type: </li></ul><ul><ul><li>Type I transverse fracture </li></ul></ul><ul><ul><li>Type II pyramidal fracture </li></ul></ul><ul><ul><li>Type III complete crainofacial </li></ul></ul><ul><ul><li>fracture </li></ul></ul>
    8. 12. Mandibular fracture type <ul><li>Unifocal fractures </li></ul><ul><ul><li>condylar fractures (32%) and angle fractures (32%). </li></ul></ul><ul><li>Bifocal fracture(>95%) </li></ul><ul><ul><li>angle and symphysis (32%) </li></ul></ul><ul><li>symptoms: </li></ul><ul><ul><li>Facial swelling </li></ul></ul><ul><ul><li>Malocclusion </li></ul></ul><ul><ul><li>drooling </li></ul></ul><ul><ul><li>V3 numbness </li></ul></ul>
    9. 13. Facial fracture management <ul><li>Seldom life-threatening unless in the airway </li></ul><ul><li>Consider spinal precautions </li></ul><ul><li>Control bleeding </li></ul><ul><li>Caution: NG tube replacement </li></ul><ul><li>High resolution CT </li></ul><ul><ul><li>Complex anatomy and fractures of the facial bones </li></ul></ul><ul><ul><li>Soft tissue complications </li></ul></ul><ul><li>Plain film facial series </li></ul><ul><ul><li>Focal (nasal fracture) </li></ul></ul><ul><ul><li>CT is unavailable </li></ul></ul>
    10. 14. Facial fracture management <ul><li>Treatment: </li></ul><ul><ul><li>173 mandibular fractures: </li></ul></ul><ul><ul><ul><li>56.9% closed reduction , 39.8% open reduction, and 3.5% observation. </li></ul></ul></ul><ul><ul><li>33 maxillary fractures: </li></ul></ul><ul><ul><ul><li>54.6% closed reduction , 40.9% open reduction, and 4.5% observation </li></ul></ul></ul><ul><li>Complications occurred in 17 (5.4%) patients and were mostly infections </li></ul>
    11. 15. Prophylactic antibiotics is necessary or not? <ul><li>Antibiotic prophylaxis has been considered a must in the surgical treatment of jaw fractures </li></ul><ul><ul><li>~ Oral and Maxillofacial Infections. Ed 4. Philadelphia, PA, Saunders, 2002, p 359 </li></ul></ul><ul><li>Evidence-based has been weak in a series of surgical disciplines from 1977 to 1986 </li></ul><ul><li>A higher infection rate in antibiotic treated situations </li></ul><ul><ul><li>May give an advantage to opportunistic infection </li></ul></ul><ul><ul><ul><li>J Oral Maxillofac Surg 48:617, 1990 </li></ul></ul></ul>
    12. 16. Factors influenced infection rate after facial fracture <ul><li>Before antibiotic prophylaxis, we should consider… </li></ul><ul><li>Type: </li></ul><ul><ul><li>closed fracture (eg, mandibular condyle or ramus fractures and maxillary Le Fort I–III fractures) </li></ul></ul><ul><ul><li>open fractures with direct communication to the oral cavity and/or the skin surface </li></ul></ul><ul><li>Treatment procedure used: </li></ul><ul><ul><li>Open reduction or close reduction </li></ul></ul>
    13. 17. Factors influenced infection rate after facial fracture <ul><li>Concerning the administration of antibiotics </li></ul><ul><ul><li>Type </li></ul></ul><ul><ul><ul><li>Streptococci( S. mutans and S. sanguis ) </li></ul></ul></ul><ul><ul><ul><li>Lactobacilli(Gram negative, anaerobes) </li></ul></ul></ul><ul><ul><ul><li>staphylococci and corynebacteria </li></ul></ul></ul><ul><ul><ul><li>anaerobes, especially bacteroides </li></ul></ul></ul><ul><ul><li>Dose </li></ul></ul><ul><ul><li>Duration </li></ul></ul><ul><ul><li>Route </li></ul></ul>
    14. 18. A Systematic Review of Prophylactic Antibiotics in the Surgical Treatment of Maxillofacial Fractures J Oral Maxillofac Surg 64:1664-1668, 2006
    15. 19. The purpose of the review <ul><li>Answer the following questions: </li></ul><ul><li>1) Does antibiotic prophylaxis decrease the </li></ul><ul><li>incidence of post-trauma infections in jaw </li></ul><ul><li>fracture treatment? </li></ul><ul><li>2) Are there situations where an antibiotic </li></ul><ul><li>prophylaxis is not indicated? </li></ul><ul><li>3) Which antibiotic is the drug of choice? In </li></ul><ul><li>what dose? And for how long? </li></ul>
    16. 20. Materials and methods <ul><li>Database MEDLINE and Cochrane </li></ul>
    17. 21. Zallen and Curry in 1975 <ul><li>Prophylactic antibiotics in the treatment of compound mandibular fractures </li></ul><ul><ul><li>RCT study (one test group and one control group) </li></ul></ul><ul><ul><li>32 p’ts with Abx. Vs 30 p’ts without Abx. </li></ul></ul><ul><ul><li>20/32 parenterally vs 10/32 orally </li></ul></ul><ul><ul><li>Infection rate 6% (Abx) vs 53%(non-Abx), p=0.0001 </li></ul></ul>
    18. 22. In 1983, Aderhold et al <ul><li>Antibiotic treatment of 120 mandibular fractures </li></ul><ul><li>All fractures had communication to the oral cavity </li></ul><ul><ul><li>40 without Abx, 40 with Abx 48 hrs, 40 with Abx >48 hrs </li></ul></ul><ul><ul><li>Open and close reduction in 3 groups was comparable </li></ul></ul><ul><ul><li>Short-term antibiotic prophylaxis was effective in reducing infection </li></ul></ul><ul><ul><li>Long-term treatment did not significantly reduce the risk of infections as compared with the control group </li></ul></ul>
    19. 23. In 1987, Chole and Yee <ul><li>Prospective clinical trial of 101 patients with facial fractures </li></ul><ul><ul><li>150 fractures(6 maxillary, 24 zygomatic, 120 mandibular) </li></ul></ul><ul><ul><li>Control vs IV cefazolin 1g 1 hour before surgery and 8 hours after </li></ul></ul><ul><ul><li>Maxillary, zygomatic, and subcondylar mandibular fractures got no infected, irrespective of antibiotic prophylaxis given or not. </li></ul></ul><ul><ul><li>37/79(14%) Abx vs 42/79 non-Abx(43%) in mandibular without condyle fracture, p=0.01 </li></ul></ul><ul><ul><li>Close reduction </li></ul></ul><ul><ul><ul><li>Infections rate: Abx 23% vs no Abx 28%, p>0.05 </li></ul></ul></ul><ul><ul><li>Open reduction </li></ul></ul><ul><ul><ul><li>Infections rate: Abx 8% vs no Abx 62%, p<0.05 </li></ul></ul></ul>
    20. 24. In 1988, Gerlach and Pape <ul><li>Antibiotic treatment on infection rates in 200 mandibular fractures all treated with open reduction </li></ul><ul><ul><li>Group 1 (n=50): 1-day Abx </li></ul></ul><ul><ul><li>Group 2 (n=50): 1-shot Abx </li></ul></ul><ul><ul><li>Group 3 (n=51): 3-day Abx course </li></ul></ul><ul><ul><li>Control (n=49): no Abx treatment </li></ul></ul><ul><li>1-shot administration of Abx is sufficient to protect the patient from wound infection </li></ul>
    21. 25. Abubaker and Rollert in 2001 <ul><li>Comparative, double-blind, placebo-controlled </li></ul><ul><li>1-day prophylaxis versus a 5-day treatment with penicillin. In a limited number of patients (n 30) </li></ul><ul><li>No benefit of a prolonged administration of antibiotics </li></ul>
    22. 26. Heit et al in 1997 <ul><li>Two different antibiotic regimens were compared in a prospective and nonrandomized clinical study </li></ul><ul><ul><li>90 patients with compound mandibular fractures </li></ul></ul><ul><ul><li>Group I: ceftriaxone (3rd cepha.) 1 g qd iv </li></ul></ul><ul><ul><li>Group II: penicillin G 2 million U q4h iv </li></ul></ul><ul><ul><li>Non-significant difference between the 2 regimens </li></ul></ul>
    23. 27. Conclusion <ul><li>Indicated for prophylatic antibiotics </li></ul><ul><ul><li>Mandibular fracture </li></ul></ul><ul><ul><li>without condyle </li></ul></ul><ul><ul><li>Open fracture </li></ul></ul><ul><ul><li>Open reduction treated </li></ul></ul><ul><li>Drug of choice </li></ul><ul><ul><li>Penicillin G 2 million U q4h iv </li></ul></ul><ul><ul><li>Cefazolin 1g qd iv </li></ul></ul><ul><li>Duration </li></ul><ul><ul><li>Short term (<48 hr), even “one shot” </li></ul></ul>
    24. 28. Discussion (cont.) <ul><li>Further analyzed subsequent stury </li></ul><ul><ul><li>This finding can be compared with similar effects in the treatment of bone fractures of the extremities </li></ul></ul><ul><ul><li>Bacteria flora </li></ul></ul><ul><ul><ul><li>A mixed infection with aerobic and anaerobic flora and a predominance of staphylococcus aureus </li></ul></ul></ul><ul><ul><li>The specific preference of wound infection to the angular region does support a dental origin (pulp canal or periodontal flora related to the molar may play a role) </li></ul></ul>
    25. 29. Basilar Skull Fracture(BSF) <ul><li>Fracture involve the floor of the skull </li></ul><ul><ul><li>cribiform plate, frontal bones, sphenoid bones, temporal bone and occipital bones </li></ul></ul><ul><li>Clinical signs: </li></ul><ul><ul><li>CSF leakage (otorrhea or rhinorrhea) </li></ul></ul><ul><ul><li>Hemotympanum (blood behind the eardrum) </li></ul></ul><ul><ul><li>Bruising behind the ears (postauricular ecchymoses) </li></ul></ul><ul><ul><li>Bruising around the eyes (periorbital ecchymoses) </li></ul></ul><ul><ul><li>Injury to cranial nerves </li></ul></ul>
    26. 30. Background <ul><li>Incidence BSF </li></ul><ul><ul><li>Nonpenetrating head trauma: </li></ul></ul><ul><ul><ul><li>7~15.8% of all skull fractures </li></ul></ul></ul><ul><ul><ul><li>CSF leakage occurring in 2% to 20.8% of patients </li></ul></ul></ul><ul><li>Special significance </li></ul><ul><ul><li>Dura mater torn  placing CNS in contact with bacteria from the paranasal sinuses, nasopharynx or middle ear  meningitis, </li></ul></ul><ul><li>Prophylactic antibiotics for preventing bacterial meningitis in patients with BSF is controversial </li></ul><ul><ul><li>Choi 1996: prophylatic ABx had higher meningitis incidences </li></ul></ul><ul><ul><li>meta-analysis (Brodie 1997): significantly prevent meningitis </li></ul></ul>
    27. 31. Antibiotic prophylaxis for basilar skull fracture Meta analysis Villalobos et al. Cli infect Dis 1998; 27:364-369. <ul><li>12 studies, 1241 patients </li></ul><ul><li>58% received antibiotics </li></ul><ul><li>Antibiotics did not prevent meningitis </li></ul><ul><ul><li>RR 1.15(0.68-1.94) p=0.68 </li></ul></ul><ul><li>CSF leakage subset </li></ul><ul><ul><li>RR 1.34(0.75-2.41) p=0.36 </li></ul></ul>
    28. 33. Objectives of this review <ul><li>Primary hypothesis: </li></ul><ul><ul><li>meningitis is lower when prophylactic antibiotics are administered as soon as a diagnosis of BSF, with or without CSF leakage compared with no treatment </li></ul></ul><ul><li>Search strategy </li></ul><ul><ul><li>The Cochrane Library Issue 3, 2005, MEDLINE (1966 to September 2005), EMBASE (1974 to June 2005), and LILACS (1982 to September 2005) </li></ul></ul><ul><li>Selection criteria </li></ul><ul><ul><li>Randomised controlled trials (RCTs) </li></ul></ul><ul><ul><li>Perform to meta-analysis </li></ul></ul>
    29. 34. Frequency of meningitis 208 participants from the four RCTs for meta-analysis <ul><li>F requency of meningitis </li></ul><ul><ul><li>T reatment: 10/109(9.2%) </li></ul></ul><ul><ul><li>C ontrol: 14/99(14.1%) </li></ul></ul>
    30. 35. All cause mortality 208 participants from the four RCTs for meta-analysis <ul><li>A ll cause mortality </li></ul><ul><li>T reatment: 5/109(4.6%) </li></ul><ul><li>C ontrol: 3/99(3.0%) </li></ul>
    31. 36. Meningitis-related mortality 208 participants from the four RCTs for meta-analysis <ul><li>M eningitis-related mortality </li></ul><ul><li>T reatment: 1/109(0.9%) </li></ul><ul><li>C ontrol: 1/99(1.0%) </li></ul>
    32. 37. T reatment: 4/51 C ontrol: 6/41 T reatment: 6/53 C ontrol: 8/53
    33. 38. Main results <ul><li>No significant differences between antibiotic prophylaxis groups and control groups in: </li></ul><ul><ul><li>frequency of meningitis </li></ul></ul><ul><ul><li>all-cause mortality </li></ul></ul><ul><ul><li>meningitis-related mortality </li></ul></ul><ul><ul><li>Subgroup </li></ul></ul><ul><ul><ul><li>CSF leakage </li></ul></ul></ul><ul><ul><ul><li>Non-CSF leakage </li></ul></ul></ul>
    34. 39. Conclusion <ul><li>Currently available evidence from RCTs does not support prophylactic antibiotic use in patients with BSF </li></ul><ul><li>Whether there is evidence of CSF leakage or not </li></ul><ul><li>Until more research is completed, the effectiveness of antibiotics in patients with BSF cannot be determined </li></ul><ul><li>Studies published to date are flawed by biases. Large, appropriately designed RCTs are needed. </li></ul>
    35. 40. What l learn <ul><li>Antibiotics prophylaxis is not indicated in </li></ul><ul><ul><li>Maxillofacial fracture included zygomatic, maxillary and condyle of mandibule </li></ul></ul><ul><ul><li>Basilar skull fracture with or without CSF leakage </li></ul></ul><ul><li>Antibiotics prophylaxis is indicated in </li></ul><ul><ul><li>Mandibular fracture without condyle </li></ul></ul><ul><ul><li>Open reduction treated </li></ul></ul><ul><li>Drug of choice </li></ul><ul><ul><li>Penicillin G 2 million U q4h iv </li></ul></ul><ul><ul><li>Cefazolin 1 g iv qd </li></ul></ul><ul><li>Duration </li></ul><ul><ul><li>Short term (<48 hr), even “one shot” </li></ul></ul>

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