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Traumatic optic neuropathy is a severe complication of a head or face trauma. Diagnosis is established by analyzing pupillary responses to light. Fundus examination and orbital CT scan help to localize the site of the lesion and may show a fracture involving the optic canal. Surgical decompression or megadose steroids are therapeutic options. No therapeutic approach has proven with sufficient evidence to be effective. Spontaneous improvement is definitely possible. Based on experiences in single cases direct compression of the optic nerve by bone fragments or optic nerve sheath haemorrhage are as a rule treated surgically. In all other cases usually high dose steroids are given without proven effectiveness.

In the case of displacement of the globe such as enophthalmos induced by trauma, the patient is affected on both counts: function and aesthetics. To prevent double vision or conspicuous asymmetry, exact correction of the globe position is required. The aim of this case report is to demonstrate an intraoperative computer-assisted, non-contact, optical 3D procedure for identification of the globe position to aid in placing the eyeball in the position required in complex reconstruction of the orbital floor. A 33-year-old man presented with a sunken eye on the right side in the horizontal and vertical plane 6 months after having undergone surgery elsewhere for a zygomatico-orbital fracture, also including the orbital floor. The patient was affected by double vision and a noticeable defective globe position. In planning the correction of the globe position, a three-dimensional image of the face with opened eyes was made with the optical sensor. Automatic comparison of symmetry revealed enophthalmos of 4 mm on relative en- and exophthalmometry. The decision was made to lift the orbital floor with a split calvarial bone graft. During surgery the position of the globe was also controlled by the three-dimensional optical technique. At the end of surgery there was exophthalmos of 1 mm. Six weeks after surgery the patient was not affected by any double vision. After 3 and 24 months enophthalmos was 1 mm. This case demonstrates how the non-ionizing, non-contact, optical 3D technique can help in planning, intraoperative transformation, and clinical monitoring to identify the correct position of the corneal vertex in complex orbital floor reconstruction.

Blindness is the most serious injury to the eye following a midfacial fracture. The onset of blindness complicating the midfacial fracture may be immediate (with the trauma), delayed (hours to days), or postoperative. The incidence of postoperative blindness lies between 0.3 and 8.3%. There are multiple mechanisms responsible for blindness but the most common reason with about 66% is probably increased intraorbital pressure attributable to intraorbital hemorrhage. The management of surgical decompression of the orbit for acute blindness is essential when treatment of a midfacial fracture is intended. Acute orbital compartment syndrome can effectively be relieved by lateral canthotomy and cantholysis and administration of high doses of corticosteroids. Further possibilities of surgical decompression of the orbit are discussed in this case report with postoperative irreversible blindness after reduction of a malar fracture and rapidly performed surgical decompression.

From the ENT specialist's view, the wearing of piercing jewelry on the outer ear, the tongue, the lips, the nose or the eyebrows is the cause of many and sometimes serious local and also systemic complications. Especially on the outer ear allergic reactions, keloid formation, traumatic tears or embedding of the piece of jewelry can occur in addition to simple, superficial infections or perichondritis. Through specific advice, early detection and treatment of complications, serious health damage to the wearer of piercing jewelry can be avoided.

Injury of salivary gland tissue in the head and neck, as the result of extensive trauma, can often be overlooked on initial examination. In two case reports, the primary treatment and further follow-up of injuries of the head resulting in a parotid-maxillary sinus fistula as well as a fistula between the skin and sublingual gland are illustrated. The successful use of botulinum toxin in the treatment of traumatic salivary gland fistulas is documented in both cases. Alternative diagnostic and treatment measures of salivary gland fistulas are discussed. Surgical repair of salivary fistulas as primary treatment should be carefully considered. Treatment of a salivary fistula with the injection of botulinum toxin is possibly advantageous compared to spontaneous fistula closure. The injection of botulinum toxin shortens fistula closure time, is minimally invasive, effective and tolerable for the patient.

In cases of stab and bite injuries to the face there is a risk of general infection and the necessity for an active and/or passive immunization must be considered by the first treating physician. In Central Europe tetanus, rabies, hepatitis B and C as well as HIV must be taken into account as possible consequences of such injuries. With regard to a tetanus immunization the indication for the post-exposition prophylaxis (PEP) should generally be as wide as possible. For other protective vaccinations a differentiated decision in co-operation with other fields of activity and public health authorities should be realized. The current recommendations for the systemic infections relevant in Central Europe are described.

The increasing distribution and social acceptance of body piercing induced us to investigate the nature and rate of complications brought about by this fashionable injury of the unscathed body. All dentists, maxillofacial surgeons and clinics within the region of the association of dentists of Bremen were asked to register all patients presenting between June and October 1998 in whom piercings of the head and neck area were visible. Response was good; 699 piercings in 273 persons were recorded and some exemplary photographs made. Some 47 persons showed local complications which ranged from keloid formation and temporary infections to cartilage necrosis and disturbances in sensibility. General diseases were described as well, mainly allergies and hepatitis. In accordance with the seriousness of the complication the medical treatment required varied. Nine persons had to be treated in hospital. In 14 cases patients suffered permanent damage. Piercings cause severe complications and considerable expense to the public health service.

Purpose: To analyse the use of transcatheter embolisation., Material and Methods: We report on 43 patients treated by transcatheter embolisation for head and neck haemorrhage from 1987 to 1995. There were 13 patients with idiopathic intractable epistaxis, 6 with iatrogenic and three with traumatic bleeding, 7 patients with bleeding from vascular malformations, 12 patients with haemorrhage from tumours, one ruptured aneurysm of the inferior thyroid artery and one patient bleeding from a retrolingual dystrophic goitre., Results: In 11/13 patients with idiopathic epistaxis, this could be stopped. In 8/9 of the traumatic and iatrogenic bleedings the haemorrhage was treated by embolisation alone. In two cases additional elective surgical interventions were necessary. In 6/7 patients with vascular malformations embolisation resulted in long-lasting periods free from bleeding. Palliative embolisation in bleeding tumours resulted in haemostasis in 10/12 patients. Bleeding was definitely stopped in a patient with aneurysm of the inferior thyroidal artery as well as in a patient with bleeding from a dystrophic goitre. We observed a total of three complications, two transitory neurological disturbances and one permanent amaurosis., Conclusion: Transcatheter embolisation is an effective tool in the treatment of life-threatening head and neck bleedings.

An apparatus to determine normal, traumatic and ontogenic facial asymmetry was developed which scans the mid-face profile three dimensionally, according to the raster principle. Nine horizontal profile lines for the metric and optic comparison of both sides are produced over a computer. The results of the measurements were presented for normal subjects and patients following trauma to the mide-face (total, 100).

In order to evaluate the frequency and indication of tracheotomy in long-term ventilated critically ill patients we analysed retrospectively patients requiring artificial ventilation for periods of more than 7 days. During 1974-75 30 out of 55 of these patients were tracheotomised. In accordance with common practice, early tracheotomy (14 patients) was performed when ventilatory support was expected to exceed 8 to 10 days. In another 16 cases, the same limits were applicable for terminating prolonged tracheal intubation in favour of tracheotomy. In contrast, during the period 1980-81 tracheotomy had been indicated in 8 out of 94 patients. Early tracheotomy was limited to four patients with severe facial injuries accompanied by acute lung failure. The decision to perform tracheotomy or to continue prolonged tracheal intubation was based on definite findings during direct laryngoscopy and fibre bronchoscopy examination of the airways. No late laryngeal sequelae after prolonged tracheal intubation were observed. The risks have been reduced by the use of recently introduced tube materials. Prolonged tracheal intubation has become a safe alternative to tracheotomy.

The most frequent swellings in the maxillofacial region can be traced to odontogenic inflammations. Chronic dental foci exacerbate and break through the soft tissue layer surrounding the jaw. There the purulent material quickly spreads along the muscular pocket and simulates a phlegomonous inflammation. Inflammations of the individual soft part niches have characteristic symptoms. Because of the loose interconnections the infectious material can spread very quickly into the parapharyngeal space and from there downwards into the mediastinum or upwards into the base of the skull. Because of the danger of an advance in these spaces, it will be necessary to incise the swellings on time.

In the mechanism of fracturing in the region of the frontobasis and of the midface there is the possibility of an orbital involvement. If the traumatic forces affect directly the frontal zone we may find a latero-orbitalfrontobasilar fracture--the socalled type IV according to the classification of frontobasilar fractures by Escher. If the middle face is more affected, the type III will result with tearing off the midface bones from the skull at the frontobasis. In a few cases there are indirect blow-out fractures of the orbital roof in communication with frontobasilar fractures especially in the ethmoidal or frontal sinus region. Penetration of foreign bodies through the orbital roof and through the lamina cribriformis cause an open frontobasal cerebral trauma. The problem of the penetrating fronto-orbital traumata is to find the foreign body and to remove it. The danger is the infection with possible development of meningitis or brain abscess. The quota of lesions of the optic nerve in frontobasilar fractures seems to be relatively high. The pathogenesis of optic nerve injury is rather unknown. Mechanisms to be considered are discussed as well as indications and contraindications for a rhinosurgical decompression operation in the optic canal.

The authors describe the diagnosis and operative methods for the treatment of 36 patients which were operated on in the last two years. These patients included 32 with various face fractures, of which 7 had blow-out fractures. In 4 patients the diplopia was caused by injuries to the soft tissues without bony fracture. The examinations comprised x-ray methods and also ophthalmological examinations, especially with the synoptometer. In 24 operated patients, reposition of the bony fragments or autologous bone grafts were done according to the kind of injury present. Although 17 patients were operated on very late (some weeks up to several months after the trauma), in 13 patients (54%) a complete cure could be achieved, and all the other patients showed an improvement. In 3 patients there was only a minor improvement, and it was decided to perform further operations on the extrinsic eye muscles. The authors emphasize the special sense of multi-disciplinary working together in the diagnosis and therapy of patients with face injuries, while this is very important for the success of the treatment.