Biomedical subjects
R B Stanley
Publications and source records attributed to R B Stanley.
Isolated intracranial mucocele.
Intracranial mucoceles have been previously reported as direct extradural extensions of mucoceles of the paranasal sinuses. We describe a patient with 2 silent mucoceles isolated within the parenchyma of the frontal lobe of the brain. The patient had undergone multiple previous intranasal polypectomy and ethmoidectomy procedures, and the unsuspected mucoceles were discovered on a computed tomographic scan obtained to evaluate recurrent rhinosinusitis symptoms. Craniotomy was required for removal of the mucoceles.
Management of displaced lateral orbital wall fractures associated with visual and ocular motility disturbances.
Impacted fractures of the lateral orbital wall are a type of orbital blow-in fracture that may be accompanied by decreased visual acuity and ocular motility limitations. Eleven patients who suffered this injury triad were retrospectively reviewed to determine the nature of the ophthalmologic injuries and the effect of fracture reduction on recovery of ophthalmologic functions. Two patients with decreased visual acuity owing to trauma to the globe recovered to subjective pretrauma levels following surgery. Nine patients were thought to have a traumatic optic neuropathy with varying degrees of visual loss. Patients with an injury to the intraorbital portion of the optic nerve and a presurgical visual acuity of 20/400 or better recovered to subjective pretrauma levels. Those with visual acuity of less than 20/400 or an injury to the intracanalicular portion of the nerve had responses ranging from no improvement to objective improvement with large field defects. Ocular motility improved in all patients, many in the immediate postsurgical period consistent with removal of a mechanical restriction. No patients had worsening of ophthalmologic deficits as a result of manipulation of fracture fragments. Our experience suggests that early surgical intervention facilitates recovery of vision and eye movement. The traumatic optic neuropathy that accompanies this fracture is distinct from the indirect type of optic nerve injury that may respond to steroids, and the ophthalmoplegia is distinct from the usual traumatic superior orbital fissure syndrome that resolves spontaneously. An understanding of the impacted lateral orbital wall fracture and its ophthalmologic implications is essential for any surgeon who desires to manage craniomaxillofacial injuries.
Oculocardiac reflex caused by orbital floor trapdoor fracture: an indication for urgent repair.
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Management of external penetrating injuries into the hypopharyngeal-cervical esophageal funnel.
OBJECTIVE: To compare outcomes related to observation versus exploration for the hypopharynx and the cervical esophagus as the site of proven external penetrating injuries. METHODS: The records of 70 patients (47 with hypopharyngeal and 23 with cervical esophageal wounds) were retrospectively reviewed. RESULTS: No patient, observed or explored, who sustained a penetration into the hypopharynx above the level of the tips of the arytenoid cartilages of the larynx developed a complication. However, 22% of the patients with a hypopharyngeal injury below this level and 39% of patients with a cervical esophageal injury developed either a deep neck infection that required drainage or a postsurgical salivary fistula. CONCLUSIONS: Overall, the consequences of an external penetrating injury become more serious in the descending levels of the funnel formed by the hypopharynx and cervical esophagus. Injuries located in the upper portion of the hypopharynx can be routinely managed without surgical intervention. Neck exploration and adequate drainage of the deep neck spaces are, however, mandatory for all penetrating injuries into the cervical esophagus and most injuries into the lower portion of the hypopharynx.
Intradiploic arachnoid cyst presenting as a frontal sinus mass.
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Management of traumatic hypopharyngeal injuries.
Violation of the hypopharynx by external penetrating trauma is an uncommon occurrence that may lead to life-threatening infectious complications if not recognized promptly and treated appropriately. A retrospective review of 48 such injuries seen during a 10-year period showed that flexible fiberoptic endoscopic examination is the best screening tool for recognition of a possible hypopharyngeal mucosal violation. Direct laryngopharyngoscopy is the best method of definitively diagnosing the injury. Size of the visualized mucosal violation alone is not sufficient information on which to base the decision for medical management versus surgical intervention (i.e., immediate exploration and drainage). Rather, the size, exact site of injury, and mechanism of the injury must be considered to have equal importance. Associated vertebral body fractures may negatively influence acute outcome if diagnosis and treatment of the hypopharyngeal injury are delayed by the cervical spine injury.
Maintenance of temporal fossa contour following anterolateral skull base surgery.
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Motion observed across maxillary continuity defects stabilized with plates and screws.
The stability of fixation obtained with internal fixation devices (plates and screws) under functional loading of maxillary continuity defects was studied using fresh cadaver skulls. Micromotion (deformation) was recorded in the model across the level of the LeFort I osteotomies even when fixation was thought to be grossly stable. Deformation in this biologically static model proved to be mostly elastic in nature, and the amount of deformation in each skull appeared to be predictable from the average stability of all screws used in each plate. Such motion in viable bone could lead to permanent deformation due to resorption and remodeling of bone around the screws if initial overall fixation stability is tenuous. The results suggest that the term "rigid" is inappropriately used to describe plate and screw fixation of maxillary continuity defects.
Diagnosis and management of external penetrating cervical esophageal injuries.
External penetrating injuries of the esophagus are more likely to cause serious morbidity and even mortality than those involving the pharynx. However, the cervical esophagus is extrathoracic in location, and controversy exists regarding the diagnosis and surgical management of penetrating injuries at this level. A retrospective review of 23 such injuries showed that contrast esophagography had only a 62% success rate in identification of cervical esophageal violations, compared to 100% for rigid esophagoscopy. Even large penetrations were successfully treated with limited debridement, primary repair when possible, muscle interposition flaps to separate common injuries of the tracheal wall, and, most important, external drainage of the adjacent neck spaces. Esophageal stricture occurred only when complex esophageal diversion procedures were performed, either as an unnecessary primary operation, or as a lifesaving secondary operation necessitated by infectious complications caused by delayed diagnosis and treatment of the esophageal violation. Penetrating injuries of the cervical esophagus can therefore be managed more as a pharyngeal injury if diagnosis and appropriate surgical treatment occur in a timely fashion.
Treatment of the compromised trachea with sleeve resection and primary repair.
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Dural invasion by craniofacial and calvarial neoplasms: MR imaging and histopathologic evaluation.
The authors prospectively correlated results of magnetic resonance (MR) imaging and histologic examination of the dura in 17 patients with craniofacial and calvarial neoplasms and possible intracranial extension. Contrast material-enhanced MR imaging revealed dural enhancement in 14 patients and no enhancement in three. In four cases, the dura deep to the tumor appeared as a continuous band of enhancement and there was a thin unbroken hypointense zone between the dura and the tumor. Histologic examination in these four patients revealed only dural inflammation without neoplastic spread. In 10 patients, there was a break in the continuity of the enhancement of the underlying dura or a portion of the dura and overlying enhancing tumor could not be separated on MR images. The hypointense zone was focally absent in nine of these cases, and in all 10 there was invasion of the dura by adjacent tumor. Among the other three patients, in whom dural enhancement was not discernible, one had dural invasion by tumor while the other two did not.
Stable internal fixation of fractures of the partially mineralized thyroid cartilage.
Thyroid cartilage fractures due to external blunt trauma have typically been thought to occur in patients over the age of 40. Lack of mineralization of the cartilage has been considered to be the protective mechanism. Our experience with laryngeal injuries has demonstrated that younger persons are indeed at risk for thyroid cartilage fractures, and that these injuries may be easily overlooked. Although these fractures do not lead to laryngeal stenosis if untreated, they may cause noticeable phonatory changes. Fixation of these fractures is difficult because of the usual soft character of the unmineralized cartilage, prompting us to adopt a wire-tube fixation technique. This technique has been uniformly successful in restoring the anatomic contour of the thyroid cartilage, and our results appear to justify open reduction of these moderately displaced or angulated thyroid cartilage fractures.
One-piece reimplantation treatment of the "Humpty Dumpty" frontal bone fracture.
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Management of severe frontobasilar skull fractures.
Immediate reconstruction of severely comminuted frontobasilar skull fractures involving the frontal sinus can be accomplished safely if the sinus is cranialized and the floor of the anterior cranial fossa is totally reconstructed. Operative time can be reduced if the pieces of the frontal bone are reassembled and stabilized with rigid fixation devices out of the surgical field and thus made ready for reinsertion as a single unit after any necessary neurosurgical procedures are completed. Immediate reconstruction provides postoperative protection for the brain and eliminates the need to return the patient to the operating room for cranioplasty at a later date.
Rigid fixation of fractures of the maxillary complex.
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The zygomatic arch as a guide to reconstruction of comminuted malar fractures.
Traditional three-point reduction may not restore proper projection of the malar prominence following a fracture dislocation of the zygoma if two of the three anterior points of realignment are comminuted. In such cases, reconstruction of the fourth or posterior projection, the zygomatic arch, increases the accuracy of the multidimensional reconstruction. Although the extended access approach required to repair the arch increases operative time and possibly length of hospitalization, its use is justified by the improved results in selected patients with severe injuries of the zygoma.
Reconstruction of the anterior skull base following craniofacial resection.
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