Aim: In this study, we aimed to investigate whether ultrasound anatomic measurements of the airway prior to anesthetic administration could be used as a predictive standard for difficult intubation in children undergoing surgery under general anesthesia.

Material and Methods: This observational study included 100 patients with an ASA I-III risk score between the ages of 0-6, whose operation was planned under general anesthesia. Age, height, body weight, Cormack-Lehane Classification and distance from skin to pre-epiglottic space (EPI), distance from skin to thyroid cartilage (TC), distance from skin to the anterior commissure (VCA) of vocal cord, distance from skin to posterior commissure (VCP) of the vocal cord and distance from skin to the hyoid bone (HYO) was recorded. These parameters were studied to examine the relationship between the classification of Cormack-Lehane.

Results: Cormack Lehane classification Grade III and above were determined in 9 (9%) patients. There was a statistically significant relationship between intubation difficulty and distance from skin to the thyroid cartilage.

Discussion: The ultrasound parameters we studied, with the possible exception of TC, which was not compared to any other anatomical, radiological or surface anatomy measurement, are virtually useless in predicting intubation difficulty in 0 – 3 years.

Keywords: Ultrasound, Cormack–Lehane Classification, Pediatric Difficult Intubation

Introduction

In the pediatric population, ‘intubation time’ and ‘airway security’ are critical due to the anatomic and physiologic characteristics. In pediatrics, a smaller lung volume, and functional residual capacity in particular, considerably reduce apnea tolerance. Despite optimal preoxygenation of sufficient duration to prevent desaturation in children, no “safety period” can be established even for short-lasting apnea events [1,2].Although measurement of anatomic structures and various scoring systems can be used, the Cormack–Lehane (CL) classification system has proven to be the best method for describing difficult intubation. CL classification has therefore become a standard for the investigational description of difficult laryngoscopy in anesthesia [3-5]. But although it is the standard for describing difficult intubation, it cannot be used in the preoperative evaluation as it is too invasive for a conscious patient [6].
Airway assessment by ultrasound is an important non-invasive, cost-effective, and instructive method. Although it has not yet been established as a standard method for assessing the airway of patients, it has great potential in the prediction of difficult airway [7]. However, there is a paucity of information focusing specifically on such methods in pediatric population where equipment, technique, and challenges are different [8].
In the present study, the aim was to investigate whether ultrasound anatomic measurement of the airway prior to anesthetic administration could be used as a predictive standard for difficult intubation in children undergoing surgery under general anesthesia.

Material and Methods

The study was conducted after obtaining written informed consent from the parents after the approval of the local ethics committee (2019/463) and in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki revised in the year 2000.
A total of 100 patients who were aged 0–6 years, included in ASA (American Society of Anesthesiologists) classification groups I–III, and scheduled for endotracheal intubation under general anesthesia prior to elective surgery were included in the study. Patients without parental consent, with significant airway malformations, with head and neck deformities were excluded from the study. All tests and endotracheal intubation attempts in the study were performed by the same surgeon with four years of experience.
Demographic characteristics recorded in the preoperative evaluation were age, sex, body weight, weight percentile, height, and body mass index (BMI). For all patients whose difficult intubation was assessed with CL classification and ultrasound, the distances between the pre-epiglottic space and the skin (EPI), between the thyroid cartilage and the skin (TC), between the anterior commissure of the vocal cord and the skin (VCA), between the posterior commissure of the vocal cord and the skin (VCP), and between the hyoid bone and skin (HYO) were measured in centimeters. Ultrasound examinations were performed using a GE LOGIQ e (GE Healthcare, USA) ultrasound scanner.
Midazolam at a dose of 0.02 mg/kg was administered intravenously to all patients as premedication before surgery. After the patient was taken to the operating room, standard monitoring (ECG, pulse oximetry, non-invasive arterial blood pressure) was performed. During induction, bolus doses of 0.5–1 µg/kg of fentanyl and 1-2 mg/kg of propofol were administered intravenously. After establishing that the patient was able to be ventilated with an appropriate mask, rocuronium was administered intravenously at 0.6 mg/kg in order to induce muscle relaxation. Laryngoscopy was initiated 2–3 minutes after the administration of rocuronium.
Under ventilation with a mask, the neck was brought into extension for measurement. A hockey stick probe (8–16 MHz) placed transversely in the submandibular region of the patient was moved in the transverse plane from cranial to caudal without changing its position. Distances between the hyoid bone and the skin (HYO), between the pre-epiglottic space and the skin (EPI), between the thyroid cartilage and the skin (TC), between the anterior commissure of the vocal cord and the skin (VCA), and between the posterior commissure of the vocal cord and the skin (VCP) were measured in centimeters and recorded.
Direct laryngoscopy was performed with Macintosh blades 0, 1, or 2. The condition of the vocal cords was assessed through their laryngoscopic appearance using CL classification. Patients were intubated and any complications during laryngoscopy were recorded.
In accordance with the CL classification system, if the glottis was completely visible, the patient was evaluated as grade I; if it was partially visible, they were evaluated as grade II; if only the epiglottis was visible, they were evaluated as grade III; and if even the epiglottis was not visible, they were evaluated as grade IV. Intubation was considered difficult if the CL test was grade III and IV despite appropriate head and neck position and the use of a laryngoscope blade.

Statistical analysis

The IBM SPSS Statistics 22 (IBM SPSS, Turkey) program was used for statistical analysis. The G Power program was used for power analysis. The conformity of numerical variables with the normal distribution was examined using the Shapiro-Wilk test. In the analysis of the study data, in addition to descriptive statistical methods (mean, standard deviation, median, frequency), the Student’s t-test was used to compare normally distributed parameters between two groups, while the Mann-Whitney U test was used to compare non-normally distributed parameters between two groups. When comparing three independent groups, an ANOVA test was used for normally distributed numeric variables, while the Kruskal-Wallis and Dunn’s tests were used for non-normally distributed variables. ROC analysis was performed to determine the threshold for significant levels. The MedCalc package program version 19.2.1 was used for ROC analysis. A p-value of less than 0.05 was accepted as significant.

Ethical Approval

Ethics Committee approval for the study was obtained.

Results

The study was conducted on 100 patients aged 0 to 6 years, including 68 (68%) boys and 32 (32%) girls. Of the patients with difficult intubation, seven (77.8%) were male and two (22.2%) were female. Sixty patients were classified as being ASA I (60%), 30 as ASA II (30%), and 10 as ASA III (10%). The C–L classification was grade I in 34 cases, grade II in 57 cases, and grade III in nine cases. There were no grade IV cases. As grades III and IV were considered difficult intubation, difficult intubation was noted in nine patients (9%), while there was no unsuccessful intubation.
The mean age of the patients was 2.1±1.44 years, mean body weight was 11.72±4.56 kg, mean height was 86.62±17.92 cm, and weight percentile was 41.96±28.95. Two of the cases were in the 3% percentile (1.9%), 12 were in the 5% percentile (11.5%), 12 were in the 10% percentile (11.5%), four were in the 15% percentile (3.8%), 16 were in the 25% percentile (15.4%), 26 of them were in the 50% percentile (25%), 14 of them were in the 75% percentile (13.5%), 12 were in the 85% percentile (11.5%), and two were in the 90% percentile (1.9%).
In the study parameters of the cases, VCA was determined as 0.49±0.06 cm, VCP as 1.41±0.17 cm, HYO as 0.54±0.11 cm, TC as 0.42±0.09 cm, and EPI as 1.9±0.22 cm, as the mean values of measurement. When we compared them, evaluated these parameters against one another in ratios, the mean value of VCA/VCP was 0.35±0.05, EPI/VCA was 3.93±0.46, and EPI/VCP was 1.36±0.46 (Table 1).
The mean age of the patients with difficult intubation was 1.88±1.22 years, the mean body weight was 10.83±4.16 kg, the mean height was 83.22±16.99 cm, and the weight percentile was 28.89±17.09.
In accordance with their CL classification, the cases were divided into two groups: difficult and simple intubation. There was no statistically significant relationship between intubation difficulty and VCA, VCP, HYO, EPI, EPI/VCP ratio, and EPI/VCA ratio (p>0.05). There was a statistically significant relationship between intubation difficulty and TC (p<0.05). There was a statistically significant relationship between intubation difficulty and VCA/VCP ratio (p<0.05) (Table 2).
The statistical sensitivity of TC was 77.78%, its specificity was 72.53%, and its cut-off value was 0.38 cm. The statistical sensitivity of the VCA/VCP ratio was 66.67%, its specificity was 82.42%, and its cut-off value was 0.31 cm (Figure 1).

Discussion

The aim of the present study was to investigate whether ultrasound anatomic measurement of the airway prior to anesthetic administration could be used as a predictive standard for difficult intubation in children undergoing surgery under general anesthesia.
Skilled airway management is the cornerstone of high-quality anesthesia management. Airway complications remain a common cause of anesthesia-related complications in children because of their unique anatomy and physiology [9]. In a retrospective study of 11,219 pediatric patients undergoing general anesthesia with endotracheal intubation, the rate of difficult direct laryngoscopy (CL grades III and IV) was 1.35%. The rate of direct difficult laryngoscopy was highest in children younger than 1 year old (0.7% in children older than 1 year vs. 4.7% in children younger than 1 year). Other predictors of difficult intubation were being classified as ASA III or IV, having a higher Mallampati score (if available), a lower body mass index, and a history of oromaxillofacial or cardiac surgery [10]. Valois-Gomez et al. reported that the incidence of intubation difficulty was 1.2% in a sample of 484 children aged 0 to 8 years [11]. In a prospective multicentre study by Fiadjoe et al., difficult tracheal intubation occurred in 2–5 per 1000 pediatric anesthesia cases [12].
Many different airway measurements have been used to predict difficult laryngoscopy in children. In a study on the airway of children younger than 5 years undergoing cardiac catheterization, it was concluded that body mass index, lower lip-to-chin distance (LCD), and thyromental distance (TMD) could be used to predict difficult laryngoscopic view. In the same study, the incidence of difficulty in viewing the larynx was 4% [13]. However, our study found a higher rate than these studies, with an incidence of 9% for difficulty in viewing the larynx.
It is critical to assess and recognize the potential for difficult airway prior to any procedure so that appropriate equipment and resources are available. For this reason, it has been emphasized that the relationship between various sonographic parameters and difficult airway should be investigated using point-of-care ultrasound (POCUS) for airway evaluation [14].Ultrasound has many advantages in upper airway imaging; it is safe, fast, portable, and accessible. It provides real-time static and dynamic images of various clinical indications of airway management [15].
In a study on 130 adult patients, Parameswari et al [16]. found that an ultrasonographically-measured distance between the epiglottis and the skin, based on CL classification, was the most sensitive (75% sensitivity) and the most specific (63.6% specificity) parameter in predicting difficult laryngoscopy. In a study on 301 patients, Falcetta et al [17] measured anterior cervical soft tissue thickness with ultrasound at two levels (thyrohyoid membrane [epiglottic area] and vocal cords [entry of the larynx]) on adult patients and found a high correlation between pre-epiglottic tissue thickness at the level of the thyrohyoid membrane and CL classification in predicting limited/difficult intubation. The fact that we have not come across any significant findings in the epiglottis region can be explained by the fact that our study was performed on pediatric patients.
In a pilot study conducted with 51 adult patients, Adhikari et al. [18] demonstrated that sonographic measurements of anterior neck soft tissue thickness at the level of the hyoid bone and thyrohyoid membrane can be used to discriminate between difficult and easy laryngoscopy, by comparing the anterior neck soft tissue thickness measured at the level of the hyoid bone and thyrohyoid membrane against CL classification. The present study demonstrated a statistically significant correlation between the difficulty of intubation and the distance between the thyroid cartilage and the skin.
In their study on 72 patients, Gupta et al. [19] found that the PES/EVC (pre-epiglottic space/distance between the epiglottis and the vocal cord) value was positively correlated with CL classification. In a study conducted with 100 patients, Reddy et al [3] showed that when measurements are taken using ultrasonography and based on CL classification, the PES/EVC value has a low-to-moderate predictive value in predicting difficult intubation. The sensitivity of the PES/EVC value was 1.2%, its specificity was 86.7%, its positive predictive value was 33.3, and its negative predictive value was 13.4%. There was a statistically significant relationship between intubation difficulty and the VCA/VCP ratio in this present study. However, we believe that there is room for more studies in this field as the results and anthropometric measurements of ultrasound studies are influenced by various parameters such as race and geography.

Conclusion

In this present study, TC and the VCA/VCP ratio were found to have a statistically significant relationship with CL classification. However, due to the multiple anatomic factors involved in difficult intubation and the lack of an ideal prediction test, an unexpectedly difficult airway should always be considered. Radiographic examination of the anatomy of the region, a method which has recently gained importance, can help predict difficult intubation during physical examination. The ultrasound parameters we studied, with the possible exception of TC, which was not compared to any other anatomical, radiological or surface anatomy measurement, are virtually useless in predicting intubation difficulty in 0 – 3 years.

Scientific Responsibility Statement

The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.

Animal and human rights statement

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.

Funding: None

Conflict of interest

None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.

References

1. Hsu G, von Ungern-Sternberg BS, Engelhardt T. Pediatric airway management. Curr Opin Anaesthesiol. 2021;34(3):276-83.
2. Hardman JG, Wills JS. The development of hypoxaemia during apnea in children: a computational modelling investigation. Br J Anaesth. 2006; 97(4):564–70.
3. Reddy PB, Punetha P, Chalam KS. Ultrasonography – A viable tool for airway assessment. Indian J Anaesth. 2016; 60(11):807-13.
4. Cook TM. A new practical classification of laryngeal view. Anaesthesia. 2000;55(3):274–9.
5. Law JA, Broemling N, Cooper RM, Drolet P, Duggan LV, Griesdale DE, et al. The difficult airway with recommendations for management—part 2: the anticipated difficult airway. Can J Anesth. 2013;60(11):1119–38.
6. Ghatge S, Hagberg CA, editors. Does the airway examination predict difficult intubation? Philadelphia: W.B. Saunders; 2009. p.101–15.
7. Daniel SJ, Bertolozio G, McHugh T. Airway ultrasound: Point of care in children-The time is now. Paediatr Anaesth. 2020;30(3):347-52.
8. Stafrace S, Engelhardt T, Teoh WH, Kristensen MS. Essential ultrasound techniques of the pediatric airway. Paediatr Anaesth. 2016; 26(2):122-31.
9. Habre W, Disma N, Virag K, Becke K, Hansen TG, Jöhr M, et al. Incidence of severe critical events in paediatric anesthesia (APRICOT): a prospective multicentre observational study in 261 hospitals in Europe. Lancet Respir Med. 2017;5(5):412-25.
10. Heinrich S, Birkholz T, Ihmsen H, Irouschek A, Ackermann A, Schmidt J. Incidence and predictors of difficult laryngoscopy in 11,219 pediatric anesthesia procedures. Paediatr Anaesth. 2012;22(8):729-36.
11. Valois-Gomez T, Oofuvong M, Auer G, Coffin D, Loetwiriyakul W, Correa JA. Incidence of difficult bag-mask ventilation in children: a prospective observational study. Paediatr Anesth. 2013; 23(10):920-6.
12. Fiadjoe JE, Nishisaki A, Jagannathan N, Hunyady AI, Greenberg RS, Reynolds PI, et al. Airway management complications in children with difficult tracheal intubation from the Pediatric Difficult Intubation (PeDI) registry: a prospective cohort analysis. Lancet Respir Med. 2016;4(1):37-48.
13. Maddali MM, Ali Al-Zaabi HM, Salim Al-Aamri IS, Arora NR, Panchatcharam SM. Preoperative predictors of poor laryngoscope views in pediatric population undergoing cardiac catheterization. Ann Card Anaesth. 2018;21(4):376-81.
14. Gottlieb M, Holladay D, Burns KM, Nakitende D, Bailitz J. Ultrasound for airway management: An evidence-based review for the emergency clinician. Am J Emerg Med. 2020;38(5):1007-13.
15. You-Ten KE, Siddiqui N, Teoh WH, Kristensen MS. Point-of-care ultrasound (POCUS) of the upper airway. Can J Anaesth. 2018;65(4):473-84.
16. Parameswari A, Govind M, Vakamudi M. Correlation between preoperative ultrasonographic airway assessment and laryngoscopic view in adult patients: A prospective study. J Anaesthesiol Clin Pharmacol. 2017;33(3):353-8.
17. Falcetta S, Cavallo S, Gabbanelli V, Pelaia P, Sorbello M, Zdravkovic I, et al. Evaluation of two neck ultrasound measurements as predictors of difficult direct laryngoscopy: A prospective observational study. Eur J Anaesthesiol. 2018;35(8):605-12.
18. Adhikari S, Zeger W, Schmier C, Crum T, Craven A, Frrokaj I, et al. Pilot study to determine the utility of point-of-care ultrasound in the assessment of difficult laryngoscopy. Acad Emerg Med. 2011;18 (7):754-8.
19. Gupta D, Srirajakalidindi A, Ittiara B, Apple L, Toshniwal G, Haber H. Ultrasonographic modification of Cormack Lehane classification for pre-anesthetic airway assessment. Middle East J Anaesthesiol. 2012;21(6):835-42.

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Mustafa Emrah Yüksek, Lütfiye Pirbudak, Elzem Sen, Mehmet Mustafa Anlaş. The use of ultrasound in the assessment of difficult laryngoscopy in children. Ann Clin Anal Med 2023;14(6):507-511

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Aim: Maxillofacial trauma (MFT) is one of the most common causes of trauma-related admissions to the emergency department (AS). The aim of this study is to determine the etiological, clinical and demographic characteristics, morbidity and mortality rates of MFT cases admitted to the emergency department.

Material and Methods: Patients aged 18 years and older who underwent maxillofacial (MF) imaging with computed tomography (CT) were included in this retrospective cross-sectional study. The aim of this study is to determine the most common injuries in MFT cases and their relationship with the trauma mechanism. In addition, surgical intervention, morbidity and mortality rates were calculated.

Results: Of the 458 cases included in the study, 72% were male. The most common trauma mechanisms are assault (41%) and fall (32%), respectively. The most frequently injured tissues and organs were soft tissues (42%) is nasal cartilage (21%). It was found that the risk of intracranial pathology increased 23.5 times in patients with frontal bone fractures compared to those without.

Discussion: MFT traumas are important both cosmetically and because surgical intervention cannot be performed everywhere. We should pay attention to the early diagnosis and treatment of frontal bone fractures, which are the most common causes of trauma depending on years and state policies. Future studies will provide clearer data on this subject.

Keywords: Maxillofacial Trauma, Emergency Department, Etiology

Introduction

Maxillofacial trauma (MFT) is one of the most common causes of trauma-related admissions to the emergency department [1,2]. Traffic accidents, beatings, falls and contact sports are the most common causes of maxillofacial trauma [3–6], and the male population is more frequently exposed to MFT [7] .
The head and neck region contains many structures necessary for life that perform complex functions such as speech, vision, swallowing and smell, and has a great aesthetic importance [8]. Emergency physicians should be careful in terms of other accompanying major traumas and complications that may occur in the management of patients with MFT. Deficiencies in the diagnosis and treatment of facial fractures can cause deformity, chewing difficulties, paresthesia, visual disturbances, and death [8–11]. The vascularization of the facial area is intense, and arterial bleeding can quickly result in massive blood loss. Segmented fractures may cause airway obstruction, orbital traumas may cause extraocular muscle squeezing, ischemia, and permanent vision loss [12]. Apart from the medical complications that may occur in acute and chronic periods, severe mental state disorders can also be observed [13,14]. Early evaluation and intervention in MFT can significantly reduce morbidity and mortality [6].
The aim of this study is to determine the etiological, clinical and demographic characteristics, morbidity and mortality rates of MFT cases admitted to the emergency department.

Material and Methods

Study design and settings

This retrospective cross-sectional study was carried out in the emergency clinic of a third-level hospital in the province of Izmir in western Turkey. After obtaining approval from the local ethics committee (Decision No: 0216 Date: 21/04/2022), patients who applied to the adult emergency service with 35-40 thousand trauma patients annually between ‘June 1 – September 30, 2021’ due to MFT were analyzed retrospectively.

Study population

Among the patients admitted to the emergency department due to trauma, patients aged 18 years and older who underwent maxillofacial (MF) imaging with computed tomography (CT) were included in the study. Non-traumatic cases and patients with missing data were excluded from the study. A total of 458 cases were included in the study.

Data collection and processing

Age, gender, type of trauma, injured tissues, organs and bones, need for surgical intervention, developing complications, accompanying intracranial or cervical injury, morbidity, hospitalization and patient outcomes were analyzed from the medical records of the cases. Trauma mechanisms included motor vehicle accidents, assaults, falls, gunshot injuries, and others. Injured tissues and organs included eye-eyelids, tear ducts, nasal cartilage, facial nerve and soft tissues, and bone structures, orbital, nasal, maxilla, mandible, zygoma and frontal bone. It was recorded whether airway obstruction, septal hematoma, bleeding, soft tissue infection and meningitis developed as complications.

Outcome measures

This study aims to determine the most common injuries in MFT cases and their relationship with the trauma mechanism. In addition, surgical intervention, morbidity and mortality rates were calculated.

Data analysis

IBM SPSS Statistics 28 (SPSS Inc., Chicago, USA) program was used for data analysis. Descriptive statistics are presented with frequency, percentage, mean and standard deviation values. Whether the data conformed to the normal distribution was evaluated using the Shapiro-Wilk test, skewness- kurtosis values, and Q-Q plots. Univariate regression analysis was performed to determine the relationship between the type of bone fracture as a result of maxillofacial trauma and surgical intervention and intracranial pathology. All parameters found to be statistically significant in Univariate regression analysis were evaluated in multinomial logistic regression analysis. A p-value of <0.05 was considered significant. All statistics were done at a 95% confidence interval.

Ethical Approval

Ethics Committee approval for the study was obtained.

Results

Of the 458 cases included in the study, 72% (n=328) were male. The mean age of men (40±17) was lower than women (48±23), and there was a statistically significant difference between them (p<0.001). The most common trauma mechanisms were assault (41%), falls (32%) and motor vehicle accidents (17%). Age and trauma mechanisms by gender are presented in Table 1. The most frequently injured tissues and organs were soft tissue (42%), nasal cartilage (21%), and eye-eyelid (13%), the most common fractures of the bones were nasal (50%), maxillary (25%), and orbital (24%). Surgical intervention was performed in 18% of the cases. In addition, 8.7% of the cases had intracranial pathology and 2.2% had cervical spine pathology. The most common complications were bleeding (19%) and septal hematoma (5.2%). Although soft tissue infection occurred in 2.2% of the cases, meningitis did not develop in any of them. Among other complications, airway obstruction was seen in 5 (1.1%) cases, and facial nerve damage was seen in 2 (0.4%) cases. Loss of function developed in 58 (13%) cases, and cosmetic damage remained in 167 (36%) cases. The hospitalization rate was 11%, the intensive care unit admission rate was 3.5%, and the mortality rate was 0.4%. Tissue, organ and bone types injured due to MFT, accompanying pathology, complications, treatment and morbidity rates are shown in Table 2.
The relationship between fractured bone type and surgical intervention and intracranial pathology was investigated. Univariate regression analysis revealed a statistically significant relationship between all bone fractures and surgical intervention. However, in the multinomial logistic regression analysis, frontal, zygoma, and maxilla fractures were found to be confounding factors. It was found that the surgical risk increased 3 times in those with mandibular fractures, 2.5 times in those with orbital fractures, and 1.9 times in those with nasal fractures. The results of the multinomial logistic regression analysis are presented in Table 3. When the relationship between intracranial pathology and bone fractures was examined, it was seen that there was a statistically significant relationship with orbita, maxilla, zygoma and frontal bone fractures according to univariate regression analysis. No significant relationship was found with nasal and mandible fractures. Orbital, maxilla and zygoma fractures were found to be confounding factors in the multilogistic regression analysis. It was found that the risk of intracranial pathology increased 23.5 times in patients with frontal bone fractures compared to those without (Table 3).

Discussion

As in the world, the most common cause of young deaths in our country is traffic accidents, assault, etc., judicial events. Since we are the only public institution in our city for emergency response related to maxillofacial trauma, patients in this category come to our hospital from all districts.
İrkören et al. [15] and studies in the literature [1,3,12] show parallelism with the gender analysis of patients who applied to the emergency department of our hospital with MFT. Applications of male patients were 2.5 times higher than those of females. In the evaluation made for the trauma mechanism for MFT, dominance is often observed in those who come with the complaint of beating. Although MFTs due to falling with the second frequency are common, the difference in the male-female ratio is preserved in all species.
Unlike the results of our study, Şimşek et al., in their study conducted in 2020, reported that the most common reason for patients presenting with MFT was falling, and the second most common cause was assault [16]. The most important reason why the data differed from our study may be that the geographical location of the province where the hospital is located is in a mountainous area. In support of this idea, the demographic data and trauma types of the nasal USG study performed by Çağlar et al. [17] in patients with maxillofacial trauma and the data of our study can be shown.
Bamjee et al. [18] , Schaftenaar et al. [19] , Erol et al. [20] reported in the data of their studies that the most common reason for application of patients with MFT was traffic accidents, followed by applications after assault. This situation differs from our study. Seasonally, this study also shows that the incidence of MFT cases is higher in summer remains statistically similar. The change in trauma types can be considered a result of the increase in the frequency of traffic controls in our country. This suggests that the socio-economic decline in the country is inversely proportional to the increase in battering incidents.
In the evaluation made among the types of broken bones in MFT, in accordance with the literature [21], it was found that nasal bone fracture was most oftenobserved. Secondly, maxilla fracture is frequently observed, and the third is the accompanying orbital fracture. As can be expected, bone fractures also change with the change in the frequency of trauma type. Although in previous studies, mandible fractures were most frequently detected in the 1st or 2nd row , which were most commonly seen in traffic accidents, more minor bone fractures were observed in our study.
Considering that 1 out of 5 maxillofacial trauma patients underwent surgical intervention, MFTs constitute an important workload for hospitals. The most surgically risky bone fractures are nasal, mandible and orbital bones. These results are similar to DeAngelis et al. [22]
Although frontal bone fractures are less common, they are the most risky condition for intracranial pathologies accompanying maxillofacial fractures. From an anatomical point of view, this is the expected result.

Conclusion

MFT traumas are important both cosmetically and because surgical intervention cannot be performed everywhere. We should pay attention to the early diagnosis and treatment of frontal bone fractures, which are the most common causes of trauma depending on years and state policies. Future studies will provide clearer data on this subject.

Limitations

This study was retrospective and determined for the presence of cosmetic damage, and the data were taken from the patient file, consultation and surgery notes. No face-to-face interviews were conducted with the patients. In addition, the high number of patients were referred to our hospital from another center.

Acknowledgment

We would like to thanks Dr. Fatih Esad Topal for his contributions to the study and also to Dr. Hüseyin Acar for his support in the development of our statistical analysis.

Scientific Responsibility Statement

The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.

Animal and human rights statement

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.

Funding: None

Conflict of interest

None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.

References

1. Trivedy C, Kodate N, Ross A, Al-Rawi H, Jaiganesh T, Harris T, et al. The attitudes and awareness of emergency department (ED) physicians towards the management of common dentofacial emergencies: Dentofacial Emergencies in the ED. Dental Traumatology. 2012;28(2):121-6.
2. Patel KK. Dental knowledge of accident and emergency senior house officers. Emerg Med J. 2002;19(6):539-41.
3. Al-Qamachi LH, Laverick S, Jones DC. A clinico-demographic analysis of maxillofacial trauma in the elderly: Elderly, maxillofacial trauma, fall. Gerodontology. 2012;29(2):e147-9.
4. Van den Bergh B, Karagozoglu KH, Heymans MW, Forouzanfar T. Aetiology and incidence of maxillofacial trauma in Amsterdam: A retrospective analysis of 579 patients. J Craniomaxillofac Surg. 2012;40(6):e165-9.
5. Muñante-Cárdenas JL, Olate S, Asprino L, de Albergaria Barbosa JR, de Moraes M, Moreira RWF. Pattern and Treatment of Facial Trauma in Pediatric and Adolescent Patients. J Craniofac Surg. 2011;22(4):1251-5.
6. Eng J, Sivam S. General Overview of the Facial Trauma Evaluation. Facial Plast Surg Clin North Am. 2022;30(1):1-9.
7. Einy S, Goldman S, Radomislensky I, Israel Trauma Group (ITG), Bodas M, Peleg K. Maxillofacial trauma following road accidents-An 11-year multi-center study in Israel. Dent Traumatol. 2021;37(3):407-13.
8. Girotto JA, MacKenzie E, Fowler C, Redett R, Robertson B, Manson PN. Long-Term Physical Impairment and Functional Outcomes after Complex Facial Fractures. Plast Reconstr Surg. 2001;108(2):312-27.
9. Dancey A, Perry M, Silva DC. Blindness after Blunt Facial Trauma: Are There Any Clinical Clues to Early Recognition? J Trauma. 2005;58(2):328-35.
10. Kishore J, Vatsa R, Singh J, Kumari M, Kumar T, Bandgar S. Psychological Impact on Maxillofacial Trauma Patients – An Observational Study. J Med Life. 2020;13(4):458-62.
11. Sen P, Ross N, Rogers S. Recovering maxillofacial trauma patients: the hidden problems. J Wound Care. 2001;10(3):53-7.
12. DeAngelis AF, Barrowman RA, Harrod R, Nastri AL. Review article: Maxillofacial emergencies: Maxillofacial trauma: Maxillofacial Trauma. Emerg Med Australas. 2014;26(6):530-7.
13. Gönüllü H, Karadaş S, Işık D, Koçak ÖF, Tekin H. Maxillofacial trauma cases appliying to an emergency service: A restrospective study. Bir acil servise başvuran maksillofasiyal travma olguları: Retrospektif bir çalişma. Turk Plastik, Rekonstruktif ve Estetik Cerrahi Dergisi/ Turkish Journal of Plastic, Reconstructive and Aesthetic Surgery. 2011;19(3):121-4.
14. Altay S, Payza U, Erdoğan N, Uluç M. Frequency of Maxillofacial Injuries and Accompanying Types of Maxillofacial Fractures. Acıbadem Üniversitesi Sağlık Bilimleri Dergisi/ Acibadem University Journal of Health Sciences. 2021; 12(4):720-4.
15. İrkören S, Sivrioğlu N, Bulut B, Sonel A, Ceylan E. Üç yıl içinde opere edilen 63 mandibula fraktürü olgusunun retrospektif analizi (Retrospective analysis of 63 cases of mandibular fracture operated within three years). Adnan Menderes Üniversitesi Tıp Fakültesi Dergisi/ Adnan Menderes University Faculty of Medicine Journal. 2011;12(3):1-4.
16. Şimşek T, Avcı S, Erdoğan M. Acil servise maksillofasiyal travma ile başvuran hastaların demografik özellikleri ve travma etiyolojisi (Demographic characteristics and trauma etiology of patients admitted to the emergency department with maxillofacial trauma). Anadolu Güncel Tıp Dergisi/ Anatolian Journal of Contemporary Medicine. 2020; 2 (4): 99-104.
17. Caglar B, Serin S, Akay S, Yilmaz G, Torun A, Adıbelli Z H, et al. The accuracy of bedside USG in the diagnosis of nasal fractures. Am J Emerg Med. 2017; 35(11): 1653-6.
18. Jung TK, De Silva HL, Konthasingha PP, Tong DC. Trends in paediatric maxillofacial trauma presenting to Dunedin Hospital, 2006 to 2012. N Z Dent J. 2015;111(2):76-9.
19. Schaftenaar E, Bastiaens GJ, Simon EN, Merkx MA. Presentation and management of maxillofacial trauma in Dar es Salaam, Tanzania. East Afr Med J. 2009; 86(6): 254-8.
20. Luciana L, Oggy BAR, Wiargitha IK, Irawan H. Management of Maxillofacial Fracture: Experience of Emergency and Trauma Acute Care Surgery Department of Sanglah General Hospital Denpasar Bali. Open Access Maced J Med Sci. 2019;7(19):3245-8.
21. Hwang K, You SH. Analysis of facial bone fractures: An 11-year study of 2,094 patients. Indian J Plast Surg. 2010; 43(1): 42-8.
22. DeAngelis AF, Barrowman RA, Harrod R, Nastri AL. Review article: Maxillofacial emergencies: Maxillofacial trauma. Emerg Med Australas. 2014; 26(6):530-7.

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Cüneyt Arıkan, Ejder Saylav Bora. Etiological changes of maxillofacial trauma admitted to the emergency department. Ann Clin Anal Med 2023;14(6):517-520

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