Actor Zac Efron Broke His Jaw

Image by Liam Mendes from Wikipedia

This past weekend, actor Zac Efron slipped in a puddle of water outside his home and fell resulting in a severe facial cut as well as a broken jaw. [link]

Unlike most facial fractures that do NOT require any surgical intervention, most jaw fractures do need to be surgically repaired and typically entail wiring the jaw shut. Often, a metal plate with screws will be utilized to stabilize the fracture as well.

The reason the jaw is wired shut is so that as the broken bone heals, it heals in such a way that the way the teeth comes together is normal (in essence, the teeth act as the cast for the jaw fracture). Of course, eating is limited to liquid diet and dental care is important as brushing the teeth thoroughly will be impossible.

The wires holding the jaw shut can be removed after a few weeks, but exact duration depends on the fracture location and severity.

Source:
Zac Efron broke his jaw this weekend. CNN 11/13/13

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Lawsuit Alleges Transcranial Magnetic Stimulation Paralyzed Patient's Face

University of Iowa Hospitals and Clinics is being sued by a patient who underwent an experimental transcranial magnetic stimulation (TMS) therapy which allegedly caused a facial paralysis which was than negligently treated. The trial is scheduled for Oct 13, 2013. [link]

Briefly, the patient in 2008 underwent experimental TMS to treat constipation and incontinence. TMS is a noninvasive method to cause depolarization or hyperpolarization in the neurons of the brain using pulses of electromagnetic induction through the scalp. Researchers were hoping to learn more about the nerve connections between the brain and the rectum and how biofeedback training may affect them.

Unfortunately, the patient contended that the treatment gave her a severe headache and by the next day, a facial paralysis. She went to the emergency room and was given an anti-viral antibiotic to take, but no steroids.

Her facial paralysis worsened and she ultimately underwent facial nerve decompression surgery 12 days later which helped with her taste loss, but not her facial paralysis.

The lawsuit contends that:
1) The patient was not informed of the risks of TMS as it relates to facial paralysis
2) Steroids should have been prescribed and the patient immediately referred for nerve decompression surgery

Does TMS carry a risk of facial paralysis?

I honestly do not know much about TMS, but I can certainly state that I've never heard of TMS causing or carrying a risk of facial paralysis. In fact, TMS is used to evaluate facial paralysis by being able to assess the integrity of the facial nerve as well as predict its potential for regeneration after injury [link].

Hypothetically, could TMS cause cranial nerve injury and swelling leading to facial paralysis??? I suppose so, but will defer to people more knowledgeable than I to answer this question.

The timing is certainly suspicious in this case with paralysis occurring within 24 hours of TMS.

But if it can, it certainly is worth a published case report.

Even more importantly, patients who are currently undergoing TMS to evaluate their facial paralysis now need to be warned of the risk that the TMS test itself may make their facial paralysis even worse!!!

What about steroids?

Although some may consider medical management of facial paralysis still controversial, I personally feel that steroids SHOULD have been immediately prescribed without any anti-virals.

The current preponderance of evidence is that anti-virals make absolutely no difference in the treatment of facial paralysis... even when the facial paralysis is due to a virus [link].  I personally do not prescribe anti-virals for patients with facial paralysis regardless of etiology.

What about steroids? Moderate quality evidence show that steroids were significantly more likely than anti-virals to produce complete recovery [link #1; link #2]. I always prescribe steroids to treat facial paralysis.

What about facial nerve decompression surgery?

Now surgical decompression of the facial nerve can be considered controversial. Decompression entails removing part of the skull, moving the brain to one side slightly, and removing all bone covering the facial nerve.

The theory being that if the facial nerve is swollen as it courses through the skull from the brain to the face, strangulation followed by nerve death occurs. To use an analogy, if a finger starts to swell from trauma, a ring being worn may prevent blood flow and eventually cause strangulation of the finger. Treatment to reestablish finger blood flow is to cut the ring off. Facial nerve decompression is akin to cutting a ring off to save a swollen finger.

Typically, surgical decompression of the facial nerve is pursued when facial paralysis occurs in the context of physical head trauma (ie, car accident). In the absence of preceding physical trauma, it would be the rare surgeon who would recommend surgical facial nerve decompression.

Obviously, the main question related to this lawsuit is whether nerve swelling occurred due to the TMS therapy necessitating surgical decompression. Presumably, an MRI scan was performed showing a highly inflamed and swollen facial nerve as well as significant nerve degeneration on ENoG testing. Supporting evidence (not mentioned in media reports) would be if profound hearing loss also occurred. Why? Because the facial nerve and hearing nerve both go through the same boney canal.

Malpractice?

TMS is not known to cause facial paralysis. As such, in a normal situation, this particular risk would not be expected to be included in the consent (as it has not been previously described). However, given this therapy was provided in the context of an experimental research protocol, the consent process is much more rigorous with much higher standards. With such higher standards, should risks never before seen be also included in the consent, especially if TMS has been performed many times for other purposes??? I don't know...

Certainly, my feeling as an ENT specialist is that steroids should have been given and not an anti-viral medication. Whether ENT specialist standards should apply to emergency room staff is harder to say.

Without more information, negligence as it pertains to delayed surgical facial nerve decompression is also hard to say.

Ultimately, we shall see what the court decides.


Source:
Lawsuit alleges Iowa doctors left patient's face paralyzed. Associated Press 8/13/13

References:
Transcranial magnetic therapy. Wikipedia

Electrical and transcranial magnetic stimulation of the facial nerve: diagnostic relevance in acute isolated facial nerve palsy. Eur Neurol. 2012;68(5):304-9. doi: 10.1159/000341624.

Antiviral therapy for Ramsay Hunt syndrome (herpes zoster oticus with facial palsy) in adults. Cochrane Database Syst Rev. 2008 Oct 8;(4):CD006851. doi: 10.1002/14651858.CD006851.pub2.

Antiviral treatment for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev. 2009 Oct 7;(4):CD001869. doi: 10.1002/14651858.CD001869.pub4.

Do either corticosteroids or antiviral agents reduce the risk of long-term facial paresis in patients with new-onset Bell's palsy? J Emerg Med. 2010 May;38(4):518-23. doi: 10.1016/j.jemermed.2009.08.016. Epub 2009 Oct 21.

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Facial Plastic Surgery Leading to Clones? Scandal? Divorce? Lawsuits?

Earlier this year, pictures of the 20 finalists for Miss Korea 2013 went viral due to the clone-like appearance of the women. Such clone-like appearance is due to suspected plastic surgery undergone by many if not all of the contestants towards the idealized "Korean plastic face look." Fueling plastic surgery in Korea is the acceptance and popularization of plastic surgery encouraged by celebrity worship culture. Check it out:

Image Taken from MailOnline

Of course, it could be all the makeup and photoshopping that made these contestants all look alike. The reality is a bit more disappointing as shown in pre-makeup pictures published in KoreaBang.

In any case, a scandal of sorts occurred when before and after pictures of Miss Korea 2012 Kim Yu-Mi  surfaced. Note the complete lack of resemblance between her natural looks and her winning appearance (see pics below):

Image Taken From KoreAm

It is perhaps little wonder that with such high prevalence of plastic surgery, that it was only a matter of time before marital strife and even divorce would occur by men who have been "deceived" by a woman's "natural" beauty which was anything but.

Indeed, a Chinese man divorced and sued his wife in 2012 for being ugly... and won [link]. Apparently his wife's appearance became an issue when his daughter was born and resembled nothing like either parent (and allegedly was "incredibly ugly" to boot). After initially thinking his wife cheated on him, the wife admitted spending $100,000 on plastic surgery to become beautiful, and never disclosed this information before marrying him. The lawsuit was based on his belief that he married her under false pretenses of her being beautiful. See pics below.

Image taken from KDVR

I wonder if potential marriages in Asia are now preceded by full disclosure of any plastic surgery done along with the more usual disclosures of educational, family, and financial background.

Sources:

Chinese man sues wife for being ugly, wins $120,000. KDVR 10/26/12

Has plastic surgery made these beauty queens all look the same? Koreans complain about pageant 'clones'.  MailOnline 4/25/13

Miss Korea’s Plastic Surgery Scandal After Photos Surface. KoreAm 7/20/12

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Singer Carnie Phillips Suffered from Bell's Palsy

Image by InSapphoWeTrust from Wikipedia

In March 2013, singer Carnie Phillips (of the Wilson Phillips) revealed that she suffered from a sudden left facial paralysis due to a condition known as Bell's Palsy.

Through a series of tweets, it was apparent that it came fast and started improving within a week.

Thought to be due to a viral infection of the facial nerve, it is commonly treated with prednisone with or without an anti-viral antibiotic (ie, valtrex). For most patients, full recovery occurs, but in some, normal facial movement is never regained.

For more info on facial paralysis, click here.

Source:
Carnie Wilson of Wilson Phillips reveals she has Bell's palsy. LA Times 3/19/13

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Stroke vs Non-Stroke Facial Paralysis

Image by Patrick Lynch from Wikipedia

A recent blog post about a ER doctor who was found negligent for not pursuing a stroke workup for an isolated facial paralysis did bring up an interesting medical phenomenon about what differentiates a facial paralysis due to stroke vs facial paralysis due to facial nerve inflammation.

To begin, the facial nerve innervates the entire half of the face. The nerve itself exits from the skull behind the ear and sends finger-like branches to all the muscles of the face (nerve is yellow).

So if something happens to the nerve, the entire face including forehead, around the eye, cheek, and lip would become paralyzed.

HOWEVER, if a stroke occurs that knocks out the part of the brain that governs facial movement on just one side, the patient will have facial paralysis only on the lower half of the face. The forehead on both sides will still move just fine!

Why is that?

At the brain level, the facial nerve branch that governs forehead movement is innervated by BOTH sides of the brain. However, the facial nerve branches for the remainder (lower part) of the face is innervated by only ONE side of the brain.

As such, if complete facial paralysis including forehead is present, it is NOT due to a stroke or any other brain problem. This condition is called Bell's Palsy.

If the forehead moves fine, but the rest of the face is paralyzed on one side, than it may be due to a stroke or some other brain-level problem. Of course, with a stroke, one would see not only facial paralysis with forehead sparing, but also paralysis involving other parts of the body (which makes it obvious).

Image by Patrick Lynch from Wikipedia

Take a look at the picture to the left illustrating the facial nerve branches. Nerve branches in solid yellow or orange come from either the right or left side of the brain. Nerve branches in yellow/orange hashes come from both sides of the brain.

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The Facial Triangle of Danger (Even Death)

Image by SpooSpa from Wikipedia

If you draw a line between the eyebrow to the corners of the lip, a triangle is created which delimits a region esoterically known as the "danger triangle".

Why is this region considered dangerous?

It's because infections within this region can lead to infections of the brain (rarely). Why? The blood supply within this triangular area communicates with the cavernous sinus found at the bottom of the brain. This anatomic structure is a major source of venous drainage of the brain.

If the cavernous sinus gets inflamed/infected due to a rip-roaring pimple of the upper lip, it could lead to multiple facial abnormalities due to injury of the numerous cranial nerves that go through it including:

• Inability to move the eyeballs (CN3, 4, 6)
• Numbness, pain of the skin over the forehead and cheeks (CNV1, V2)
• Loss of pupillary constriction (CN3)
• Visual loss/changes (CN1)

The cavernous sinus could also become thrombosed.

Cavernous Sinus shown by red arrow. Taken from Sonoworld.

From there, the infection can spread to the rest of the brain and potentially can even lead to death if not treated promptly and aggressively.

Of course, tiny infections like a small pimple or a small laceration due to biting a lip is not going to cause problems.

However, rapidly progressive major infections of the skin with abscess formation do need to be treated cautiously.  Typically, such patients are hospitalized on IV antibiotics until definite and significant improvement can be seen at which time patients can be discharged home on oral antibiotics.

At which point a "minor" infection becomes "major" requiring hospitalization is a judgement call.

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Cheerleading A Dangerous Sport from an ENT Perspective

The American Academy of Pediatrics (AAP) published its first policy statement regarding cheerleading due to the increasing rate of injuries found in this increasingly competitive sport.

Who knew that although the overall risk of injury is lower than other sports, it has one of the highest rates of catastrophic injuries including closed-head injury, skull fractures, cervical spine injuries, paralysis, and even death.

After all, cheerleaders do not wear protective gear and safety is utterly dependent on external factors such as spotters and floor protection.

From an ENT perspective of a solo private practice, cheerleading is one of the leading causes of facial fractures in a student population.

Such fractures include nasal bone and orbital blow-out fractures sustained from elbows and other flying limbs.

Although AAP made 12 recommendation to make this sport safer, I was going to suggest that all cheerleaders should wear face-guards to minimize risk of facial trauma.

Here's one called Mueller Nose Guard. Available for purchase on Amazon.com.

Reference:
Cheerleading Injuries: Epidemiology and Recommendations for Prevention. Pediatrics 2012;130:966-971.

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US Gymnast Maroney Suffers Nasal Fracture

World vault champion McKayla Maroney on the US gymnastics team suffered a nasal fracture during pre-meet training when she over-rotated at the end of a tumbling run and fell hard earlier this month. She also suffered a concussion. A visit to the ER revealed her injuries. Apparently no surgical intervention was pursued.

This case illustrates that most nasal and even facial fractures do NOT require surgical repair.

The key elements that lead towards a decision for facial and/or nasal fracture surgery are the following (not all-inclusive, but general pointers):

- Any functional deficit including inability to open and close the jaw.
- Change in your occlusion (the way your teeth come together).
- Double vision (blurry vision does not count).
- Cosmetic deformity due to nasal/facial fracture (bruising and swelling does not count).
- Nasal obstruction not due to swelling.

The two main specialties able to assess whether surgery is required or not is ENT and Plastic Surgery as well as some oral surgeons.

Source:
Maroney suffers concussion, nasal fracture. ESPN 6/10/12

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Vice-President Biden's Daughter Marries an ENT Doctor

On June 2, 2012, Vice-President's daughter Ashley married Dr. Howard Krein in Delaware.

Though this news is not really all that interesting in itself, the neat thing is that Dr. Howard Krein is an ENT!

He received his medical degree from Jefferson Medical College in 2000 (same year as me!)...

He obtained his otolaryngology training at Thomas Jefferson University Hospital and completed a facial plastics fellowship at the Medical College of Virginia in Richmond, VA.

After fellowship completion, he later joined the faculty at Thomas Jefferson University Hospital as a facial plastic and reconstructive surgeon.

He is also active in social media... Chief Medical Officer of Organized Wisdom and goes by the twitter handle @howardkrein as well as @kreinmd.

Congratulations to the happy couple!

Source:
VP Biden's daughter Ashley marries a doctor in Delaware. USA Today. 6/2/12

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New Webpage on Facial Fractures and Nasal Fractures

Our office has created a new webpage describing the evaluation and management of not only nasal fractures, but also facial fractures.

Fracture types discussed include:

• Nasal Fractures
• Orbital Fractures (around the eye)
• Maxillary Fractures (cheek)
• Zygomatic Fractures (behind cheekbone)
• Tripod Fractures (cheekbone)
• Mandible (lower jawbone)
• LeFort (upper jawbone)

Check it out here!

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