Late complications of craniofacial trauma following a paragliding accident

Introduction

Craniofacial trauma is a critical area of study in medicine due to its potential for severe long-term complications. While the incidence of craniofacial injuries in extreme sports, such as paragliding, is relatively rare compared to other activities, the severity of injuries when they do occur can be significant. A systematic review of sports-related injuries found that craniofacial trauma constitutes about 20% of all sports injuries, underscoring the need for heightened awareness in paragliding, where high-velocity impacts and fall dynamics often lead to complex craniofacial injuries [1]. In paragliding accidents, the injury mechanism typically involves high-velocity impacts, such as collisions with the ground or obstacles during a fall. These falls can result in fractures of facial bones, soft tissue damage, and neurological impairments [2, 3].
The unpredictable nature of the sport, which combines aerial navigation and environmental factors, contributes to the complexity of these injuries. Impact forces may not only cause immediate trauma but also lead to delayed complications, complicating clinical management. Diagnosing late-onset complications in craniofacial trauma can be challenging as symptoms may develop gradually and can be masked by initial treatments. This often results in underdiagnosis or mismanagement of conditions like osteomyelitis or sinus infections, which are common complications following such injuries [4]. The intricate anatomy of the craniofacial region, coupled with overlapping symptoms from initial trauma, requires a high index of suspicion and thorough follow-up to identify complications early. Late complications of craniofacial trauma include chronic pain, aesthetic deformities, and infections such as osteomyelitis, which may arise from fractures disrupting facial bone integrity [2]. Managing these complications requires a multidisciplinary approach, involving specialists in otolaryngology, neurosurgery, and maxillofacial surgery. The psychological impact, including post-traumatic stress disorder (PTSD) and depression, also warrants integrated care to address both physical and mental health needs [4]. Rehabilitation is a crucial component of recovery from craniofacial trauma. Effective rehabilitation often includes physiotherapy to restore function and mobility, along with psychological support to help patients cope with the emotional aftermath [5]. A comprehensive rehabilitation program plays a vital role in physical recovery and psychological well-being, improving the quality of life for patients affected by craniofacial trauma from extreme sports like paragliding [6].
The following case report details the long-term complications experienced by a patient who sustained craniofacial trauma in a paragliding accident. It aims to highlight the challenges in managing such complex cases, emphasize the importance of a multidisciplinary treatment approach, and underscore the necessity of ongoing monitoring to ensure the best possible outcomes.

Case report

A 57-year-old patient was admitted to the ENT Department with upper eyelid edema, accompanied by a headache and subfebrile state. Two days prior to admission, the patient was consulted by an ophthalmologist who prescribed amoxicillin, resulting in some improvement in his condition. The patient had a history of a craniofacial injury from a paragliding accident in 2003, which led to many health complications. Following the accident, multiple embolizations of the left cavernous sinus were necessary due to a carotid-cavernous fistula (in 2003, 2004, 2005, and 2010). Furthermore, the injury resulted in exophthalmos, blindness in the left eye, and two episodes of phlegmon in the left orbital cavity, treated using Beck’s method (in 2016).
Physical examination revealed soft, non-pulsating edema of the left eyelid and sellar region, with marked exophthalmos. The patient underwent a computed tomography (CT) scan of the head and neck which showed an airless left frontal sinus with bone destruction and cystic changes extending into the orbital cavity (Figure 1). The sphenoid sinus was also deformed and airless. An magnetic resonance imaging (MRI) was recommended to further characterize the type of findings and to confirm if the carotid-cavernous fistula was permanently closed (Figure 2). Conservative treatment was initiated, including oral antibiotic and local steroid therapy, resulting in an improvement of local conditions. After consultation with neurosurgeons, the patient was scheduled for surgery which included a wide opening of the left frontal sinus with removal of inflammatory changes and sinus mucosa, as well as a left upper orbitotomy.
The procedure was performed four months later by a multidisciplinary team, including a neurosurgeon and a laryngologist. Under general anesthesia, a skin incision was made along the left brow line. The subcutaneous tissues were dissected to visualize anterior wall of frontal sinus and upper superior orbital rim, revealing destruction of the anterior orbital cavity, with multiple scars and defects. A large amount of material was evacuated from the superior part of the orbital cavity and sent to a bacteriological and histopathological analysis that revealed mucocele. The sphenoid sinus was assessed using a 0-degree endoscope and no pathological changes were observed. The patient was discharged 2 days after the procedure, in good general condition with a prescription for antibiotics, probiotics, a moisturizing ointment and a nasal steroid.
A month later, the patient returned with upper eyelid edema and pain. A CT scan revealed significant exophthalmos. The frontal sinus was airless, with deformation and extensive loss of the superior orbital wall. Hyperdense material was seen protruding from the sinus into the orbital cavity, raising suspicion of purulent content or blood clots. There were bone deformities at the site of the dura mater of the frontal sinus, along with segmental thinning of the dura mater and localized malacic changes in the frontal lobe.
Based on the CT scan findings, the patient was scheduled for an upper orbitotomy and functional endoscopic sinus surgery (FESS). The procedure was performed 2 days after the assessment. Under general anesthesia, a skin incision was made along the left brow line to expose the anterior wall of frontal sinus and the superior orbital rim. Dissection of the subcutaneous tissues revealed a significant destruction of the anterior orbital cavity wall, with multiple scars and defects measuring 0.5 cm in diameter. Purulent material was drained from the superior part of the orbital cavity and sent for bacteriological examination. Using a 30-degree endoscope and neuronavigation, partial clearance of the frontonasal recess was achieved, and a connection to the nasal cavity was established. A silicone drain was inserted to maintain the opening. Additionally, communication between the frontal sinuses was created by removing the medial wall of the right frontal sinus. The patient was discharged two days after the procedure in good general condition with a prescription for antibiotic, xylometazoline nasal spray, and a moisturizing ointment.
One year later, the patient was admitted to the Emergency Department with swelling of the left upper eyelid. The patient did not report any pain or fever, though he had experienced itching the day before. Physical examination revealed left periorbital edema without redness, increased warmth, pain or purulent discharge. A blood test showed an elevated C-reactive protein (CRP) level of 75.5 mg/l (normal range: < 5 mg/l). A CT scan presented a frontal sinus deformation, with mucosal thickening of 8 mm and frothy discharge (Figure 3). Left eye exophthalmos was present, though it was less severe when compared to the previous CT scans. The final conclusion indicated no presence of abscesses or fluid collection. The patient was discharged with prescriptions for oral antibiotics, as well as a local antibiotic and anti-inflammatory eye drops.

Discussion

This case highlights the long-term complications and complex management of craniofacial trauma. The initial injury led to numerous health challenges, including exophthalmos, blindness in the left eye, and recurrent episodes of orbital phlegmon. The development of a carotid-cavernous fistula required multiple embolization procedures, and the persistence of sinus and orbital complications required both conservative and surgical interventions. Conservative management, including antibiotics and steroids, initially provided symptomatic relief, but recurrent symptoms led to surgical intervention. The decision to perform a left upper orbitotomy and FESS was guided by CT scan findings of sinus deformation, bone destruction, and cystic changes extending into the orbital cavity.
A multidisciplinary approach is essential in managing complex facial trauma [3, 7]. The collaboration between neurosurgeons and ENT specialists allowed for a comprehensive treatment of the patient’s condition, addressing both the sinus and orbital deformities. Moreover, the use of advanced surgical techniques, including neuronavigation, allowed for precise removal of pathological tissue, reducing the risk of post-surgery complications.
Long-term craniofacial trauma presents significant challenges as injured patients more often experience PTSD, negative body image, alcoholism, and depression [8]. In our patient’s case, the chronic nature of his condition with the need for frequent hospitalizations might have had a considerable impact on his daily functioning and emotional well-being.
Our case emphasizes the complexity of long-term craniofacial complications, particularly those affecting the orbit and sinuses. Recurrent infections, anatomical deformities, and multiple surgeries highlight the importance of a multidisciplinary approach, advanced diagnostic and surgical techniques. Continuous monitoring, both clinically and through imaging, is essential for such cases [9]. Furthermore, attention to the patient’s overall well-being, including quality of life, is crucial for long-term successful outcomes.

Funding

No external funding.

Ethical approval

Not applicable.

Conflict of interest

The authors declare no conflict of interest.

References