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which were the features of our case. Capillary hemangioma shows tiny vascular networks filled with red blood cells, and it lacks fibrous tissue.17,18 Although the medical history is usually nonspecific, and the origins of intraosseous hemangioma are unclear, there have been many hypotheses regarding the histogenesis. Some studies suggest a hereditary nature for ‘‘vascular malformations’’ in the cranial region with an autosomal recessive mode of inheritance.19,20 But Chatterji et al21 and Relf et al22 suggested that the differentiation and proliferation of the undifferentiated primitive mesenchymal cells induced by various stimuli was the origin. In our literature review, previous trauma was reported in some cases (Table1), especially those that occur in the frontal bone.6,17,23,24 As described in our case report, there is indeed a connection between the intraosseous hemangioma and the previous trauma because the histogenesis appeared exactly on the site of the crania trauma, as has been proven radiologically.

CONCLUSION Intraosseous cavernous hemangiomas of the skull are rare benign tumors of unclear origin. They can be resected completely, but adequate preparation to minimize blood loss such as embolization must be considered before the operation.25 Based on our cases and the findings reported by others in the literature, trauma would likely be the most likely origin of intraosseous cavernous hemangiomas.

REFERENCES 1. Marshak G. Hemangioma of the zygomatic bone. Arch Otolaryngol 1980;106:581Y582 2. Sasagawa Y, Akai T, Yamamoto K, et al. Multiple cavernous hemangiomas of the skull associated with hepatic lesions. Neurol Med Chir 2009;49:162Y166 3. Heckl S, Aschoff A, Kunze S. Cavernomas of the skull: review of the literature 1975Y2000. Neurosurg Rev 2002;25:56Y67 4. Naama O, Gazzaz M, Akhaddar A, et al. Cavernous hemangioma of the skull: 3 case reports. Surg Neurol 2008;70:654Y659 5. Roel H, Jim D, Robert GR, et al. Posttraumatic skull hemangioma: case report. J Neurosurg 2012;117:1082Y1088 6. McIntyre NG, Brebner DM, Gluckman J. The cavernous haemangioma of the frontal bone: a case report. S Afr Med J 1977;52:537Y538 7. Valentini V, Nicolai G, Lore B, et al. Intraosseous hemangiomas. J Craniofac Surg 2008;19:1459Y1464 8. Reis BL, Carvalho GT, Sousa AA, et al. Primary hemangioma of the skull. Arq Neuropsiquiatr 2008;66:569Y571 9. Sargent EN, Reilly EB, Posnikoff J. Primary hemangioma of the skull: case report of an unusual tumor. AJR Am J Roentgenol 1965;95:874Y879 10. Moravan MJ, Petraglia AL, Almast J, et al. Intraosseous hemangiomas of the clivus: a case report and review of the literature. J Neurosurg Sci 2012;56:255Y259 11. Kumar S, Grupta S, Puri V, et al. Intradiploic hemangioma of skull bone. Indian Pediatr 1993;30:399Y401 12. Garcı´a-Perla A, Infante-Cossı´o P, Acosta-Feria M, et al. Primary intraosseous hemangioma of the orbit: report of two cases. Neurocirugia. 2007;18:320Y325 13. Moore SL, Chun JK, Mitre SA, et al. Intraosseous hemangioma of the zygoma: CT and MR findings. AJNR Am J Neuroradiol 2001;22:1383Y1385 14. Amaral L, Chiurciu M, Almeida JR, et al. MR imaging for evaluation of lesions of the cranial vault. Arq Neuropsiquiatr 2003;61:521Y532 15. Nair P, Srivastava A, Kumar R, et al. Giant primary intraosseous calvarial hemangioma of the occipital bone. Neurology India 2011;59:775Y776 16. Nasser K, Hayashi N, Kurosaki K, et al. Intraosseous cavernous hemangioma of the frontal bone. Neurol Med Chir 2007;47:506Y508 17. Khanam H, Lipper MH, Wolff CL, et al. Calvarial hemangiomas: report of two cases and review of the literature. Surg Neurol 2001;55:63Y67

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18. Politi M, Romeike BF, Papanagiotou P, et al. Intraosseous hemangioma of the skull with dural tail sign: radiologic features with pathologic correlation. AJNR Am J Neuroradiol 2005;26:2049Y2052 19. Bottrill I, Poe DS. Imaging quiz case 2. Intraosseous cavernous-type hemangioma of the petrous temporal bone. Arch Otolaryngol Head Neck Surg 1995;121:348Y350 20. Fierek O, Laskawi R, Kunze E. Large intraosseous hemangioma of the temporal bone in a child. Ann Otol Rhinol Laryngol 2004;113:394Y398 21. Chatterji P, Sharma ML, Chatterji S, et al. Cavernous haemangioma of fronto-ethmoid region. J Laryngol Otol 1969;83:925Y933 22. Relf SJ, Bartley GB, Unni KK. Primary orbital intraosseous hemangioma. Ophthalmology 1991;98:541Y547 23. Hornig GW, Beatty RM. Osteolytic skull lesions secondary to trauma. Report of two cases. J Neurosurg 1990;72:506Y508 24. Cheng NC, Lai DM, Hsie MH, et al. Intraosseous hemangiomas of the facial bone. Plast Reconstr Surg 2006;117:2366Y2372 25. Tyagi DK, Balasubramaniam S, Sawant HV. Giant primary ossified cavernous hemangioma of the skull in an adult: a rare calvarial tumor. Neurosci Rural Pract 2011;2:174Y177

Diagnostic Value of Ultrasonography in the Diagnosis of Nasal Fractures Saied Atighechi,* Mohammad Hossein Baradaranfar,* Ghasem Karimi, MD,* Mohammad Hossein Dadgarnia,* Hamid Reza Mansoorian,Þ Najmeh Barkhordari,þ Batool Sadat Sajadinejad,* Nasim Behniafard, MD§ Introduction: This study examined the diagnostic value of ultrasound and radiography compared with clinical examinations as the gold standard method to determine whether ultrasound can be used for early diagnosis of nasal fracture. Methods: This prospective study was conducted on 128 patients with clinical signs of nasal fracture. Radiography in all patients was performed by 2 different radiologists on Waters and lateral view with a 10-MHz ultrasound probe, and clinical examinations were done by an ENT specialist. Radiography and ultrasound findings were recorded and compared with the final diagnosis which was based on clinical examinations. Results were analyzed with different statistical

From the *Department of Otolaryngology, Head and Neck Surgery, Rhinology Research Center, Shahid Sadoughi University of Medical Sciences and Health Services, Yazd; †Department of Radiology, Shahid Sadoughi University of Medical Science and Health Services, Yazd; ‡Department of Otolaryngology, Head-Neck Surgery, Khatam Hospital, Shahid Sadoughi University of Medical Science and Health Services, Yazd; and §Rhinology Research Center, Shahid Sadoughi University of Medical Science and Health Services, Yazd, Iran. Received May 30, 2013. Accepted for publication June 15, 2013. Address correspondence and reprint requests to Dr Ghasem Karimi, Department of Otolaryngology Head and Neck Surgery, Rhinology Research Center, Shahid Sadoughi Hospital, Avicenna Blvd, Safaeeh, Yazd, Iran; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0b013e3182a2eeda

* 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

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methods to determine sensitivity, specificity, accuracy, positive predictive value, and negative predictive value. Results: In the assessment of fracture with ultrasound, sensitivity was 84%, specificity 75%, accuracy 82%, positive predictive value 91%, and negative predictive value 61%. In the assessment of fracture on lateral view radiography, sensitivity was 50%, specificity 72%, accuracy 55%, positive predictive value 84%, and negative predictive value 32%. On Waters view radiography, sensitivity was 53%, specificity 65%, accuracy 56%, positive predictive value 82%, and negative predictive value 31%. On lateral-waters view radiography, sensitivity was 64%, specificity 58%, accuracy 62%, positive predictive value 82%, and negative predictive value 34%. Fracture diagnosis by ultrasound was significantly better as compared with radiography (P = 0.04). Conclusion: The nasal bone ultrasound study is a useful method in determining the nasal fracture and radiography can be replaced with ultrasound in early diagnosis of fracture. Key Words: Nasal bone, fracture, ultrasound, radiography

N

asal bone fracture is the most common facial bone fractures in patients with maxillofacial trauma.1 Nasal fracture is seen in 39% of with maxillofacial fractures.2 These fractures can be seen commonly in men than women with 2:1 ratio. Nasal fractures can be commonly seen between 15 and 25 years and as a secondary peak after 60 years of age. Generally, young people are more prone to fractures than older people.3Y5 Approximately 80% of fractures occur between the middle third and the lower part of the nose.6,7 Some studies have reported that it is not normally possible to use radiography for assessment of nasal fractures. The standard imaging procedure for suspected nasal fractures has been radiography (x-ray). However, its utility for clinical decision is extremely controversial; high-resolution ultrasonography currently offers a promising new diagnostic imaging choice.8 These studies showed that radiography is negative in 25% of patients with nasal fracture who required surgery.9 Another study showed that Waters view in 55 fractures with no previous history of trauma to the nose was false positive in 33% of cases. Therefore, if there is no legal aspect and respiratory or beauty problems due to the trauma to the nose, routine radiography is not needed.10 Although a physical examination is considered the gold standard for the diagnosis of nasal fracture, the surrounding hematoma and edema could also be extended and might make the diagnosis of nasal fracture more difficult to determine.11 On the other hand, it is unlike the Waters and lateral x-ray method which are accompanied with high positive and negative predictive values in the diagnosis of fracture, and high exposure area with high doses of x-ray.12 An alternative to radiography is ultrasound, a standard and straightforward technique involving no extra radiation exposure; the significance of ultrasound imaging as a diagnostic tool for the detection of bone fractures (eg, in inherent hip dislocation, fractures of the radial or clavicle bone, or fractures of the ribs or skull) has been proven in various studies.11 In a systematic review done by Adeyemo et al, the sensitivity and specificity of ultrasound in detecting nasal fractures have been reported as 90%Y100% and 98%Y100%, respectively. The sensitivity and specificity of sonography are usually comparable to CT in conventional radiography. The superimposition of images of the superimposed structures generally makes definite radiological interpretation difficult. Another disadvantage is that period image visualization is impracticable and is a non-digital technology; hence, only a hard copy image of 2-dimensional plain films is available.12 The examination

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of nasal fractures by ultrasound can be a standard methodology involving no radiation exposure compared with the radiographic occipitomental view. Furthermore, ultrasound can be an adequate diagnostic tool for the assessment of distinct lateral nasal wall fractures. Nasal dorsum fractures were clearly delineated in the lateral radiographic view of the inside of the nose. In the ultimate assessment of the nasal pyramid, radiography and ultrasound were considered as equivalent methods, although ultrasound showed a slight advantage within the descriptive statistical analysis. Therefore, in the assessment of the nasal pyramid fractures, ultrasonography can be considered an alternative to radiography, with equivalent diagnostic efficiency.6 All nasal fractures which are diagnosed by radiography are also shown with ultrasound.13 So this study was performed to investigate the diagnostic value of ultrasound in the assessment of nasal fracture.

MATERIALS AND METHODS This prospective cross-sectional study was conducted on 128 patients with clinical signs of fracture referred to 2 clinics in Yazd, Shahid Sadoughi and Shahid Rahnemoun, during 2010Y2012. Selection method was nonrandom (sequential); thus, all eligible individuals were selected to complete the necessary sample size respectively. Inclusion criteria consisted of recent nasal trauma, clinical evidence of fracture (hematoma, deformity, ecchymosed, and tenderness), and having the consent to enter the study. Patients who did not consent to participate in the study and pregnant women were excluded. All patients were physically examined by an ENT specialist for investigating legal or medical reasons. Also, these patients were assessed by conventional method of radiography and ultrasound. In this study, physical examination was considered as the gold standard method for diagnosis of fracture when entering the study. Lateral and Waters view radiography were performed for all patients after physical examinations. Radiographic results were reported by an experienced radiologist. Based on the existence of a fracture, the reports were recorded as positive or negative. Then ultrasound was performed for all patients. Ultrasonography was performed by another experienced radiologist who was unaware of the results of radiography and physical examinations. Ultrasound [Medison SonoAce 6000-30 (Korea) with 7Y12 MHz multifrequency linear probe] was done in the right and left lateral wall and the nasal dorsum. Two radiologists completed the patients’ report while we are unaware of the findings of patients’ physical examinations and each other’s reports. Patients were placed in supine position, and the right and left lateral wall and nasal dorsum were evaluated in these patients. The demographic information and results of radiography, ultrasound, and physical examinations were recorded on the prepared sheets. All information were encoded and entered into the computer memory using SPSS software. If ultrasound or radiographic findings were consistent with the findings of physical examination, it was considered as the diagnosis, and if the ultrasound or radiographic findings were not consistent with the findings of physical examination, it was considered as a result of the identification. Moreover, if the ultrasound or radiographic findings were not consistent with the findings of physical examination, it was considered as a result of the identification, and if the ultrasound or radiographic findings were compared with the results of physical examination, additionally the sensitivity, specificity, positive predictive value, and negative predictive value were calculated. In comparing the diagnostic value of 2 diagnostic ways in which a chi-square test was done, P greater than 0.05 was considered statistically significant. * 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

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& Volume 25, Number 1, January 2014

RESULTS The mean age of subjects was 24.6 T 15 years with an age range of 18 years; 100 (78.1%) men and 28 (21.9%) women were assessed. Among these patients, 10 cases (8.7%) had an unspecified diagnosis (2 patients in physical examination, 4 in sonography, and 4 in radiography) and 118 cases (92.2%) had a definite diagnosis of fracture. Nasal fracture was significantly diagnosed more in ultrasound than in radiography on the lateral view (P = 0.028). Also, nasal fracture was significantly diagnosed more in ultrasound than in radiography on Waters view (P = 0.04), and nasal fracture was significantly diagnosed more in ultrasound than in radiography on lateral-Waters view (P = 0.049).

DISCUSSION In this study, sensitivity, specificity, and accuracy were 84%, 75%, and 82% for ultrasound; 50%, 72%, and 55% for radiography on lateral view; 53%, 65%, and 56% for radiography on Waters view; and 64%, 58%, and 62% for radiography on lateral-Waters view, respectively. Considering the low sensitivity of radiography, the diagnosis of nasal fracture is done by performing a physical examination.8 In previous studies, sensitivity of radiography on lateral and Waters view in the diagnosis of fracture has been reported as 75%.9 CT scan can accurately show the details of the nasal bone and soft tissue anatomy; however, these finding are not enough for the diagnosis of nasal bone fracture.8 In previous studies, it is demonstrated that 0.1-mm fractures can also be shown with ultrasound.13 In a study done by Oliver et al on 63 patients, it is reported that the diagnostic value of ultrasound in the diagnosis of fracture lines is more than radiography.8 Hong et al stated that the sensitivity of ultrasound in the diagnosis of nasal fracture is more than that of radiograph.11 Danter et al’s study that was conducted on 18 patients reported that 20 MHz ultrasound probe has 83% sensitivity and 50% specificity in comparison with physical examinations. Also, they showed that the sensitivity and specificity of ultrasound, as compared with radiography, is 94% and 83%, respectively.14 In Kwon’s study, the sensitivity of radiography was 70%Y60% while it was 100% for ultrasound. Kwon also demonstrated a positive relationship between ultrasound and CT scan in the assessment of 45 patients with suspected fracture.15 After assessment of 21 patients with suspected nasal fracture by 5Y75 MHz ultrasound probe and radiography, Beck et al reported that all fractures reported by radiography were also shown with ultrasonography.13 Strek and Zagolski’s study showed that nasal fracture can be diagnosed based on ultrasound results.16 Another study also reported that ultrasound can show the trauma to the cartilaginous parts of the nose with more diagnostic accuracy than radiography.10 In a study on the clinical identification of a reference standard, identification of nasal bone fractures was created absolutely from radiographs in 108 of 138 cases. The sensitivity, specificity, and accuracy of the radiographs for nasal fractures were 78%, 100%, and 78.6%, respectively, and also the interobserver agreement rate was good (J = 0.62). Computed axial tomography discovered nasal fractures in 129 of 138 patients; its sensitivity, specificity, and accuracy were 92.8%, 50%, and 92.1%, respectively, and therefore the interobserver agreement rate was good (J = 0.7). High-resolution ultrasound detected all 138 nasal fractures; its accuracy in detection nasal fractures was 100%.10 Rapid developments in computing hardware and electronics technology have led to the technological advancement in sonography within the last 3 decades, extending its applicability not only to soft tissues but also to bony lesions of the head and neck. This has raised interest in evaluating ultrasound imaging as an alternative to conventional radiography and CT

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within the diagnostic analysis of maxillofacial fractures. Most reports are very promising; however, whether or not sonography will be replaced by radiography remains to be seen.17 In this study, the 10-MHz ultrasound probe was used which was similar to the results of Beck’s study in which a 5Y57-MHz probe had been used.15

CONCLUSIONS The study concluded that the ultrasound is a rapid and inexpensive method with high diagnostic value in the diagnosis of fractures, which is expected to show the detailed anatomy of the nose better than the conventional radiography method .Ultrasound is a very rapid imaging procedure in cases of suspected nasal fracture. By using ultrasound, radiography is not needed and can be used in early diagnosis of nasal fracture. Also, by using ultrasound instead of conventional radiography method, radiation to the lenses and other complications resulting from the exposure can be prevented.

REFERENCES 1. Hwang K, You SH, Kim SG, et al. Analysis of nasal bone fractures; a six-year study of 503 patients. J Craniofac Surg 2006;17:261Y264 2. Alvi A, Doherty T, Lewen G. Facial fractures and concomitant injuries in trauma patients. Laryngoscope 2003;113:102Y106 3. Cummings CW, Flint PW, Phelps T, et al. Cummings Otolaryngology Head & Neck Surgery. Philadelphia, PA: Elsevier Mosby; 2005:498Y500 4. Daly BD, Russell JL, Davidson MJ, et al. Thin section computed tomography in the evaluation of naso-ethmoidal trauma. Clin Radiol 1990;41:272Y275 5. Murray JA, Maran AG, Busuttil A, et al. A pathological classification of nasal fractures. Injury 1986;17:338Y344 6. Thiede O, Kromer JH, Rudack C, et al. Comparison of ultrasonography and conventional radiography in the diagnosis of nasal fractures. Arch Otolaryngol Head Neck Surg 2005;131:434Y439 7. Pilija V, Buljcik M, Mihalj M, et al. [Classification and qualification of nose injuriesVclinical and forensic aspects]. Medicinski pregled 2005;58:33Y36 8. Gurkov R, Clevert D, Krause E. Sonography versus plain x rays in diagnosis of nasal fractures. Am J Rhinol 2008;22:613Y616 9. Dammann F. [Imaging of paranasal sinuses today]. Der Radiologe 2007;47:576, 8Y83 10. Lee MH, Cha JG, Hong HS, et al. Comparison of high-resolution ultrasonography and computed tomography in the diagnosis of nasal fractures. J Ultrasound Med 2009;28:717Y723 11. Hong HS, Cha JG, Paik SH, et al. High-resolution sonography for nasal fracture in children. AJR Am J Roentgenol 2007;188:W86YW92 12. Siegert R, Weerda H. [Ultrasound measurement of skin and cartilage thickness in healthy and reconstructed ears with a 20-MHz ultrasound device]. Laryngorhinootologie 1996; 75:91Y94 13. Beck A, Maurer J, Mann W. Sonographische diagnose von nasenbeinfrakturen:otorhinolaryngologie. In: Verhandlungsbericht der Deutschen Gesellschaft fu¨r Hals-Nasen-Ohrenheilkunde, Kopf Hals-Chirurgie. Stuttgart, Germany: Thieme-Verlag; 1992:68 14. Danter J, Klinger M, Siegert R, et al. [Ultrasound imaging of nasal bone fractures with a 20-MHz ultrasound scanner]. Hno 1996;44:324Y328 15. Kwon TK, Cha JH, Kim YW, et al. The Role of Ultrasound in the Diagnosis of Fractured Nasal Bone. New York, NY: Kuglar Publications Amsterdam; 1995 16. Zagolski O, Strek P. [Ultrasonography of the nose and paranasal sinuses]. Pol Merkur Lekarski: organ Polskiego Towarzystwa Lekarskiego 2007;22:32Y35 17. Adeyemo WL, Akadiri OA. A systematic review of the diagnostic role of ultrasonography in maxillofacial fractures. Int J Oral Maxillofac Surg 2011;40:655Y661

* 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

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Diagnostic value of ultrasonography in the diagnosis of nasal fractures.

This study examined the diagnostic value of ultrasound and radiography compared with clinical examinations as the gold standard method to determine wh...
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