Tehran University Medical Journal

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Background: Traumatic tympanic membrane (TM) perforation is a common injury of the ear with a high rate of spontaneous healing if the patients strictly adhere to water precautions. The purpose of this study was to determine the factors involved in the spontaneous healing of traumatic TM perforations in order to ascertain the best treatment plan including observation, paper patch and finally surgery.
Methods: In this correlative–descriptive study, we recorded the outcome of each patient with three-month follow up. Included in this study were a total of 202 forensic medicine patients from the Dept. of Otolaryngology Head & Neck Surgery at the Yazd University of Medical Sciences, Yazd, Iran. All patients included in this study had traumatic TM perforation. Based on otoscopic examination, the perforations were classified as pinpoint or large. All patients received an audiometry exam and were followed for three months. The data was collected using a special form and analyzed by chi-square test, Fisher exact test and ANOVA.
Results: This study consisted of 118 male and 84 female patients with a mean age of 23.6 years (6-48 years). The types of trauma included compression injury (104 patients), instrumental injury (59 patients), burn–slag injury (2 patients) and blast injury (1 patient). One hundred and eighty patients had pinpoint TM perforations, 99.4% of which healed spontaneously by the second month, and 32 patients had large TM perforations, 50% of which healed spontaneously by the second month. During the first month, 87.3% of the patients observing water precautions had healed, however the healing rate was only 5.6% in patients not adhering to water precautions, who suffered from otorrhea. Therefore, during this study, 185 (91.58%) patients had spontaneous healing by two months and only 6 patients of remaining 17 patients healed with paper patch. The mean hearing loss at 500, 1000 and 2000 Hz was 10.55 dB (5-30 dB).
Conclusion: In our experience, patients with traumatic TM perforations have higher spontaneous healing rate when observing water precautions. Furthermore, we recommend observation and paper patching for three months before attempting any surgical intervention in such patients.

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Background: Acute abdominal pain is a common complaint in an emergency setting. An immediate and precise diagnosis is necessary for reducing morbidity and mortality. Several studies have reported that CT scan increases diagnostic accuracy for patients with acute abdominal pain. This study was designed to evaluate the sensitivity, specificity and accuracy of spiral CT scan compared to that of abdominal ultrasound and plain radiography. 

Methods: We assessed the data of 91 consecutive patients, including 45 males and 46 females, ranging in age from 8 to 84 years (mean age 52.38 years) presenting to the emergency department of Sina Hospital, Tehran, Iran, with acute non-traumatic abdominal pain during the years 2003-2005. All patients underwent spiral CT scanning in addition, sonography and plain radiography were performed for 66 and 64 of the patients, respectively. The sensitivity, specificity and accuracy were calculated and compared, based on the final diagnosis, which was established with surgical, pathologic, and clinical follow-up. The data was analyzed by SPSS 13.0 software.

Results: Among the 91 patients examined, CT scan was reported to be normal in 15 patients (16.5%). The most common CT findings were aortic aneurysm (12.1%), pancreatitis (9.9%), ovarian cyst (7.7%), intestinal distension (7.7%), and hepatic cyst (7.7%). The overall sensitivity, specificity, and accuracy of unenhanced spiral CT were 92.2%, 92.86%, and 92.3%, respectively, whereas those of plain radiography were 13.2%, 72.7%, and 23.4%, respectively, and ultrasound 73.2%, 90%, and 75.7%, respectively.

Conclusions: This study suggests that plain radiography is an insensitive technique in the evaluation of nontraumatic acute abdominal pain presenting in the emergency department. Unenhanced spiral CT is accurate for adult patients with nontraumatic acute abdominal pain and should be considered as an alternative to radiography as the initial imaging modality.

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Background: Trauma is the most common cause of mortality in the first four decades of life. In our country, cardiovascular diseases and trauma are leading causes of mortality, respectively. By gathering information on trauma mortalities, we can learn more about causes, and that knowledge can lead to prevention.
Methods: This is a prospective descriptive study in Tehran during 12 months period (Sep 1999- Sep 2000). Two hundred and forty five trauma deaths in six hospitals were evaluated. The data was collected through a questionnaire, designed in Sina Trauma and Surgery Research Center (STSRC) used for the study. The questionnaires were completed by trained physicians visiting trauma patients in emergency room and wards round the clock. Data obtained included patient demographics, level of prehospital care, medical and operative procedures performed in emergency rooms (ER) and wards (according to ICD-10 coding), Glasgow Coma Scale (GCS) and vital signs at time of presentation to emergency rooms, Injury Severity Score (ISS), length of hospital stay and outcome of patients.
Results: Twenty and forty five (3%) of 8000 trauma patients was died. Mean age was 40.7 (±23.5) years old and 208 (84.9%) patients were male. The highest mortality rate was seen in the age group of 25 to 30 years. Road Traffic Accident was the main cause of death followed by falling with 174(71%) and 41(16.85), respectively. Among victims of road traffic accident, pedestrians and motorcyclists were prominent with 119 and 28 cases respectively. The majority of cases were dead due to head injuries (69%) and abdominal trauma was the second cause with 19 (7.8%) cases.
Conclusions: Based on our findings the mechanism of injury have the positive effect on trauma outcome .Traffic accidents and assault is preventable and must be attended.

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Background: Penetrating thoracoabdominal stab wounds may cause diaphragmatic and abdominal organ laceration. However, 15-20% of these cases who are stable and managed by conservative treatment might have hidden diaphragmatic injuries, which could ultimately lead to chronic diaphragmatic hernia. Therefore, a safe and exact diagnostic method for the detection of occult diaphragmatic injuries is very valuable. In this study we have assessed the diagnostic value of thoracoscopy in occult diaphragmatic injuries resulting from penetrating thoracoabdominal stab wounds.

Methods: From March 2005 to October 2007, 30 hemodynamically stable patients with penetrating thoracoabdominal injuries, not requiring emergent exploration, were enrolled in this study. All subjects underwent thoracoscopy to evaluate probable diaphragmatic injury. Diaphragmatic injuries were repaired via thoracoscopy or laparatomy. All patients were evaluated for chronic diaphragmatic hernia by CT-scan six months later.

Results: The mean patient age was 26.2 years, with a male/female ratio of 5:1. Using thoracoscopic exploration, we observed five (16.7%) hidden diaphragmatic injuries, three (9.9%) of which were repaired using the thoracoscopic approach and two (6.6%) by laparatomy. Lung parenchymal laceration was seen in two patients (6.6%), for whom the repair was performed using thoracoscopy. Intra-abdominal injury was seen in one patient (3.3%), which was repaired by laparatomy. After thoracoscopy, there were no complications or evidence of chronic diaphragmatic hernia in the chest and abdominal CT-scans performed six months later. Therefore, the diagnostic accuracy of thoracoscopy in occult diaphragmatic injuries in our study was 100%.

Conclusion: With its high degree of diagnostic accuracy, low degree of invasiveness, as well as its utility in treatment, we recommend thoracoscopy for all clinically stable patients with penetrating thoracoabdominal stab wounds.

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Background: Trauma is a common problem in the world, predominately affecting young adults. Considering the high mortality rate in patients suffering from thoracic trauma, the condition is considered to be extremely important. The purpose of this study was to evaluate the prevalence and the epidemiology of chest trauma as well as the severity of the resulted injury in Tehran, Iran.

Methods: This prospective, descriptive study was conducted on patients admitted to three medical centers in Tehran during June 1997 and 1998 due to chest trauma. The data on the demographic information of the patients, the mechanism of the trauma and the severity of the injury were collected and analyzed.

Results: Three hundred forty two patients were admitted to hospital due to thoracic trauma the majority of which were male adults. Blunt trauma especially secondary to motor vehicle accidents were the most frequent cause of chest injury in the studied patients. In 280(82%) of the cases, another form of trauma was also reported. Chest wall injury was the most common type of thoracic trauma in these patients. The trauma was reported to be mild in 181(53%) of the patients (ISS<7). Only 42(12%) patients required surgical intervention. The overall mortality rate was 14% which was reported to be ISS- related.

Conclusion: Chest injury is quite prevalent among trauma patients and is associated with other injuries in a considerable number of the patients. This type of trauma is associated with a high mortality rate among elderly and therefore needs special attention and care.

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Background: Although nonoperative management is as an alternative method for surgery in the management of blunt splenic trauma, there are many contraversies in criteria for appropriate selection of the best method of management in patients. This study was conducted to find clinical and diagnostic criteria for selection of patients for surgery.

Methods: One hundred and one patients with blunt splenic injury entered in our prospective observational and cross sectional study. Patients with unstable hemodyna-mics and obvious abdominal symptoms underwent emergency splenectomy was performed. In stable patients, abdominal and pelvic CT scan with IV contrast was performed. Patients with stable hemodynamics who lack obvious abdominal symptoms, admitted in ICU ward. Patients' demographics, blood pressure changes, hemoglobin concertration, severity of trauma with injury severity score (ISS) scoring system, CT scan findings, amount of blood transfusion Hospitalization time and mechanism of injury were recorded.

Results: From 101 patients, 61(60.3%) underwent early laparotomy. 40 patients were planned for conservative management. In 30 patients (29.7%) nonoperative management was successful. In 10 patients (9.9%) This management failed and they underwent surgery. Hypotension, hemoglobin concentration dropping more than one episode and blood transfusion requirement more than one time, increased the risk of operation. Higher ISS number and ISS≥16 had a direct relation with operative management. In patients who underwent early laparotomy CT grade of injury was higher. CT findings correlated well with laparotomy findings.

Conclusion: Nonoperative management was successful in 75% of selected patients. With correct selection of patients and concerning to homodynamic status, hemoglobin concentration changes and injury severity score in conjunction with CT findings, we can use this management in greater number of patients.

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Normal 0 false false false EN-GB X-NONE AR-SA MicrosoftInternetExplorer4 !mso]> ject classid="clsid:38481807-CA0E-42D2-BF39-B33AF135CC4D" id=ieooui> Background: Trauma is the 2nd cause of mortality in Iran, after cardiovascular diseases. In traumatic patients, head and neck and face skeletal fracture is common. The most common facial fracture is mandible fracture and the least common is frontal fracture. Complications due to orbital fracture are more devasting than the other fractures in face.
Methods: These descriptive cross sectional studies are designed on 92 patients with orbital fractures in a referral educational trauma center, Imam Khomeini hospital, Tehran, Iran. Sample size was the patients who referred to this hospital with orbital fracture during the ten years period (1986-2000).
Results: In this study 74 patients were male and 18 patients were female. Mean age of patients was 30 years. The most common cause of orbital fracture was motor vehicle accident which was seen in 38 patients.46 patients had fracture in left orbit and 44 patients in right. Isolated orbital fracture was seen in 38 patients and 54 patients had concomitant trauma and fracture in the other organs. Management of orbital fracture was reduction of displaced bone fragment and fixation for osteosynthesis. The most common methods for osteosynthesis was fixation with miniplate which used in 53 patients and then reconstruction of orbital floor and roof with autologus bone graft. The most common complications due to orbital fracture was related to eyes that were seen in 20 patients.
Conclusion: Face fractures are a piece of all problems in multiple trauma patients as the tip of iceberg. Concomitant injuries are the concealed part of this iceberg. Early detection of orbital fracture and immediate treatment that prevent the future complications and deformities due to orbital fractures.

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Normal 0 false false false EN-US X-NONE AR-SA MicrosoftInternetExplorer4 !mso]> ject classid="clsid:38481807-CA0E-42D2-BF39-B33AF135CC4D" id=ieooui> Background: The aim of this study was to describe the prevalence of different types of maxillary fractures, concurrent fractures and accompanying signs and symptoms. Trauma is the second cause of mortality in Iran, after cardiovascular diseases. In traumatic patients, head, neck and facial bones fractures are common. The maxillary fractures are seen much less commonly than the fractures of the mandible, zygoma, or nose. Maxillary fractures include: (Le fort I, II, III fractures- alveolar process fracture and Sagittal fracture). The most common cause of maxillary fracture is motor vehicle accidents.
Methods: This descriptive cross sectional study designed on 56 patients with maxillary fractures in a referral educational trauma center of Tehran. Sample size was the patients who referred to this hospital with maxillary fracture during past seven years.
Results: Forty eight (86%) patients were male and 8(14%) were female. Male to female ratio was 6/1. Mean age of patients was 30 years. The most common type of maxillary fracture was infra orbital rim and floor fracture. Among Le fort fracture Le fort type II was the most common. Paresthesia of infra orbital nerve and malocclusion were more common than the other especial signs of maxillary fracture. Concomitant fracture with maxilla include: zygomatic fracture in 62%, mandibular fracture in 25%, nasoethmoidal fracture in 9% and skull base fracture in 4%. Management of maxillary fracture was reduction of displaced bone fragment and fixation for osteosynthesis. The most common way for osteosynthesis was fixation with miniplate and screw.
Conclusions: Face fractures are a piece of all problems in multiple trauma patients as the tip of iceberg. Early diagnosis of maxillary fractures and immediate treatment will prevent the future deformities and complications.

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Background: Central venous catheters are useful instruments in monitoring of critical patients and are important roots for total parentral nutrition. The catheters are widely used in general wards and intensive care units. Their use may be associated with serious and rare complications.

Case presentation: We reported a 24 years old woman that admitted to Ghaem hospital Mashhad University of Medical Science, in Mashhad, Iran, because of penetrating chest wall injury and surgical exploration indicated due to massive hemorrhage. Central vein (right jugular vein) was canulated for resuscitation and monitoring. Superior vena cava was injured after canulation and presented with delay massive mediastinal hematoma.

Conclusion: We aim to introduce this rare complication and its management. This management could be conservative or surgical intervention according to severity of the vein damage.

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Background: Anosmia is a physical sign in post-traumatic patients, which significantly reduces the quality of life. Anosmia occurs in up to 30% of cases with head trauma. In this study we aimed to compare the Olfactory Bulb Volume (OBV) in patients with posttraumatic anosmia in different impact positions and also with healthy individuals to find the relation between the two variables.
Methods: Thirty-eight patients with posttraumatic anosmia and 27 healthy individuals with normal olfactory function were recruited in this case-control study performed in Amir Alam Hospital in Tehran, Iran. Variables of age, sex, time of trauma, site of trauma (frontoparietal/occipital), side of trauma, OBV, the results of olfactory identification tests and olfactory threshold were extracted and evaluated. We used non-contrasted 1.5-Tesla coronal brain MRI for the measurement of OBV.
Results: There were no significant differences between cases and controls regarding sex and age. Olfactory bulb volume was significantly smaller in cases compared to the controls (P=0.004). Among the case group, OBV was smaller in anterior versus posterior head traumas (P=0.02). OBV was also smaller in ipsilateral rather than the contralateral side of trauma (P=0.01).
Conclusion: The direction of trauma had a significant effect on OBV and it was smaller in traumas to the anterior and also ipsilateral sides of the head. It seems that changes in OBV differ due to the direction of head trauma and it can be helpful in predicting the prognosis of posttraumatic anosmia. Further studies are required for more conclusive statements.

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Background: Bispectral Index (BIS) may be used in traumatic brain injured patients with different anatomical sites of injury to evaluate the level of consciousness. The objective of this study is to evaluate the relation between type of brain injury and the presence or absence of frontal lobe damage based on brain CT-scan with BIS monitoring in intubated acute head trauma patients admitted to the intensive care unit (ICU). Methods: Participants of this cross-sectional study consisted of 30 intubated head trauma patients over the age of 15 years old, without any known history of visual or hearing impairments, neurologic disorders, mental retardation, or frontal skin laceration, who were admitted to the ICU in Rasool Akram University Hospital, Tehran. Patients who needed muscle relaxant administration, or those who showed instability of vital signs, hypoxemia, disorders of the blood biochemistry, or blood gases, liver or kidney failure, convulsion or hypoxic encephalopathy during the study were excluded. In the first three days of admission, each patient underwent monitoring of BIS every sixty minutes for just six hours a day. All the hypnotic drugs were discontinued six hours prior to the start of monitoring and fentanyl was the only opioid, which was administered if an analgesic was required. Statistical analysis were used to evaluate the data and p-value less than 0.05 was considered statistically significant. Results: Mean age of all patients was 43.6 years with a Standard Deviation (SD) of 18.96. Presence or absence of frontal lobe injury, had no statistically significant correlations with mean BIS in each three days of study and the mean BIS total. However, mean BIS in the second and third days had statistically significant differences in different types of cranial lesions (contusion, subdural hemorrhage, subarachnoid hemorrhage, etc) which usually have different prognoses. Conclusion: Different kinds of acute traumatic cranial lesions with different prognosis may have different values in BIS monitoring. Presence or absence of frontal lobe injury, had no statistically significant correlations with BIS values.

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Background: Acute respiratory distress syndrome (ARDS) is one of the most important complications associated with traumatic brain injury (TBI). ARDS is caused by inflammation of the lungs and hypoxic damage with lung physiology abnormalities associated with acute respiratory distress syndrome. Aim of this study is to determine the epidemiology of ARDS and the prevalence of risk factors.

Methods: This prospective study performed on patients with acute traumatic head injury hospitalization in the intensive care unit of the Shohaday-e Haftom-e-Tir Hospital (September 2012 to September 2013) done. About 12 months, the data were evaluated. Information including age, sex, education, employment, drug and alcohol addiction, were collected and analyzed. The inclusion criteria were head traumatic patients and exclusion was the patients with chest trauma. Questionnaire was designed with doctors supervision of neurosurgery. Then the collected data were analysis.

Results: In this study, the incidence of ARDS was 23.8% and prevalence of metabolic acidosis was 31.4%. Most injury with metabolic acidosis was Subarachnoid hemorrhage (SAH) 48 (60%) and Subdural hemorrhage (SDH) was Next Level with 39 (48%) Correlation between Glasgow Coma Scale (GCS) and Respiratory Distress Syndrome (ARDS) were significantly decreased (P< 0.0001). The level of consciousness in patients with skull fractures significantly lower than those without fractures (P= 0.009) [(2.3±4.6) vs (4.02±7.07)]. Prevalence of metabolic acidosis during hospitalization was 80 patients (31.4%).

Conclusion: Acute respiratory distress syndrome is a common complication of traumatic brain injury. Management and treatment is essential to reduce the mortality. In this study it was found the age of patients with ARDS was higher than patients without complications. ARDS risk factor for high blood pressure was higher in men. Most victims were pedestrians. The most common injury associated with ARDS was SDH. Our analysis demonstrates that Acute respiratory distress syndrome is common after traumatic brain injury. Management of traumatic brain injury is necessary to manage and reduce the mortality.

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Background: Brain hypothermia by reducing the temperature of the cerebrospinal fluid is done by a cooling pad in the thoracic region and protect brain from the ischemic injuries. Along with the spinal cord, the brain is an essential partner in the central nervous system, and similarly, it is surrounded and protected from the bony skull and from shock by cerebrospinal fluid. The brain analyzes information that is both internal and external to the body, transforms the information into sensations, and stores them as memories. So in this study we investigated the brain hypothermia by finite element modeling. Methods: To investigate this phenomenon, in this study a numerical model of the head with respect to the structure of brain tissue and its contribution to heat transfer is presented in the fluid lab of the Amirkabir University of Tehran in January of 2016. In this model, Pennes's bioheat equation and finite element analysis has been used to predict temperature distribution in the brain tissue. The model geometry is designed in two state without considering the ventricles of the brain that are involved in the production of cerebrospinal fluid and with considering cerebrospinal fluid. So, in the second case, the cerebrospinal flow is considered as a heat transfer factor. Results: We concluded that with cooling about 5 °C, in the first model without considering the ventricles, the gray matter temperature is reduced by about 4 °C and there is no change in white matter temperature. In the second model temperature distribution became more asymmetric. The temperature reduced about 3 °C in the corners. However, the temperature reduction at the edge of brain tissue and near cerebrospinal fluid were about 0.5 °C.

Conclusion: It was observed that in the case of ischemia, the temperature drop was higher than normal. So, during brain injuries to prevent serious damage, the brain metabolism can be reduced by cooling the spinal fluid.

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Background: Acute compartment syndrome is considered a debilitating complication of limb trauma. Early detection of this compartment syndrome helps us in the early initiation of treatment which will result in preventing its subsequent complications reported in these cases.
Methods: This research was an analytical cross-sectional study. Patients with direct trauma to extremities, who were referred to the emergency department of Valiasr and Amir Al-Momenin hospitals were studied from October 2018 to April 2019 in Arak, Iran. Patients were selected if they met all of the inclusion criteria and none of the exclusion criteria. Vital signs were measured and recorded for each patient. Also, the results of physical examination, intra-compartmental pressure measurement by a wick catheter and the level of the creatine phosphokinase were recorded. All data analyses were performed with the use of SPSS v21 software.

Results: A total number of 70 subjects were included in this study, comprising 65 males (93.1%) and 5 females (6.9%). The results showed that there is a significant relationship between intra-compartment pressure and the level of creatine phosphokinase enzyme. The higher the intracompartmental pressure, the higher the creatine phosphokinase level. Statistically significant associations were observed between intracompartmental pressure and pallor, edema, lack of limb pulse, and diastolic blood pressure. No significant relationship was found between intracompartmental pressure and limb pain, numbness, inability to move the injured limbs, and systolic blood pressure. In addition, our findings indicated that creatine phosphokinase is significantly associated with edema and lack of limb pulse. No significant relationship was found between creatine phosphokinase with pain, pallor, numbness, inability to move limbs, and systolic and diastolic blood pressure. Conclusion: The study findings suggest that measurement of intracompartmental pressure could be considered as an effective alternative approach to creatine phosphokinase levels to diagnose compartment syndrome. So, this will prevent irreparable damage to the extremities and is of great importance.

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Background: Traumatic Spinal Cord Injury (TSCI) is one of the catastrophic events, the rate of which has been growing compared to the past decades. Complications caused by TSCI have a wide spectrum and can range from complete paralysis to numbness of the limbs. Additional to the injury severity and disability of the patient, the recovery rate depends on the treatment strategies. Despite extensive efforts and research in this field, there are still few treatment options for TSCI patients. Controversial results have been reported, however, spinal cord decompression is the only certainty for the treatment of these patients. In the present study, patients with thoracic and lumbar fractures were undergone decompression, less and more than 24 hours, and the recovery rate (RR) was compared after 6 months.
Methods: In this study, patients with lumbar and thoracic fractures who were referred to the neurosurgery department of Ahvaz Golestan Hospital during May 2019 to December 2021 were included. Decompression was performed at the fracture level as a total and at the upper and lower levels of the fracture as a partial decompression. To evaluate fine motor movements, picking up a small object with toes and following a rectangular path were used. Also, the gross motor movements, upper and lower proximal and distal muscle forces were measured. Conclusion: This study showed that decompression<24 hours in TSCI is associated with a significant improvement in lower fine movements.
 

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