Essential skills 










219
Chapter8
Essentialskills
Local anaesthesia 220
Intra- oral suturing 224
Managing the bleeding socket 225
Managing the dry socket 226
Suturing facial lacerations 228
Packing the nose and midface for bleeding 230
Re- implanting and splinting teeth 231
Temporomandibular joint relocation 232
Bridle wiring and intermaxillary xation 233
Incision and drainage of intra- and extra- oral abscesses 234
Biopsy of intra- and extra- oral lesions 236
Nasendoscopy 238
Taking dental impressions 239
Cricothyroidotomy 240

220
CHAPTER8 Essentialskills
220
Local anaesthesia
Generalpoints
Maximum dosages are important and are covered in Chapter 11
(see E pp. 276–7).
In this chapter we give practical tips on how to give eective mucosal
and cutaneous anaesthesia with minimal discomfort.
Use the nest needle you can and as few punctures as possible, so a
long needle is better. Inject slowly, warm the solution, and give enough
anaesthetic, especially for diusion throughbone.
If you have to make more than two punctures in the skin, change the
needle. The patient will notice the dierence as it becomesblunt.
If the skin is breached, inject into the edges of the wound from inside to
avoid puncturing the epidermis, to minimizepain.
Wherever possible use regional blocks rst followed by local inltration
afterwards if needed. For example, for a tongue biopsy, do a relatively
painless lingual nerve block in the posterior FOM and then use local
inltration into the numb tongue for help with haemostasis. Don’t
put the needle into the tip of the tongue rst as this would be very
uncomfortable!
The inferior alveolar nerve (IAN)block
Otherwise known as the inferior dental block(IDB).
The aim is to block the IAN as it enters the mandibular foramen. This
will render all the ipsilateral mandibular teeth, the lower lip, and part of
the chinnumb.
It is easiest to do this with a special self- aspirating dental syringe, but this
is not essential.
Do not bend the needle. They rarely break but it does still happen.
Open the mouth wide and with your non- dominant thumb feel for the
external oblique ridge. At about 1.5cm above the plane of the lower
teeth advance a long needle lateral to the pterygomandibular raphe for
about1cm.
Deposit 0.5 mL of solution there to block the lingualnerve.
Turn whole syringe through 760° so that the needle tip is pointing
laterally and continue to advance slowly until you feel bone. Withdraw
by 1– 2mm. Before depositing the rest of the cartridge, gently press on
the plunger to make sure that you are not in a vessel (blood will appear
in the cartridge if you are). If so, reposition and tryagain.
If you are using a non- aspirating syringe, you should aspirate rst and
check that you are not in a vessel.
Wait a few minutes and check whether the lower lip is beginning to lose
sensation— if not, repeat theblock.

LOCAL ANAESTHESIA
221
Other LAblocks
You can block the mental, greater palatine, incisive, infra- orbital, supra-
orbital, and supra- trochlear nerves by depositing some solution at the
respective foramina.
The mental foramen lies between the apices of the lower premolar
teeth and blocking here will render the ipsilateral premolar and incisor
teeth numb as well as the lower lip and chin. It is much kinder to block
the nerve than to inject directly into the lip. You only need to insert the
needle a few millimetres under the mucosa and the solution will reach
thenerve.
The infra- orbital foramen lies 1cm below the inferior orbital rim on
the mid- pupillary line. You can approach it intra- or extra- orally. It
will render much of the cheek, side of nose, upper lip, and ipsilateral
anterior teeth numb. If you place your non- dominant index nger on the
orbital rim and your non- dominant thumb inside the mouth in a pincer-
like fashion, thereby elevating the upper lip, you will nd that it is really
quite easy to direct the needle to the right spot. Do not attempt to put
the solution within the canal. There is almost no indication and you may
inject intravascularly or cause a painfulbleed.
The supraorbital foramen is on approximately the same vertical axis
as the infraorbital and mental foramina, and blocking here will render
the temporal side of the forehead numb. Beware— the vessel which
runs with the nerve is easily encountered, so this block is rarely used
for forehead lacerations. It is often less painful to inject into the wound
edges. Similarly, the supratrochlear block is not oftenused.
The greater palatine and incisive nerves can be blocked, thus rendering
the entire palate numb with three injections. This is often preferred as
palatal local inltration is painful. The incisive nerve lies in the midline
just behind the upper incisors. The greater palatine nerve will be found
about a nger’s breadth medial to the very back of the upper alveolar
bone. Ideally use some topical benzocaine cream rst as these injections
are painful.
Local inltration inthemouth
Depositing LA solution under the mucosa and above the periosteum will
render the overlying mucosanumb.
In all areas of the jaws, with the exception of the posterior mandible, it
will also render the pulp of the adjacent teeth numb by diusing through
the alveolarbone.
This will not occur in the mandible distal to the premolars as the bone
is too dense, hence the need for IDB or injecting into the periodontal
ligament.
They key to good inltration is to inject slowly and remember that
injecting into tightly adherent mucosa such as gingivae and palate will
be very painful. Therefore you should try a regional block whenever
possible, or inject from a numb area into a sensate area, thereby
advancing the area of anaesthesia from an easy site into the dicultsite.
Teeth can be anaesthetized by injecting into the periodontal ligament. It
is much easier if the tooth has periodontal disease.

222
CHAPTER8 Essentialskills
222
Local inltration forskin surgery
Regional blocks have been discussed earlier in thistopic.
When closing lacerations it can be less painful to inject via the open
wound into the dermis, thereby bypassing the epidermis.
Use as few injections as possible. Along thin needle which can be
advanced as the anaesthetic is given isideal.
Dental anaesthetic and a syringe with a long needle is preferred by many
surgeons.
If you are anaesthetizing for elective surgery, inject around the lesion in
as few sites as possible in the dermal layer using a solution containing
epinephrine, and then wait for it to work. You will see the skin blanch in
<1 minute.
If you are removing an epidermoid cyst, try not to inject into the cyst
as it will cause it to rupture. Injecting around it may help by means of
hydro- dissection.

LOCAL ANAESTHESIA
223

224
CHAPTER8 Essentialskills
224
Intra- oral suturing
Generalpoints
Good patient positioning is essential for all surgical skills, but especially
for working in the mouth. The patient can be sitting or lying down, but
their head must be supported to remain still. You must have a good light
source, suction, and an assistant, and feel comfortable with your back
straight.
Practise performing instrument ties as much as possible.
The main problem that beginners have is ‘getting the knot down’. The
key is to pull the needle end of the suture out of the mouth with one
hand, while moving the needle- holders which are holding the free end of
the suture down towards the suture line. However, it takes practice.
Most intra- oral suturing uses resorbable sutures, but this is not always
the case (e.g. when the wound needs support for prolonged periods
of time:periodontal plastic surgery, over membranes, or closure of an
OAF). In these instances a monolament non- resorbable suture may be
used, but these can be uncomfortable for the patient.
J- shaped needles can be very useful in places that are hard to reach,
such as the palate.
Probably the best advice is to remember that the oral cavity is best
approached from the front! This means that you may have to change
the way you hold the needle- holders or position the needle in the tips in
order to reach the wound from the front of themouth.
Suturing is a two- handed business. At times it may be easier to pick up
the tissues with your non- dominant hand using forceps and place it onto
the needle, so remember to use both your hands together.
Don’t always try to do it in one pass. You will often bend the needle or
tear the tissues.
Use the curve of the needle. Sometimes there will be a limited amount
of tissue available and you may have only one or two tries before the
tissue is damaged and unsuturable. Be aware of the cutting eect of the
needle and how its angle of passage aects whether mucosa is pierced
or incised.
Don’t think that you always need to close everything tightly. In most
instances you just need to put mucosa back where it came from. Open
tooth sockets heal very well if a clot remains inthem.
If you are advancing some mucosa across a defect you may need to
‘score’ the periosteum only to allow it to move more freely. You will
need long relieving cuts into the reected mucosa and the sutures
should lie over sound bone. Be gentle when cutting the periosteum or
else you may have the separated ap in yourhand!
Try to avoid attached gingivae pulling away around teeth, especially in
the upper anterior region (the aestheticzone).
If possible, avoid having the needle coming out through the periodontal
sulcus. It may worsen periodontal disease.
The oral cavity heals well and is quite forgiving if you get the basicsright!

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219 Chapter8EssentialskillsLocal anaesthesia 220Intra- oral suturing 224Managing the bleeding socket 225Managing the dry socket 226Suturing facial lacerations 228Packing the nose and midface for bleeding 230Re- implanting and splinting teeth 231Temporomandibular joint relocation 232Bridle wiring and intermaxillary xation 233Incision and drainage of intra- and extra- oral abscesses 234Biopsy of intra- and extra- oral lesions 236Nasendoscopy 238Taking dental impressions 239Cricothyroidotomy 240 220CHAPTER8 Essentialskills220Local anaesthesiaGeneralpoints• Maximum dosages are important and are covered in Chapter 11 (see E pp. 276–7).• In this chapter we give practical tips on how to give eective mucosal and cutaneous anaesthesia with minimal discomfort.• Use the nest needle you can and as few punctures as possible, so a long needle is better. Inject slowly, warm the solution, and give enough anaesthetic, especially for diusion throughbone.• If you have to make more than two punctures in the skin, change the needle. The patient will notice the dierence as it becomesblunt.• If the skin is breached, inject into the edges of the wound from inside to avoid puncturing the epidermis, to minimizepain.• Wherever possible use regional blocks rst followed by local inltration afterwards if needed. For example, for a tongue biopsy, do a relatively painless lingual nerve block in the posterior FOM and then use local inltration into the numb tongue for help with haemostasis. Don’t put the needle into the tip of the tongue rst as this would be very uncomfortable!The inferior alveolar nerve (IAN)blockOtherwise known as the inferior dental block(IDB).• The aim is to block the IAN as it enters the mandibular foramen. This will render all the ipsilateral mandibular teeth, the lower lip, and part of the chinnumb.• It is easiest to do this with a special self- aspirating dental syringe, but this is not essential.• Do not bend the needle. They rarely break but it does still happen.• Open the mouth wide and with your non- dominant thumb feel for the external oblique ridge. At about 1.5cm above the plane of the lower teeth advance a long needle lateral to the pterygomandibular raphe for about1cm.• Deposit 0.5 mL of solution there to block the lingualnerve.• Turn whole syringe through 760° so that the needle tip is pointing laterally and continue to advance slowly until you feel bone. Withdraw by 1– 2mm. Before depositing the rest of the cartridge, gently press on the plunger to make sure that you are not in a vessel (blood will appear in the cartridge if you are). If so, reposition and tryagain.• If you are using a non- aspirating syringe, you should aspirate rst and check that you are not in a vessel.• Wait a few minutes and check whether the lower lip is beginning to lose sensation— if not, repeat theblock. LOCAL ANAESTHESIA221 Other LAblocksYou can block the mental, greater palatine, incisive, infra- orbital, supra- orbital, and supra- trochlear nerves by depositing some solution at the respective foramina.• The mental foramen lies between the apices of the lower premolar teeth and blocking here will render the ipsilateral premolar and incisor teeth numb as well as the lower lip and chin. It is much kinder to block the nerve than to inject directly into the lip. You only need to insert the needle a few millimetres under the mucosa and the solution will reach thenerve.• The infra- orbital foramen lies 1cm below the inferior orbital rim on the mid- pupillary line. You can approach it intra- or extra- orally. It will render much of the cheek, side of nose, upper lip, and ipsilateral anterior teeth numb. If you place your non- dominant index nger on the orbital rim and your non- dominant thumb inside the mouth in a pincer- like fashion, thereby elevating the upper lip, you will nd that it is really quite easy to direct the needle to the right spot. Do not attempt to put the solution within the canal. There is almost no indication and you may inject intravascularly or cause a painfulbleed.• The supraorbital foramen is on approximately the same vertical axis as the infraorbital and mental foramina, and blocking here will render the temporal side of the forehead numb. Beware— the vessel which runs with the nerve is easily encountered, so this block is rarely used for forehead lacerations. It is often less painful to inject into the wound edges. Similarly, the supratrochlear block is not oftenused.• The greater palatine and incisive nerves can be blocked, thus rendering the entire palate numb with three injections. This is often preferred as palatal local inltration is painful. The incisive nerve lies in the midline just behind the upper incisors. The greater palatine nerve will be found about a nger’s breadth medial to the very back of the upper alveolar bone. Ideally use some topical benzocaine cream rst as these injections are painful.Local inltration inthemouth• Depositing LA solution under the mucosa and above the periosteum will render the overlying mucosanumb.• In all areas of the jaws, with the exception of the posterior mandible, it will also render the pulp of the adjacent teeth numb by diusing through the alveolarbone.• This will not occur in the mandible distal to the premolars as the bone is too dense, hence the need for IDB or injecting into the periodontal ligament.• They key to good inltration is to inject slowly and remember that injecting into tightly adherent mucosa such as gingivae and palate will be very painful. Therefore you should try a regional block whenever possible, or inject from a numb area into a sensate area, thereby advancing the area of anaesthesia from an easy site into the dicultsite.• Teeth can be anaesthetized by injecting into the periodontal ligament. It is much easier if the tooth has periodontal disease. 222CHAPTER8 Essentialskills222Local inltration forskin surgery• Regional blocks have been discussed earlier in thistopic.• When closing lacerations it can be less painful to inject via the open wound into the dermis, thereby bypassing the epidermis.• Use as few injections as possible. Along thin needle which can be advanced as the anaesthetic is given isideal.• Dental anaesthetic and a syringe with a long needle is preferred by many surgeons.• If you are anaesthetizing for elective surgery, inject around the lesion in as few sites as possible in the dermal layer using a solution containing epinephrine, and then wait for it to work. You will see the skin blanch in <1 minute.• If you are removing an epidermoid cyst, try not to inject into the cyst as it will cause it to rupture. Injecting around it may help by means of hydro- dissection. LOCAL ANAESTHESIA223 224CHAPTER8 Essentialskills224Intra- oral suturingGeneralpoints• Good patient positioning is essential for all surgical skills, but especially for working in the mouth. The patient can be sitting or lying down, but their head must be supported to remain still. You must have a good light source, suction, and an assistant, and feel comfortable with your back straight.• Practise performing instrument ties as much as possible.• The main problem that beginners have is ‘getting the knot down’. The key is to pull the needle end of the suture out of the mouth with one hand, while moving the needle- holders which are holding the free end of the suture down towards the suture line. However, it takes practice.• Most intra- oral suturing uses resorbable sutures, but this is not always the case (e.g. when the wound needs support for prolonged periods of time:periodontal plastic surgery, over membranes, or closure of an OAF). In these instances a monolament non- resorbable suture may be used, but these can be uncomfortable for the patient.• J- shaped needles can be very useful in places that are hard to reach, such as the palate.• Probably the best advice is to remember that the oral cavity is best approached from the front! This means that you may have to change the way you hold the needle- holders or position the needle in the tips in order to reach the wound from the front of themouth.• Suturing is a two- handed business. At times it may be easier to pick up the tissues with your non- dominant hand using forceps and place it onto the needle, so remember to use both your hands together.• Don’t always try to do it in one pass. You will often bend the needle or tear the tissues.• Use the curve of the needle. Sometimes there will be a limited amount of tissue available and you may have only one or two tries before the tissue is damaged and unsuturable. Be aware of the cutting eect of the needle and how its angle of passage aects whether mucosa is pierced or incised.• Don’t think that you always need to close everything tightly. In most instances you just need to put mucosa back where it came from. Open tooth sockets heal very well if a clot remains inthem.• If you are advancing some mucosa across a defect you may need to ‘score’ the periosteum only to allow it to move more freely. You will need long relieving cuts into the reected mucosa and the sutures should lie over sound bone. Be gentle when cutting the periosteum or else you may have the separated ap in yourhand!• Try to avoid attached gingivae pulling away around teeth, especially in the upper anterior region (the aestheticzone).• If possible, avoid having the needle coming out through the periodontal sulcus. It may worsen periodontal disease.• The oral cavity heals well and is quite forgiving if you get the basicsright! MANAGING THEBLEEDINGSOCKET225 Managing thebleedingsocketGeneralpoints• Sit the patient up; get good mouth opening; use head support suction, good light, and an assistant.• Remove all clots and see exactly where the bleeding pointis.• Is it the gum edges, within the socket, or is it from under a mucoperiosteal ap which was lifted to get the tooth out? The long buccal artery for lower third molars is notorious forthis.• If it is bleeding from under the ap, you may need to lift it back up to examine underneath.• Consider the possibility of a clotting issue. Ask about warfarin, clopidogrel, and aspirin, and manage accordingly. Has the patient taken metronidazole postoperatively with their warfarin? Remember, this raises theINR.• Could there be an undiagnosed clotting disorder or haematological problem— consider haematology and coagulation bloodtests.• Give plenty of LA— a regional block rst and then, using a solution containing adrenaline (epinephrine), give a lot around the site including the socket edges and wait for at least 7 minutes for the homeostatic eect to work. During this time the patient can bite on apack.• If there are sutures and/ or a packed socketalready, remove them and startagain.• Clean the socket and pack it with resorbable cellulose (Surgicel®).• Suture the socket tightly with a horizontal mattress suture of 3- 0 braided resorbable suture or black silk (see next subsection).• Apply a pressure pack over the socket and ask the patient to bite down on it for 30 minutes.• During this time you can recheck their observations and do any medical jobs you may need to do, like checking theirINR.• In almost all cases these measures are enough.• You can consider tranexamicacid.• Don’t assume that a tooth socket cannot be a major source of blood loss. It can, and in some patients it could be fatal. Treat them in the same way as you would any other bleeding patient.• Always go back to ensure the patient has stopped bleeding before discharge.Suturing thebleedingsocket• The purpose is to compress the gum edges against the bone and to hold the resorbable cellulose pack inplace.• Ahorizontal mattress suture in 3- 0 braided resorbable suture or black silk isbest.• It must be tight, so take good- sizebites.• This may require you to mobilize some of the attached gingival tissue around thesocket.• Acouple of interrupted sutures will also do, but if it is not tight take it out and do it again. If you are struggling to keep the tension on, try handtying. 226CHAPTER8 Essentialskills226Managing thedrysocketGeneralpoints• This is also known as localized osteitis.• Adry socket is one that is not healing and is extremely painful.• The normal blood clot within the socket (which is the rst step of the normal healing process) has been lost, possibly because of anaerobic bacterial action and food debris collected in the empty socket. The bone of the socket is exposed and painful to touch, there may be some degree of inammation of surrounding soft tissues, the smell is unpleasant, and the patient may have trismus in thebone.• It usually presents about 3– 4days after extraction.• Giving perioperative antibiotics probably does not make any dierence, and postoperatively denitely doesn’t, so don’t blame the dentist.• It is most common in the lower third molar area, in women on OCP and smokers, and possibly after periodontal ligament injection.• Not everyone who presents with pain and swelling after dental extractions has a dry socket, so always examine them fully and check that they have not got an abscess somewhere. In particular, look out for pus on the lingual side or around the pharynx as this can be life- threatening.• Consider other possibilities. Is there a fragment of tooth or bone that has been left behind in the socket? Is there a fracture through the socket which may have occurred peri- or postoperatively? If you think so, get a radiograph.Treatment• It may be helpful to give an IDB (for a lower molar dry socket) but this is not always necessary.• Irrigate the socket with copious warm saline to remove all the food debris.• If you have a good IDB, you can scrape the lining of the socket to encourage bleeding and remove the non- vitalbone.• In most cases it is kinder and just as eective to pack the socket with Alvogyl® (see E p. 282) or a similar substance.• Antibiotics are not indicated unless there is evidence of systemic infection or signicant local inammation of the soft tissues, or the patent is immunocompromised.• NSAIDs are sucient for the pain, which usually settles quite quickly after Alvogyl® is placed.• One visit is normally enough, but occasionally further packing may be needed. MANAGING THEDRYSOCKET227 228CHAPTER8 Essentialskills228Suturing facial lacerationsGeneralpoints• Make sure that you are not missing an underlying facial (or skull) fracture. The classic is a chin laceration with associated condylar fractures.• Look for facial nerve injury before you putinLA.• Most minor facial lacerations can be closed quickly in the ED under LA and no follow- up is required.• The more serious lacerations require special attention to give the patient the best long- term outcome. If you see them in the middle of the night, consider washing and dressing the wound, then bringing the patient back the following day when there is more help and perhaps an operating theatre available.Wound preparation• Clean the wound with copious saline.• Give LA— a combination of regional blocks and local inltration into wound edges is usuallyideal.• Remove any debris and irrigateagain.• Excise non- vital tissue and crushed wound edges so that the wounds are clean and incised at 90° to the skin surface.Suturing• Align anatomical borders, such as vermilion, brow, and eyelid,rst.• If there is skin loss (which is rare), surgery becomes tricky. Call your senior.• For deep layers use resorbable sutures (e.g. 4- 0 Vicryl® or Monocryl®) to close the dead space and take tension o the skinedges.• If the laceration is a straight line, a continuous dermal suture may be ideal. This could be a resorbable or non- resorbable monolament.• 5- 0 or 6- 0 non- resorbable monolament suture is suitable to close facial skin. In small children, a 6- 0 or 7- 0 resorbable suture may be better to avoid the need for sedation or GA to remove sutures.• Sutures on the face can be removed at 5days. Scalp wounds 10– 14days.• If the wound is not gaping or the deep sutures hold the skin edges together well, you may be able to use a dermal adhesive as long as you are familiar with the product. Don’t get it in the eye. Don’t use it with a non- compliant patient, and don’t get it in the wound! It acts as a bridge across the wound surface by sticking to the skin on each side of the wound. It also acts as a barrier to uid, so once it has set the wound is watertight. Advise the patient to apply white soft paran to the glue after about 7days and denitely not to pick at theglue.• Alaceration which is clean and not gaping may only need Steri- Strips™. SUTURING FACIAL LACERATIONS229 Lip lacerations• Check if the laceration is full thickness. In punch injuries and falls the lip may be pushed against the tooth, so check for an associated dental or bony injury.• Mental nerve blocks are kind. Local inltration afterwards may help haemostasis.• Align the vermilion borderrst.• Suture the muscle and then the mucosa, both with resorbable sutures.• Close the skinlast.Ear lacerations• Look for a perichondral haematoma— if untreated, this leads to cauliower ear, so if you nd it, drain it! Asmall stab incision under LA will allow drainage.• Exclude base of skull fractures and examine the external auditory meatus.• Wash well and close the skin over the cartilage with non- resorbable sutures.• You may need a pressure dressing for 24hours.Eyebrow lacerations• Align the tissue carefully.• Excise non- vital tissue parallel to the hair shafts.• Shaving or cutting the hair is not necessary.Eyelid lacerations• Senior assistance is often required.• Exclude globe injuries. Discuss with the ophthalmologist.• In upper eyelid wounds, assess for damage or rupture to levator palpebrae superioris, which would cause a drooping eyelid (ptosis).• Does the wound involve the lacrimal apparatus? If so, you will denitely need help. Call your senior and the ophthalmologist.• The tarsal plate and eyelid margin must be realigned accurately.• Eyelid skin heals well, so you can be minimalist with your suturing.Nose lacerations• Check for a septal haematoma and drain it if you ndit.• If the laceration is full thickness, close the mucosarst.• Align skin, especially around the alar margin, and close with non- absorbable sutures.• If there is lost tissue, call for senior help, do not attempt to close. It is often treated conservatively initially, especially if the wound is dirty. Formal reconstruction can then be done at a laterdate. 230CHAPTER8 Essentialskills230Packing thenose and midface forbleedingGeneralpoints• Some of this is covered in E Chapter 10, but it is important and so there may be some duplication.• Patients can die because of inadequate resuscitation and delay in treatment.• In this chapter, we deal only with the techniques. Knowledge of the general management of bleeding patients is expected and specics are covered in E Chapter10.Packing thenasalcavity• Sit the patient forward and pinch nostrils.• While they are sitting there, explain that you are going to place a couple of ‘tampons’ in their nose which will stop the bleeding.• Explain that it will be uncomfortable briey but you will do it quickly.• Get two nasal tampons (Merocel®) and lubricate the end that does not have a string attached with plenty of water- based lubricant.• If the patient is sitting they must have head support, it may be easier to do this with them lying down briey.• The tampon is a bit like a lolly stick! The at surface should be parallel to the nasal septum.• Lift the nasal tip and in one brisk rm movement push the tampon backwards along the nasal oor parallel to the hard palate.• It may be necessary to insert one on eachside.• They should not normally be left in situ for more than about 24hours.• The strings can be tied together and a bolster placed under thenose.Packing themidface• If immobilized on a spinal board, stopping bleeding quickly is essential from an airway point ofview.• If not immobilized and safe to do so, sit the patient up and allow them to lean forward.• Get a good light source and suction out the mouth and anteriornose.• Try to nd the source of bleeding.• Pass a Foley catheter along the nasal oor so that the balloon is just beyond the posterior nasal aperture and inate the balloon. Repeat on otherside.• Pull the inated balloons against the posterior nasal aperture and then pack the anterior nasal cavity with nasal tampons on bothsides.• Use a disposable drain clamp to secure the Foley catheter and maintain pressure. RE-IMPLANTING AND SPLINTINGTEETH231 Re- implanting and splintingteethGeneralpoints• The socket must be adequately anaesthetized, so give injections as if you were taking the toothout.• Make sure that it really is a permanent tooth. There is no reason to re- implant a deciduoustooth!• Re- implantation is most likely to be successful in young people who have presented within an hour or two with a tooth which has been kept in saliva, saline, ormilk.• Do not attempt re- implanting a tooth which has been out for hours and is dry and dirty. It is not a pleasant procedure and in such cases it will not work anyway.• If you are not dentally qualied, try and get someone who is to helpyou.• Time is the major factor determining success, so it cannot wait until the morning.• Give the patient a short course of broad- spectrum antibiotics and regular simple analgesia.• After re- implantation or reduction of a displaced tooth, it is usually necessary to splintit.• The patient will need a follow- up the next day with a dentist.Re- implanting or repositioning atooth• Hold the tooth by the crown and gently rinse it in sterile saline. Do not touch the root surface atall.• Ensure that you have the right tooth for the right hole. This can be dicult if both central incisors have been lost, but if you look carefully at someone else (e.g. the patient’s partner) as a guide, you will see the subtle dierences with the incisive slant— the distal part (towards the back of the mouth) looking from the front has more of a curve at the incisal edge than the medial edge (towards the front).• Make sure that the socket is clean and empty, give LA, and irrigate the socket.• Firmly push the tooth back into the socket. Then place a gauze pack between the upper and lower teeth and ask the patient to bite on it in such a way as to hold the tooth in the socket. You will now need to splint thetooth.• Repositioning the tooth is much same. You need lots of LA and you physically move the tooth back to the correct position and splintit.SplintingteethThere are many ways of splinting a tooth. Get someone to show you one and practise it. Most use a wire and some composite resin, or a glass iono-mer that sticks to dry tooth enamel. When you have mixed it, put it on the labial side of the tooth with two teeth either side, and place a pre- bent orthodontic wire into the material. Put some more over the wire and wait for it to set! It’s really quiteeasy! 232CHAPTER8 Essentialskills232Temporomandibular joint relocationGeneralpoints• Patients with dislocated TMJs present unable to close the mouth, with pain, and drooling.• It may follow trauma, yawning, prolonged dentistry, vomiting, or anaesthesia. Some patients can do it voluntarily.• If there is anything in the history to suggest that there could be a fracture, you should get radiographs, but these are not usually needed to diagnose a dislocated mandible.• Can be unilateral or bilateral.• If the patient can close their teeth together, the TMJ cannot be dislocated, but they may have a displaced temporomandibular disc which is another matter entirely.• If possible, sit them in a chair so that their head is at your elbow height.• Stand in front of them and place the thumbs of both hands inside the mouth on the bone lateral to the mandibular molar teeth as far back as possible, with your ngers supporting the lower border.• You are going to close the mouth while pushing down on your thumbs.• Keeping your arms straight, lean forward and push down and backwards (backwards for the patient, that is) using your body weight onto your thumbs in a slow controlled fashion while rotating your wrists and pushing under the jaw in an upwards direction with your ngers.• You may nd that one side goes in rst, and if you continue the action the other side will ‘clunk’ inplace.• An alternative technique is to place a 5 mL syringe across the posterior- most molars and advise the patient to bite together while you push upwards from under thechin.• If this fails, which is more common if the jaw has been dislocated for more than a couple of hours, it may be necessary to relocate under sedationorGA.• Be very cautious about giving sedation in the ED for this problem. Talk to your seniorrst.• Recurrent dislocation can be a nuisance, and sometimes it is worth showing the patient’s partner or carer how to relocate the mandible.• Afollow- up appointment is usually worthwhile. BRIDLE WIRING AND INTERMAXILLARY FIXATION233 Bridle wiring and intermaxillary fixationGeneralpoints• Sharps injuries from wires are more common than they should be, so be careful. Never leave a wire sticking out of the mouth. It must have an instrument on theend.• Bridle wiring can help support a fracture and reducepain.• Intermaxillary xation (IMF) is useful for reducing or immobilizing a fracture, or just guiding the mandible in function during the healing phase. It can vary from rigid IMF to minimal guidance.Placing a bridlewire• This is usually best done underLA.• Use 0.45mm pre- stretched stainless steelwire.• Using an appropriate wire- holding instrument (heavy clip), push the wire between the teeth so that it goes around at least one tooth on each side of the fracture and both ends come out on the labial side of themouth.• Using both clips wrap the wires once around each other in a clockwise direction.• Now place one clip on both wires where they are wrapped around each other and pull the wire towards you. Then, without pulling, gradually tighten the wire by turning the clip clockwise. You should see the wire wrap around itself and the fracture will be reduced and immobilized.• Beware of loose teeth which can be extruded using this technique.Intermaxillary xation• Archbars, eyelet wires, IMF screws, or Leonard buttons are usually put on under GA, and that is the best time for you to learn the technique.• Orthognathic and some trauma patients may have some IMF using orthodontic appliances.• Elastic IMF is achieved with orthodontic elastic bands which come in packets of dierent colours depending on their size and strength. Red seems to be a favourite inOMFS.• You need to know how tight and what direction to apply theIMF.• Force will be light, moderate, orrigid.• The ‘vector’ of the elastic traction is as follows:• ClassIII elastics are positioned to have vector of force pulling the lower jaw backwards.• ClassII is the opposite.• ClassIis neutral.• In orthognathic patients, the ideal occlusion is normally to have coincident centre lines (between the anterior incisors) if that was the planned nal occlusion.• With trauma patients, the aim is to achieve their pre- morbid occlusion. 234CHAPTER8 Essentialskills234Incision and drainage ofintra- and extra- oral abscessesGeneralpoints• Dental infection can be life- threatening.• You must answer the following questions:• Is the patient systemically unwell or is there an airwayrisk?• What is the source of the abscess (tooth, skin cyst,etc.)?• What is the extent of the abscess?• Does the patient have any underlying medical problems— diabetes, immunocompromise?• Can the abscess be dealt with adequately under LA or is GA required?• If the patient is to be admitted, get baseline WCC and CRP and commence IV antimicrobials.• These patients should also have a blood sugar measurement to check for undiagnosed diabetesSimple intra-oral abscesses• Inject a small amount of LA intramucosally at the point of maximum convexity of the abscess.• This may be less painful if the needle approaches from theside.• When the overlying mucosa is blanched, quickly incise it with a No. 11 blade and send a pus sample for microbiology culture and sensitivity.• On the palate it may be necessary to excise a window of mucosa to allow further drainage or use a small Penrosedrain.• Treat the source of the abscess. Is there a tooth which requires draining (extirpation) or extraction?• An alternative approach is to raise a mucoperiosteal ap. This usually warrants a Penrosedrain.A few otherpoints• Maxillary sinus cancer may erode through the palate and present as a palatal abscess.• You will rarely be criticized for putting a drain in, but eventually there will be a time when you didn’t, and then you will wish youhad!• If you don’t treat the source of the infection, it will usually comeback.• Upper lateral incisors often discharge to the palatalside.• The canine fossa is an intra- oral site adjacent to the nostril. Pus from the canines and incisors accumulates there and you may need to drain this site using an intra- oral approach. It is a lot farther up than most people realize and hence inadequate drainage is common— but now you know that you will avoid making that mistake! 235 INCISION AND DRAINAGE OFINTRA- & EXTRA-ORAL ABSCESSESSimple skin abscesses• These are usually secondary to folliculitis or inamed epidermoidcysts.• They can usually be incised and drained with a small amount of LA into the overlying skin or an injection into the skin around the abscess as previously described.• Sometimes a spray with ethyl chloride (wait until skin blanches) and a quick stab is sucient.• Always use a drain— Penrose or Wick is the usual choice.• Always get a pus sample and describe what you nd in the notes. Is it a ‘cheesy’ substance?• Put a dressing on and bring the patient back to clinic in about 4days.• If there is surrounding cellulitis always consider giving antibiotics.Complex head and neck abscesses• Some head and neck abscesses require drainage through the skin underGA.• These are usually collections in the submandibular, submental, sublingual, and parapharyngeal spaces.• Most common causes are dental and salivary gland abscesses.• The patient needs admission, FBC, CRP, random glucose, IV antibiotics, and uid resuscitation. Some advocate dexamethasone (always get senior advice before starting this yourself ).• Try to determine the source of the infection. It will often be dealt with at the time of drainage, especially if dental in origin, so you may need anOPG.• Keep patients NBM and get an airway assessment quickly if you think that there is any risk to airway competence.• If they have trismus the anaesthetist may have trouble intubating and will usually want to get the case done in daylight hours (often using the breoptic intubation technique), so inform them straight away. Even if there is no airway compromise, these patients can still present an intubation problem.• For management of airway compromise, see E pp. 262–3. 236CHAPTER8 Essentialskills236Biopsy ofintra- and extra- oral lesionsGeneralpoints• Biopsies can be either incisional or excisional.• The most common fault with biopsies is not giving the pathologist enough clinical information— provide a brief history and description.• If you are sending something which is visible on a radiograph, it is sometimes worth sending acopy.• If you are doing an incisional biopsy, ensure that you get a piece of reasonable size and don’t crush or tearit.• If you suspect cancer, mark it as urgent.• For oral blistering conditions you may need a special transport medium (Michel’s) for immunouorescent tests. Ask the laboratoryrst.• Do not do an incisional biopsy of a melanoma unless you have been told to do so. It is usually inappropriate except in some delicate anatomical areas or in cases of suspected lentigo maligna.• If there is any possibility that you are about to cut into a vascular lesion, put a needle into it rst to check. High- ow vascular malformations bleed copiously and can be dicult tostop.• Use diagrams and consider photography.• Histopathology will not always give you the diagnosis. Sometimes the diagnosis is better reached with a good old history and clinical examination.Biopsy ofmucosal lesions• Inject a small amount of LA under or around the lesion, never into it or else it will damage the architecture and may make diagnosis dicult.• Excise an ellipse with the long axis running postero- anteriorly.• Close with a couple of interrupted resorbable sutures. You can invert them to avoid any looseends.• For incisional biopsies include a representative sample and make sure that you are not just excising a necrotic area which will not be diagnostic. Biopsying from the edges of the lesion is usuallyideal.Biopsy ofskin lesions• Think about where the scar will run. Try to hide it in a skin crease.• Prepare the skin with a cleansingagent.• Do not operate on broken or inamed skin, unless that is the reason for the biopsy. It is more likely to become infected and healbadly.• If you are taking a sample of a diuse area or the edge of a suspicious lesion, consider punch biopsy. It is quicker.• If primary closure is not possible, it is best to talk to your senior before you start and to make a plan for local reconstruction.• Refer to the British Association of Dermatology guidelines for margins of malignant lesions (3– 4mm for nodular BCC, 4– 6mm for SCC, etc.). Unless you are very familiar with this practice, it is advisable to talk to your senior.• You should have a bipolar diathermy tohand. BIOPSY OFINTRA- AND EXTRA-ORAL LESIONS237 Minor salivary glandbiopsy• This is usually for the diagnosis of Sjögren syndrome.• Ask your assistant to squeeze the lower lip at the corners bilaterally and evert the lower lip somewhat as well. This reduces bleeding and makes access much easier.• Incise the lower lip mucosa vertically. Do not extend onto theskin.• The minor salivary glands will burst out of the wound like couscous!• Remove ve minor salivary glands and send them in formalin— don’t go foraging around. You can damage the delicate sensory nerves, resulting in a numb patch over the biopsysite.• Close with a couple of interrupted resorbable sutures.• Make sure that you tell the histopathologist that you are looking for a diagnosis of Sjögren syndrome.Temporal arterybiopsy• This is usually to diagnose cranial giant cell arteritis.• Palpate the anterior or posterior branch of the supercial temporal artery and mark its course on the skin. It often goes into spasm when the LA is inltrated and can then be harder tond.• Inject LA into the dermis in a 5cm radius around the artery and wait for the skin to blanch.• There should be no need to shave the skin, but you should prepare it with a cleansing solution.• Make an incision within the hairline, parallel to the hair shafts over the artery just through the skin. The artery is deep to skin and there is no need to worry about cutting into it if you are careful.• Using a couple of ‘cat’s paw’ retractors, ask your assistant to retract the skin on bothsides.• Bluntly dissect through the dermis and subdermis carefully, opening the tissues with an arteryclip.• When you nd the artery choose a 2cm long piece and tie and cut it at bothends.• Send it in formalin, making it clear you are looking for cranial arteritis.• Close with a few interrupted sutures of your choice.Biopsy ofintra- bony lesions• Beware of high- ow vascular malformations. Massive bleeding is quite possible.• Wherever possible, raise a muco- periosteal ap from the gingival margin with one or two relieving incisions.• You may nd that the lesion has perforated the bony cortex, but if not, remove some overlying bone with a roundburr.• If it is likely to be a cyst, aspirate some uid using a needle and syringe and send that separately. Get a good sample of the cyst lining, taking care not to damage the IAN or tooth apices.• Close the ap over the defect. 238CHAPTER8 Essentialskills238NasendoscopyIf you have done an ENT job you will not need to read this section.General points and technique• Sit the patient in a chair with head support.• Tell them you are going to put a small tube up their nose so you can see down their throat, and it is uncomfortable and they will feel as if they have a head cold for a while afterwards.• Check that they have a patent nostril and use the bestside.• Spray 5% lidocaine up the nostril and tell them to sni. Give them a tissue and warn them that it is unpleasant and that their eyes will run. Sometimes patients in the head and neck clinic who are used to this procedure ask not to have the lidocainespray.• The nurse will have set up the scope for you. Don’t do this alone— you won’t know the sterilization and cross- infectionrules.• Check that the light source is working and try reading something on the side through the scope before you start to ensure that it is in focus and the lens piece is placed in such a way that up is up and down is down. Adjust if necessary.• If you are lucky enough to have a camera and a display screen, check that these work. Most cameras are digital these days and photographs may be useful for writing case reports of unusual ndings!• Apply some water- based lubricant to the side of the tip of thescope.• Slip the end of the scope over the nasal sill and run it along the oor of the nose at the base of the septum.• You will pass over the soft palate, and by using the controller point the tip down as you go over the back of the palate.• It is often helpful to ask the patient to swallow at this stage to clean mucus from the lens. You can also gently clean the lens by rubbing it on mucosa but you may make itbleed.• You should be able to inspect the pharynx and larynx as far as the vocal cords in thisway.• If you ask the patient to say ‘Eeeh’, you will see the cords in function and can assess their symmetry of movement and see their surface.• If they blow their cheeks out it can make it easier to assess the crevices, especially around the tongue base and valleculae.• On the way out, have a look at the nasopharynx around the opening of the Eustachian tubes and look at the upper surface of the soft palate andnose. TAKING DENTAL IMPRESSIONS239 Taking dental impressionsIf you are dentally qualied you will not need to read this section.Generalpoints• Ideally you should have a dental nurse withyou.• Position the patient sitting upright in a dental chair with head support so their mouth is just above your elbow height.• You will probably be using alginate (see E p. 283).• Find some impression trays and try them in rst. Ensure that they can be seated over the teeth and extend back far enough.• There are normally small, medium and large options.• Check for any really loose teeth, crowns, or bridges. They could come out in the impression material, so it may help to coat them in white soft paran rst to stop it sticking.• Remove any dentures, unless you are doing a special impression with the denture in, which is unlikely inOMFS.• Has the patient had this done before? If so, did they have problems? Some patients just gag too much and are not really suitable for a novice.• Load the tray with the impression material. It should be like mashed potato, not pureed potato, so it remains within thetray.• For the upper impression seat it at the back rst and then rock it so that it sits anteriorlyalso.• Make sure that it is centrally positioned and lift up the lip and look at the soft palate. If it is running down the throat, scoop out the excess material with a nger but keep the tray in place with your otherhand.• Hold the tray rmly in place until the nurse tells you the material hasset.• Remove the tray by pulling sharply down. This is best done by tilting the tray so that the back (palatal area) comes away rst. If it is dicult, try releasing around theedges.• For the lower impression, seat the tray at the back rst (retromolar area) and ask the patient to lift up their tongue. You may need to pull the lower lip out of theway.• Remove by lifting up sharply by the handle— again, a rotating motion to lift up the back rst often worksbest.• The patient will want to wash out their mouth and clean theirface.• The nurse will show you how the impressions must be cleaned and prepared before going to the laboratory.• Fill in the laboratory work request card carefully, explaining exactly what you want. If there is any uncertainty go to the laboratory and talk to the technicians— it will save you time in the long run. It is also a good time to meet the laboratory sta and have a cup of coee withthem. 240CHAPTER8 Essentialskills240CricothyroidotomyGeneralpoints• You have probably completed an approved ATLS (or similar) course and understand the role of cricothyroidotomy in emergency situations. However, such is the importance of this technique that we felt it would be worthwhile including a reminder section in this handbook.• You may have only performed a cricothyroidotomy on a course, but unlike some of the other procedures trainees do on courses you must realize that a situation could arise where you are the only person available trained to do one and in such a case you must ‘step up to themark’.• You can prepare for this in a number ofways:• First, read this section.• Secondly, think about doing cricothyroidotomies when you are in theatre with a senior. Palpate the landmarks, and run through with your senior about how you woulddoit.• Thirdly, if a tracheostomy is being done, try to make yourself avail-able as they are a good time to discuss this procedure.• Finally, if you are called to see a patient with a potential emergency airway problem think about the worst- case scenario on your way there and re- read this section!• When you arrive be aware that a tracheostomy is not an emergency procedure, and in almost every scenario a cricothyroidotomy is the life- saving procedure of choice. Do not assume that the anaesthetist or trauma leader knows how to do a ‘crico’. Let them know youdo!The cricothyroidotomy• Ideally the patient will be supine and motionless, but often they may be agitated and hypoxic.• If you have time prepare some equipment such as a good light source, suction, oxygen, a cricothyroidotomy kit if possible and some oxygen, tubing, and tracheal dilators. Obviously if you have not got everything you might need but no time to wait, you will just have to get on withit.• With your non- dominant hand hold the thyroid cartilage between your thumb and middle nger; your elbow is over the patient forehead. Using your index nger palpate the thyroid protuberance and follow it down to the cricothyroid membrane, which is not particularly soft. About a nger’s breadth further south you will feel the cricoid cartilages as a hard raised ring; come back north again to the membrane and be decisive that this is the membrane. Mark it with a pen if you have time (Fig.8.1).• If the patient is still conscious you may need to use some LA and skin cleanser.• You can now do either a needle or a surgical cricothyroidotomy.• Aneedle cricothyroidotomy will buy you about 30– 40 minutes. Push a cricothyroidotomy needle or large 14 G intravenous cannula through the membrane at 45° heading inferiorly. Asyringe on the needle can be used to conrm correct position. Air will be drawnback! CRICOTHYROIDOTOMY241 • Connect immediately to an oxygen source with a valve system to allow expiration, and put the oxygen on maximum ow. You now need to prepare for a denitive airway, and probably the best option still is to convert the needle cricothyroidotomy into a surgical cricothyroidotomy using the needle as aguide.• The landmarks for a surgical cricothyroidotomy are the same as for a needle cricothyroidotomy, but you must make a horizontal incision through the skin overlying the membrane and then cut the membrane itself. There may be a lot of bleeding, but be bold and calm. Hold the thyroid cartilage rmly and make a 2cm incision through the skin and membrane. Then dilate with tracheal dilators (if available). Use these so that they spread the tissues in the long axis of the trachea and insert either a dedicated cricothyroidotomy tube, if you have one, or any tube you can nd. Size 6 usually ts. Put the balloon up and connect to oxygen.• Well done. You have just saved the patient’slife!HyoidCricothyroid membraneposition for insertion ofemergency airwayThyroidcartilageCricoidcartilageTracheaFig.8.1 Cricothyroidotomy. Reproduced from Corbridge R and Steventon N, ‘Oxford Handbook of ENT and Head and Neck Surgery’ (2009) with permission from Oxford UniversityPress. 242

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