In the emergency department 










71
Chapter4
In theemergency
department
OMFS in the A&E department 72
The paediatric OMFS patient 74
Overview of maxillofacial trauma 78
Mandibular fractures 80
Zygomatic fractures 84
Orbital oor fractures 88
Maxillary fractures 90
Nose, nasoethmoidal, and frontal bone fractures 92
Face and scalp soft tissue injuries 94
Penetrating injuries to the neck 98
Intra- oral injuries 102
Dentoalveolar trauma 104
Dentoalveolar infections 108
Post- extraction complications 112
Head and neck soft tissue infections 116
Salivary gland diseases 118
Miscellaneous conditions 120

72
CHAPTER4 In theemergency department
72
OMFS inthe A&E department
A signicant proportion of OMFS routine ‘on- call’ work is carried out in
A&E under local anaesthetic (LA). Therefore many patients can be seen,
treated, and discharged home by the OMFS on- call junior.
Tips forsuccess
Be prepared. Bear in mind that some emergency units are woefully
under- equipped for the full range of OMFS procedures, so take it upon
yourself to organize an OMFS cupboard or trolley stocked with all the
essentials:ne suture kits, absorbable/ non- absorbable suture materials,
LA (dental syringes are ner and kinder to the patient if you can nd
them), dental splinting materials, bridle- wiring kits, gauze, Steri- Strips™,
microbiology swabs, and anything else you may need at arm’s length.
Escape the hubbub. Try to nd a quiet room or area, with a good light
source to perform examinations and minor procedures.
Don’t be afraid to ask for an assistant. There may be a willing nurse
or trainee happy to put on some gloves to hand you equipment or cut
sutures etc. An assistant can retract soft tissues, improve access, and cut
sutures, as well as providing extra support if your patient is dicult to
manage, particularly if they are under the inuence of alcohol.
Develop your skills. Many OMFS juniors resent being seen as a facial
‘suture service’ for A&E, but try to see it as an opportunity to enhance
your surgical skills. Think about reconstruction, aesthetics, and healing,
and take an interest in your work by following up the patients to see if a
dierent approach may produce better results.
Trauma patients andOMFS
Facial injuries often go hand in hand with injuries to other body parts—
particularly head and neck, and lower limb. Every trauma patient
should be assessed using an advanced trauma life support (ATLS)
approach— primary and secondary survey. Do not assume that these
have been completed by the A&E assessment— check before focusing in
on facial injuries. If you have any doubts, make it known to the referring
emergency doctor.
If a head injury is suspected, or there is a history of loss of
consciousness, the patient must be examined and investigated by A&E
before being deemed t for discharge (see NICE guidelines for head
injury
1
). If the patient requires admission for neurological observation,
they should remain under the care of the emergency or trauma team
until t for discharge from a neurological point ofview.
1 National Institute for Health and Care Excellence (NICE) (2014, updated 2017). Head
Injury: Assessment and Early Management. Clinical Guideline [CG176]. London: NICE. M http://
www.nice.org.uk/ guidance/ cg176

OMFS INTHE A&E DEPARTMENT
73
Admitting patients fromA&E
Patients should be admittedif:
they are systemicallyunwell
they warrant observation overnight
they require an operation under general anaesthesia(GA)
there are concerns regarding their home support or socialcare.
OMFS and alcohol consumption
Alcohol and facial injuries go hand inhand.
Be wary of patients under the inuence of alcohol who may have had a
head injury— signs of an intracranial injury may be disguised.
Record carefully what the patient tells you regarding the history. If
assault has been alleged, your notes will be used to produce a medical
report for the police.
‘Hospital dentist’
A signicant proportion of A&E referrals will be for dental advice. Most
OMFS departments do not want their juniors working as dentists in the
A&E. Patients with simple dental problems should be given telephone num-
bers and hours of opening for local emergency dental services to treat or
advise patients accordingly. Dental abscesses requiring drainage are a dier-
ent matter (see E pp. 234–5).

74
CHAPTER4 In theemergency department
74
The paediatric OMFS patient
Facial and dental injuries are common in the paediatric patient— as with
adults, always exclude more serious injury before dealing with the OMFS
problem.
Always examine in a paediatric department with a paediatricnurse.
You may be lucky enough to have a paediatric dentist (see E p. 289)
on site. If so, they will be an invaluable resource for dental injuries.
Deciduous dental injuries
Re- implantation of avulsed teeth is not recommended in the primary
dentition. All you need to do is account for the tooth— if not known, a
chest X- ray (CXR) is required.
Subluxation (displaced) teeth can be left unless interfering with
function— consider removal or manipulation (see E p. 231).
If a deciduous tooth has been intruded or displaced, the patient/ parents
should be warned that the permanent successor may be damaged and
the general dental practitioner (GDP) should be informed.
Upper central incisors are the most commonly avulsed teeth. Adult
central incisors erupt from around 7years of age, and 6years in the
lower arch (see E Table 2.1 and Table 2.2 in Chapter2, p. 11, for
eruption dates).
See E p. 104 for other tooth injuries.
Non- accidental injury andabuse
Unfortunately, a high index of suspicion is required. Facial injuries occur
in many children suering abuse. Check the history carefully, and consider
whether it ts with the injuries.
Injuries of dierent ages are suspicious.
Cartilaginous structures may be deformed from repeated injury.
Frenal tears in the very young and lacerations on the hard palate may
indicate objects being forced into themouth.
Neglect may be heralded by multiple cariousteeth.
Pharyngeal gonorrhoea is an indication of sexualabuse.
If in doubt, discuss with child safeguarding ocer early— these are normally
senior doctors/ nurses in A&E or on paediatricwards.
Lacerations
Skin:both parent and child will be concerned about permanent scarring
so be sensitive.
Tissue glues and Steri- Strips™ work well if the wound edges can be
easily opposed.
If a couple of stitches are required, GA may be avoided if both
parent and child are cooperative. Use a topical anaesthetic before
injecting the skin (see E pp. 220–2).
Oral mucosa:
Most intra- oral injuries will heal spontaneously.
Tongue lacerations do not generally require suture. Sucking an ice
cube can help control bleeding. Aforked tongue or tip injury may
need repair.

THE PAEDIATRIC OMFS PATIENT
75
Falling with an object in the mouth (e.g. a toothbrush or pen) can
result in pharyngeal trauma. This may implant bacteria into the
parapharyngeal spaces, causing local abscess or tracking mediastinitis,
both of which can be life- threatening. If there is no foreign body,
this can often be managed conservatively (discuss with a senior).
Consider prophylactic antibiotics. Parents must be told to bring
the child back immediately if there is any temperature, drooling, or
diculty in swallowing or breathing. Injuries which breach muscle will
normally require suture.
Fractures
Facial fractures are rare in children, but if present often involve the
mandibular condyle. This can have a serious impact on mandibular
growth, with hypoplasia on the aected side resulting in possible facial
asymmetry and occlusal abnormalities.
Make sure that you have a high index of suspicion and adequate
radiographs.
Dental pain and infections
Dental infections can spread quickly in children.
GA may be required to examine the mouth properly.
Have a low threshold for admission; a couple of doses of IV antibiotics
may help the situation.
Oral infections
There are many types (see E pp. 246–7). The most common complaints
are:
Ulceration:
aphthousulcers
trauma
primary herpetic gingivostomatitis
hand, foot, and mouth disease
herpangina
varicella zoster (chickenpox)
infectious mononucleosis (glandular fever).
Acute pseudomembranous candidiasis (thrush).
Facial and oral swellings
Parotitis (mumps) is much less common now but bacterial infection can
also cause painful swelling of the parotidgland.
Abscess:usually (but not always) painful. Look for a dischargingsinus.
Lymph nodes:cervical, auricular, and parotid lymph nodes are often
enlarged in children. Check the scalp and inside the ears and mouth for
possible causes.
Un- erupted teeth:a displaced tooth may be palpable in the buccal sulcus
or palate.
Mucocoele:damaged minor salivary gland usually presents as a bluish
swelling inside the lower lip or oor of mouth (FOM) (ranula).
Eruption cyst:a cyst over an emerging tooth will usually pop
spontaneously.

76
CHAPTER4 In theemergency department
76
Epiglottitis
Traditionally the preserve of ENT surgeons, this frightening condition must
be recognized quickly before the airway is threatened.
Signs
Fever, tachycardia, tachypnoea, inability to swallow, drooling, change in cry
or speaking voice (hot potato voice).
Management
Do not try to examine or lay the patient at. Alert seniors and arrange
immediate transfer to theatre for intubation or surgical airway.
Foreignbodies
Small objects frequently disappear up noses. If you can’t see it, don’t go
hunting— you’ll only make it more dicult to nd. GA may be required.

THE PAEDIATRIC OMFS PATIENT
77

78
CHAPTER4 In theemergency department
78
Overview ofmaxillofacialtrauma
Maxillofacial trauma is one of the most common presenting complaints
at A&E. At least half a million facial injuries occur annually in the UK
according to the results of the 1997 National Facial Injuries Survey.
2
Assessment can often be dicult because of the presence of a
cervical collar, gross soft tissue swelling, and an uncooperative patient.
Therefore a methodical approach must beused.
All major trauma should be managed using ATLS principles. Technically,
evaluation of maxillofacial injuries comes under the secondary survey.
However, certain patterns of injury can lead to airway compromise and
must be picked upearly.
Bilateral mandible fractures— the tongue loses its anterior muscular
anchorage. The patient may refuse to lie at to prevent airway
occlusion.
Inhaled teeth or dentures.
Midface fractures— the entire palate can drop backwards to obstruct
the oropharynx.
Brisk bleeding in the mouth may necessitate log rolling to prevent
inhalation (see E p. 268).
Laryngeal trauma— a surgical airway may be required (see E pp. 262–3).
Examination ofthe patient withmajor facialtrauma
Establish your own routine for examination.
If the patient’s C- spine is not yet cleared, you will need someone to
hold the head with in- line traction while you remove the collar to
examine the mouth andneck.
It is not uncommon for injuries to be missed, so ideally the examination
should be performed again at a laterdate.
Clear the head and face ofblood.
Examine the entire face and scalp for lacerations, abrasions, and foreign
bodies (e.g. road grit). The patient may need to be turned to examine
the back of thehead.
Methodically palpate the cranium, not forgetting the mastoid processes,
and bony ridges of the facial skeleton looking for boggy swellings, step
deformities, and depressions.
Assess for exo- or enophthalmos. This can be very dicult if there is a lot
of swelling, but a tense bulging eye indicates a retrobulbar haemorrhage
(RBH) requiring immediate decompression (see E pp. 272–4).
Check pupillary reexes, eye movements, and visual acuity. Note any
subconjunctival haemorrhage or trauma to the globe and eyelids.
Feel the bridge of the nose. Is it widened, attened, or deviated? Look
up the nose (use a nasal speculum and suction) for septal haematoma,
septal deviation, bleeding points, and CSFleak.
2 Hutchison IL, Magennis P, Shepherd JP, et al. (1998). The BAOMS United Kingdom survey of
facial injuries part1:aetiology and the association with alcohol consumption. Br J Oral Maxillofa Surg
36:3– 13.

OVERVIEW OFMAXILLOFACIALTRAUMA
79
Examine the pinna for lacerations. Clean the ear canal and perform
otoscopy. Is there bleeding from behind the drum (a bulging purplish
appearance)? Is it perforated? You must distinguish blood from the
face pooling in the ear to blood coming from inside the ear, which is an
important clinical sign, indicating base of skull fracture (ditto with CSF
from theear).
Grasp the upper incisors and alveolus between nger and thumb
and gently rock backwards and forwards to detect any movement
(movement means fracture). Press on the face with your other hand
whilst rocking the palate to assess the level of fracture (see E p. 90).
Slide a nger up into each buccal sulcus feeling for bulges from zygomatic
complex fractures.
Look inside the mouth, noting lacerations, missing or damaged teeth,
alveolar fractures, dentures (remove to prevent aspiration).
Feel along the lower border of the mandible, assess mouth opening, and
check for mobile segments and lacerations on the gingiva (see E pp. 80–4).
Look at the neck for swelling, bruising, and puncture wounds. Feel for
airway deviation and surgical emphysema.
Examine the cranial nerves.
Record your ndings carefully. Not only will it help you to organize your
investigations and treatment of complex injuries, but sometimes criminal
proceedings follow an injury and you may be required to testify incourt.
Investigations
If the patient is having a CT head to exclude intracranial injury, discuss
with the radiologist to ensure that the facial skeleton is included and that
it is reformatted in the coronalplane.
Remember that the patient will not be able to have facial X- rays until
the C- spine is cleared, and a DPT will have to wait until the patient can
standup.
Thinking beyondtheface
Serious intracranial injury, cervical injury, pulmonary injury, and sight-
threatening ocular injuries are not uncommon in severe maxillofacial
trauma.
3
Early recognition of these injuries is key to improving outcome.
Alcohol is often implicated in the aetiology of facial injuries.
2
Always
ask for an alcohol history and prescribe appropriate medication if
withdrawal is likely.
Large numbers of women suering domestic abuse will attend A&E with
facial injuries. (Sensitively) ask about home life— an admission for social
reasons may be necessary.
3 Alvi A, Doherty T, Lewen G (2003). Facial fractures and concomitant injuries in trauma patients.
Laryngoscope 113:102– 6.

80
CHAPTER4 In theemergency department
80
Mandibular fractures
Mandibular fractures are common, but do not underestimate the force
taken to break a jaw. The mandible is the densest bone in the body so
the cranium will have absorbed a considerable impact— always rule out
signicant head injury.
As always, be mindful that swelling can develop, especially in the FOM,
and threaten the airway.
Occasionally it can be dicult to detect a fracture. Agood knowledge
of the patterns of fractures will help direct you in examining the
radiographs (see E p. 81).
Some isolated uncomplicated non- displaced fractures can be managed
conservatively. Advise a soft diet and review in the clinic.
Because of its shape, the mandible often fractures in more than one
place (most commonly parasymphysis and angle/ condyle), so if you
diagnose one fracture look formore.
Anterior mandible fractures are commonly missed on radiographs due
to C- spine shadow— check clinically and consider lower occlusal if
necessary.
History
The most common mechanism of injury is assault or road trac accidents,
although sports- related fractures are increasing. > is implicated in up
to 40%. Patients may describe hearing a crack on impact. Some ignore the
injury until they wake up in the morning with a sore swollenface.
Symptoms
Diculty in swallowing or breathing should ring alarm bells. Pain is variable
and worsened by eating and talking. Swelling is also variable and can hinder
examination. Patients describe their teeth not meeting together; this is not
a reliable indicator of fracture as it can occur with bruising or joint eusion.
However, paraesthesia of the lower teeth and lip is a good indicator of frac-
ture and must be carefully documented to exclude later iatrogenic damage.

MANDIBULAR FRACTURES
81
Radiographs
(See Fig.4.1.)
Most commonly DPT plus PA mandible but lower occlusal views are also
acceptable and give a good view of the anterior region (see E pp. 50–1).
Ensure that both condylar heads are completely visualized.
Systematically trace the outline of the mandible, noting any discontinuity.
Fractures often extend through the roots of teeth (i.e. where the bone
is thinnest). Canines have the longest roots, so parasymphyseal fractures
here are common.
Angle fractures commonly involve 8s if present.
Note the degree of displacement and comminution, and the prognosis
of the teeth (i.e. are the teeth grossly carious?)
CT is helpful for condylar fractures and complicated fractures.
Signs
Posturepatients often use their hands to support the fractured
segment and may be unable to close fully, resulting in drooling.
Swelling can be diuse and extend into the submandibular space and
down theneck.
Step deformity on the lower border of the mandible (may be dicult
to assess).
Trismus from swelling or condylar fracture.
Malocclusion ‘step’ or anterior/ lateral openbites.
Mobileteeth.
Gingival laceration/ bruising at the site of the stepped occlusion.
Sublingual haematoma.
Paraesthesia in distribution of the inferior dental nerve(IDN).
Compression testif the fracture is obvious there is no need to test
for mobility. Gentle backward pressure on the point of the chin can
provoke pain in angle of condylar fracture; likewise, simultaneous
medial pressure on the angles can reveal fractures of the symphyseal
region.
Bite strengthask the patient to bite rmly on a cotton roll or tongue
depressor. If you can’t withdraw it from their teeth, the chance of
fracture issmall.
NB:bilateral symphyseal fractures mean that forward attachment of the tongue is lost and there
is a danger of loss of airway from its backward displacement.

82
CHAPTER4 In theemergency department
82
(a)
(b)
Fig.4.1 (a)OPG showing displaced right parasymphyseal fracture and non-
displaced left low condyle fracture. (b)PA mandible showing the same patient, note
how the left condylar fracture is almost invisible on the PAview.

MANDIBULAR FRACTURES
83
Management
Most fractures will need open reduction and internal xation (ORIF)
(see E pp. 176–8). Some undisplaced fractures can be managed
conservatively— discuss with your senior.
Mandible fractures are usually open fractures, communicating with
either the tooth socket or directly into the oral cavity. IV antibiotics
(e.g. benzylpenicillin and metronidazole) are indicated.
Admit the patient, place on the emergency list, and work up for theatre
(preoperative bloods etc.), analgesia, IV uids, and nil by mouth(NBM).
Simple bridle wiring of mobile segments can relieve pain (see E p. 233).
Take impressions if custom- made arch bars will be needed (e.g. condylar
fractures, multiple fractures).
Angle fractures may run through the third molar socket. There is little
evidence that infection is more likely if this tooth is left, but if there
is a clear indication to remove the tooth (carious, fractured, mobile,
preventing reduction of fracture), it must be removed at the time
ofORIF. Undisplaced third molars are often left in situ.
You must be adequately trained to take consent. The important points
are listed in the following subsections.
Special circumstances
Children often fall onto their chin and will not open their mouth.
Condylar intracapsular fractures are common, result in intense pain, and
are undetectable on plain X- ray. Cone beam computed tomography
(CBCT) can show up fractures. Management is generally conservative.
Guardsman fracture— fall onto chin in an adult resulting in bilateral
condylar head fracture and midline symphysis fracture. So called because
the injury is found in soldiers who faint while on guardduty.
Points tonote whenobtaining consent
Fractures are xed with plates and screws; occasionally inter- maxillary
xation (IMF; jaw wiring) is required. They may need elastics (small
rubber bands) postoperatively.
The approach is usually intra- oral, but sometimes very small incisions
need to be made on the face to gain access.
Teeth with a poor prognosis may have to be extracted.
There will be postoperative swelling and trismus.
Numb lip ± tongue is common postoperatively. There is a small
chance of lasting paraesthesia, usually when the nerve has been
severely damaged by the trauma.

84
CHAPTER4 In theemergency department
84
Zygomatic fractures
Most fractures occur at the junction of the zygoma with other bones
(i.e. orbit and maxilla) and so are probably best termed ‘zygomatic
complex fractures’. It is possible however, to have an isolated arch
fracture.
The classic fracture pattern caused by a direct blow to the
prominence of the cheek is the ‘tripod fracture’ with disruption of the
zygomaticofrontal suture, depression of the zygomatic arch, and fracture
of the infraorbital rim. Some argue that there is a fourth fracture of the
zygomatic buttress, which is commonly buckled.
It can be a challenge to assess these fractures because of the marked
periorbital swelling.
Very rarely there is an indication for immediate action— RBH is a
surgical emergency and requires urgent decompression to preserve
eyesight (see E pp. 272–4).
Always fully assess eyes and record results of the Snellen chart in the
notes (a handy copy is on the E inside back cover of this handbook).
Signs
There is usually a cosmetic ± functional problem:
Loss of prominence of the cheekbest examined from behind the
patient looking down onto theface.
Zygomaticofrontal (ZF) tendernesspalpation over the ZF suture
(upper outer corner of the orbit) can reveal a step deformity.
Step in the infraorbital rim or zygomaticarch.
Subconjunctival haemorrhageif the posterior limit cannot be
identied, this suggests orbital wall fracture.
Buttress fracturethis is examined intra- orally by sliding a nger along
the buccal sulcus above the upper molars. Bruising may be visible in
the mucosa.
Trismusthe depressed arch impinges the mandibular condyle (can be
confused with mandible fracture).
Infraorbital nerve paraesthesiausually a neuropraxic injury as it exits
the infraorbital foramen, resulting in variable altered sensation to the
cheek, side of nose, and upper lip. This can also occur in the absence
of fracture.
Unilateral epistaxisoverow from the maxillary sinus as it lls up
withblood.
Eye injuriesthe globe is relatively protected by the orbital rims, but
depending on the mechanism of injury a range of injuries are possible.
You must fully examine the eye and refer to Ophthalmology if there
are any concerns.
0 Always remember to check that the maxilla is stable to avoid missing
a Le Fort fracture.

ZYGOMATIC FRACTURES
85
Investigations
Radiographs
Two OM views (see E ‘Facial and skull radiography’, p. 56). Assess
systematically:
Campbell’s lines— follow a line across both zygomatic arches and
another line through both coronoid processes across the maxillary
antrum and base ofnose.
Look at the ZF suture and compare with the other side to detect
widening.
Check the distance between the coronoid process and the lower border
of the arch on each side. It will be reduced in a fracture.
Fluid levels can sometimes be seen in the maxillary antrum, but this can
also occur in the absence of a fracture (e.g. from a nosebleed or even
acold).
Complex fractures require ne cut CT with 3D reformatting (see Fig.4.2).
Management
Any eye problems should be referred to Ophthalmology (except RBH
which you should manage expectantly and then refer).
Some surgeons advocate early surgical reduction of displaced zygoma
fractures. However, most units review a fracture in clinic in 5– 7days
and if surgery is indicated plan this for about 2 weeks post injury when
swelling has lessened and therefore adequate reduction can be assessed
on the operating table (see E pp. 180–2).
0 Always inform the patient not to blow their nose— this can result in
surgical emphysema from the maxillary sinus and upper respiratory tract
bacteria may be implanted into the tissues. If this does happen, consider
prophylactic antibiotics.
Warn them that diplopia may improve or get worse as the swelling
resolves (see E pp. 128–9).
Fig.4.2 Axial CT image demonstrates a mildly displaced fracture of the left
zygomatic arch, left lateral orbital wall, and anterior and lateral walls of the left
maxillary sinus. Reproduced from Abujudeh H ‘Emergency Radiology’ (2016) with
permission from Oxford UniversityPress.

86
CHAPTER4 In theemergency department
86
Eye assessment
Ask about diplopia, reduced vision,pain.
Look for swelling, exo/ enophthalmos (posterior displacement of
globe), hypoglobus (downward displacement), subconjunctival
haemorrhage.
Feelassess how tense the globe is. There should be some give— feel
yourown.
Visual acuityideally a full sized Snellen chart at 3 m.Often a mirror
is used to double the distance (i.e. at 1.5 m). You must record an
objective gure (e.g.3/ 3).
Reexesred, direct, and consensual (in RBH direct is lost but
consensual remains).
Fieldscheck all movements and record any subjective diplopia and
objective restriction in movement.
Fundoscopy and slit lamp examinationthis may not be needed if the
patient is to be reviewed by Ophthalmology, but it is good practice
to check inside the eye. Cells within the anterior chamber can be
identied fairly easily.
0 Eye examination is often complicated by the patient’s inability to open
the eyelid because of swelling. Check that they can perceive light through
the lid and look for a consensual reex in the unaectedeye.

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71 Chapter4In theemergency departmentOMFS in the A&E department 72The paediatric OMFS patient 74Overview of maxillofacial trauma 78Mandibular fractures 80Zygomatic fractures 84Orbital oor fractures 88Maxillary fractures 90Nose, nasoethmoidal, and frontal bone fractures 92Face and scalp soft tissue injuries 94Penetrating injuries to the neck 98Intra- oral injuries 102Dentoalveolar trauma 104Dentoalveolar infections 108Post- extraction complications 112Head and neck soft tissue infections 116Salivary gland diseases 118Miscellaneous conditions 120 72CHAPTER4 In theemergency department72OMFS inthe A&E departmentA signicant proportion of OMFS routine ‘on- call’ work is carried out in A&E under local anaesthetic (LA). Therefore many patients can be seen, treated, and discharged home by the OMFS on- call junior.Tips forsuccess• Be prepared. Bear in mind that some emergency units are woefully under- equipped for the full range of OMFS procedures, so take it upon yourself to organize an OMFS cupboard or trolley stocked with all the essentials:ne suture kits, absorbable/ non- absorbable suture materials, LA (dental syringes are ner and kinder to the patient if you can nd them), dental splinting materials, bridle- wiring kits, gauze, Steri- Strips™, microbiology swabs, and anything else you may need at arm’s length.• Escape the hubbub. Try to nd a quiet room or area, with a good light source to perform examinations and minor procedures.• Don’t be afraid to ask for an assistant. There may be a willing nurse or trainee happy to put on some gloves to hand you equipment or cut sutures etc. An assistant can retract soft tissues, improve access, and cut sutures, as well as providing extra support if your patient is dicult to manage, particularly if they are under the inuence of alcohol.• Develop your skills. Many OMFS juniors resent being seen as a facial ‘suture service’ for A&E, but try to see it as an opportunity to enhance your surgical skills. Think about reconstruction, aesthetics, and healing, and take an interest in your work by following up the patients to see if a dierent approach may produce better results.Trauma patients andOMFS• Facial injuries often go hand in hand with injuries to other body parts— particularly head and neck, and lower limb. Every trauma patient should be assessed using an advanced trauma life support (ATLS) approach— primary and secondary survey. Do not assume that these have been completed by the A&E assessment— check before focusing in on facial injuries. If you have any doubts, make it known to the referring emergency doctor.• If a head injury is suspected, or there is a history of loss of consciousness, the patient must be examined and investigated by A&E before being deemed t for discharge (see NICE guidelines for head injury1). If the patient requires admission for neurological observation, they should remain under the care of the emergency or trauma team until t for discharge from a neurological point ofview.1 National Institute for Health and Care Excellence (NICE) (2014, updated 2017). Head Injury: Assessment and Early Management. Clinical Guideline [CG176]. London: NICE. M http:// www.nice.org.uk/ guidance/ cg176 OMFS INTHE A&E DEPARTMENT73 Admitting patients fromA&EPatients should be admittedif:• they are systemicallyunwell• they warrant observation overnight• they require an operation under general anaesthesia(GA)• there are concerns regarding their home support or socialcare.OMFS and alcohol consumption• Alcohol and facial injuries go hand inhand.• Be wary of patients under the inuence of alcohol who may have had a head injury— signs of an intracranial injury may be disguised.• Record carefully what the patient tells you regarding the history. If assault has been alleged, your notes will be used to produce a medical report for the police.‘Hospital dentist’A signicant proportion of A&E referrals will be for dental advice. Most OMFS departments do not want their juniors working as dentists in the A&E. Patients with simple dental problems should be given telephone num-bers and hours of opening for local emergency dental services to treat or advise patients accordingly. Dental abscesses requiring drainage are a dier-ent matter (see E pp. 234–5). 74CHAPTER4 In theemergency department74The paediatric OMFS patient• Facial and dental injuries are common in the paediatric patient— as with adults, always exclude more serious injury before dealing with the OMFS problem.• Always examine in a paediatric department with a paediatricnurse.• You may be lucky enough to have a paediatric dentist (see E p. 289) on site. If so, they will be an invaluable resource for dental injuries.Deciduous dental injuries• Re- implantation of avulsed teeth is not recommended in the primary dentition. All you need to do is account for the tooth— if not known, a chest X- ray (CXR) is required.• Subluxation (displaced) teeth can be left unless interfering with function— consider removal or manipulation (see E p. 231).• If a deciduous tooth has been intruded or displaced, the patient/ parents should be warned that the permanent successor may be damaged and the general dental practitioner (GDP) should be informed.• Upper central incisors are the most commonly avulsed teeth. Adult central incisors erupt from around 7years of age, and 6years in the lower arch (see E Table 2.1 and Table 2.2 in Chapter2, p. 11, for eruption dates).• See E p. 104 for other tooth injuries.Non- accidental injury andabuseUnfortunately, a high index of suspicion is required. Facial injuries occur in many children suering abuse. Check the history carefully, and consider whether it ts with the injuries.• Injuries of dierent ages are suspicious.• Cartilaginous structures may be deformed from repeated injury.• Frenal tears in the very young and lacerations on the hard palate may indicate objects being forced into themouth.• Neglect may be heralded by multiple cariousteeth.• Pharyngeal gonorrhoea is an indication of sexualabuse.If in doubt, discuss with child safeguarding ocer early— these are normally senior doctors/ nurses in A&E or on paediatricwards.Lacerations• Skin:both parent and child will be concerned about permanent scarring so be sensitive.• Tissue glues and Steri- Strips™ work well if the wound edges can be easily opposed.• If a couple of stitches are required, GA may be avoided if both parent and child are cooperative. Use a topical anaesthetic before injecting the skin (see E pp. 220–2).• Oral mucosa:• Most intra- oral injuries will heal spontaneously.• Tongue lacerations do not generally require suture. Sucking an ice cube can help control bleeding. Aforked tongue or tip injury may need repair. THE PAEDIATRIC OMFS PATIENT75 • Falling with an object in the mouth (e.g. a toothbrush or pen) can result in pharyngeal trauma. This may implant bacteria into the parapharyngeal spaces, causing local abscess or tracking mediastinitis, both of which can be life- threatening. If there is no foreign body, this can often be managed conservatively (discuss with a senior). Consider prophylactic antibiotics. Parents must be told to bring the child back immediately if there is any temperature, drooling, or diculty in swallowing or breathing. Injuries which breach muscle will normally require suture.Fractures• Facial fractures are rare in children, but if present often involve the mandibular condyle. This can have a serious impact on mandibular growth, with hypoplasia on the aected side resulting in possible facial asymmetry and occlusal abnormalities.• Make sure that you have a high index of suspicion and adequate radiographs.Dental pain and infections• Dental infections can spread quickly in children.• GA may be required to examine the mouth properly.• Have a low threshold for admission; a couple of doses of IV antibiotics may help the situation.Oral infectionsThere are many types (see E pp. 246–7). The most common complaints are:• Ulceration:• aphthousulcers• trauma• primary herpetic gingivostomatitis• hand, foot, and mouth disease• herpangina• varicella zoster (chickenpox)• infectious mononucleosis (glandular fever).• Acute pseudomembranous candidiasis (thrush).Facial and oral swellings• Parotitis (mumps) is much less common now but bacterial infection can also cause painful swelling of the parotidgland.• Abscess:usually (but not always) painful. Look for a dischargingsinus.• Lymph nodes:cervical, auricular, and parotid lymph nodes are often enlarged in children. Check the scalp and inside the ears and mouth for possible causes.• Un- erupted teeth:a displaced tooth may be palpable in the buccal sulcus or palate.• Mucocoele:damaged minor salivary gland usually presents as a bluish swelling inside the lower lip or oor of mouth (FOM) (ranula).• Eruption cyst:a cyst over an emerging tooth will usually pop spontaneously. 76CHAPTER4 In theemergency department76EpiglottitisTraditionally the preserve of ENT surgeons, this frightening condition must be recognized quickly before the airway is threatened.SignsFever, tachycardia, tachypnoea, inability to swallow, drooling, change in cry or speaking voice (hot potato voice).ManagementDo not try to examine or lay the patient at. Alert seniors and arrange immediate transfer to theatre for intubation or surgical airway.ForeignbodiesSmall objects frequently disappear up noses. If you can’t see it, don’t go hunting— you’ll only make it more dicult to nd. GA may be required. THE PAEDIATRIC OMFS PATIENT77 78CHAPTER4 In theemergency department78Overview ofmaxillofacialtrauma• Maxillofacial trauma is one of the most common presenting complaints at A&E. At least half a million facial injuries occur annually in the UK according to the results of the 1997 National Facial Injuries Survey.2 Assessment can often be dicult because of the presence of a cervical collar, gross soft tissue swelling, and an uncooperative patient. Therefore a methodical approach must beused.• All major trauma should be managed using ATLS principles. Technically, evaluation of maxillofacial injuries comes under the secondary survey. However, certain patterns of injury can lead to airway compromise and must be picked upearly.• Bilateral mandible fractures— the tongue loses its anterior muscular anchorage. The patient may refuse to lie at to prevent airway occlusion.• Inhaled teeth or dentures.• Midface fractures— the entire palate can drop backwards to obstruct the oropharynx.• Brisk bleeding in the mouth may necessitate log rolling to prevent inhalation (see E p. 268).• Laryngeal trauma— a surgical airway may be required (see E pp. 262–3).Examination ofthe patient withmajor facialtrauma• Establish your own routine for examination.• If the patient’s C- spine is not yet cleared, you will need someone to hold the head with in- line traction while you remove the collar to examine the mouth andneck.• It is not uncommon for injuries to be missed, so ideally the examination should be performed again at a laterdate.• Clear the head and face ofblood.• Examine the entire face and scalp for lacerations, abrasions, and foreign bodies (e.g. road grit). The patient may need to be turned to examine the back of thehead.• Methodically palpate the cranium, not forgetting the mastoid processes, and bony ridges of the facial skeleton looking for boggy swellings, step deformities, and depressions.• Assess for exo- or enophthalmos. This can be very dicult if there is a lot of swelling, but a tense bulging eye indicates a retrobulbar haemorrhage (RBH) requiring immediate decompression (see E pp. 272–4). Check pupillary reexes, eye movements, and visual acuity. Note any subconjunctival haemorrhage or trauma to the globe and eyelids.• Feel the bridge of the nose. Is it widened, attened, or deviated? Look up the nose (use a nasal speculum and suction) for septal haematoma, septal deviation, bleeding points, and CSFleak.2 Hutchison IL, Magennis P, Shepherd JP, et al. (1998). The BAOMS United Kingdom survey of facial injuries part1:aetiology and the association with alcohol consumption. Br J Oral Maxillofa Surg 36:3– 13. OVERVIEW OFMAXILLOFACIALTRAUMA79 • Examine the pinna for lacerations. Clean the ear canal and perform otoscopy. Is there bleeding from behind the drum (a bulging purplish appearance)? Is it perforated? You must distinguish blood from the face pooling in the ear to blood coming from inside the ear, which is an important clinical sign, indicating base of skull fracture (ditto with CSF from theear).• Grasp the upper incisors and alveolus between nger and thumb and gently rock backwards and forwards to detect any movement (movement means fracture). Press on the face with your other hand whilst rocking the palate to assess the level of fracture (see E p. 90). Slide a nger up into each buccal sulcus feeling for bulges from zygomatic complex fractures.• Look inside the mouth, noting lacerations, missing or damaged teeth, alveolar fractures, dentures (remove to prevent aspiration).• Feel along the lower border of the mandible, assess mouth opening, and check for mobile segments and lacerations on the gingiva (see E pp. 80–4).• Look at the neck for swelling, bruising, and puncture wounds. Feel for airway deviation and surgical emphysema.• Examine the cranial nerves.Record your ndings carefully. Not only will it help you to organize your investigations and treatment of complex injuries, but sometimes criminal proceedings follow an injury and you may be required to testify incourt.Investigations• If the patient is having a CT head to exclude intracranial injury, discuss with the radiologist to ensure that the facial skeleton is included and that it is reformatted in the coronalplane.• Remember that the patient will not be able to have facial X- rays until the C- spine is cleared, and a DPT will have to wait until the patient can standup.Thinking beyondtheface• Serious intracranial injury, cervical injury, pulmonary injury, and sight- threatening ocular injuries are not uncommon in severe maxillofacial trauma.3 Early recognition of these injuries is key to improving outcome.• Alcohol is often implicated in the aetiology of facial injuries.2 Always ask for an alcohol history and prescribe appropriate medication if withdrawal is likely.• Large numbers of women suering domestic abuse will attend A&E with facial injuries. (Sensitively) ask about home life— an admission for social reasons may be necessary.3 Alvi A, Doherty T, Lewen G (2003). Facial fractures and concomitant injuries in trauma patients. Laryngoscope 113:102– 6. 80CHAPTER4 In theemergency department80Mandibular fractures• Mandibular fractures are common, but do not underestimate the force taken to break a jaw. The mandible is the densest bone in the body so the cranium will have absorbed a considerable impact— always rule out signicant head injury.• As always, be mindful that swelling can develop, especially in the FOM, and threaten the airway.• Occasionally it can be dicult to detect a fracture. Agood knowledge of the patterns of fractures will help direct you in examining the radiographs (see E p. 81).• Some isolated uncomplicated non- displaced fractures can be managed conservatively. Advise a soft diet and review in the clinic.• Because of its shape, the mandible often fractures in more than one place (most commonly parasymphysis and angle/ condyle), so if you diagnose one fracture look formore.• Anterior mandible fractures are commonly missed on radiographs due to C- spine shadow— check clinically and consider lower occlusal if necessary.HistoryThe most common mechanism of injury is assault or road trac accidents, although sports- related fractures are increasing. ♂>♀ is implicated in up to 40%. Patients may describe hearing a crack on impact. Some ignore the injury until they wake up in the morning with a sore swollenface.SymptomsDiculty in swallowing or breathing should ring alarm bells. Pain is variable and worsened by eating and talking. Swelling is also variable and can hinder examination. Patients describe their teeth not meeting together; this is not a reliable indicator of fracture as it can occur with bruising or joint eusion. However, paraesthesia of the lower teeth and lip is a good indicator of frac-ture and must be carefully documented to exclude later iatrogenic damage. MANDIBULAR FRACTURES81 Radiographs(See Fig.4.1.)• Most commonly DPT plus PA mandible but lower occlusal views are also acceptable and give a good view of the anterior region (see E pp. 50–1).• Ensure that both condylar heads are completely visualized.• Systematically trace the outline of the mandible, noting any discontinuity. Fractures often extend through the roots of teeth (i.e. where the bone is thinnest). Canines have the longest roots, so parasymphyseal fractures here are common.• Angle fractures commonly involve 8s if present.• Note the degree of displacement and comminution, and the prognosis of the teeth (i.e. are the teeth grossly carious?)• CT is helpful for condylar fractures and complicated fractures.Signs• Posture— patients often use their hands to support the fractured segment and may be unable to close fully, resulting in drooling.• Swelling can be diuse and extend into the submandibular space and down theneck.• Step deformity on the lower border of the mandible (may be dicult to assess).• Trismus from swelling or condylar fracture.• Malocclusion ‘step’ or anterior/ lateral openbites.• Mobileteeth.• Gingival laceration/ bruising at the site of the stepped occlusion.• Sublingual haematoma.• Paraesthesia in distribution of the inferior dental nerve(IDN).• Compression test— if the fracture is obvious there is no need to test for mobility. Gentle backward pressure on the point of the chin can provoke pain in angle of condylar fracture; likewise, simultaneous medial pressure on the angles can reveal fractures of the symphyseal region.• Bite strength— ask the patient to bite rmly on a cotton roll or tongue depressor. If you can’t withdraw it from their teeth, the chance of fracture issmall.NB:bilateral symphyseal fractures mean that forward attachment of the tongue is lost and there is a danger of loss of airway from its backward displacement. 82CHAPTER4 In theemergency department82(a)(b)Fig.4.1 (a)OPG showing displaced right parasymphyseal fracture and non- displaced left low condyle fracture. (b)PA mandible showing the same patient, note how the left condylar fracture is almost invisible on the PAview. MANDIBULAR FRACTURES83 Management• Most fractures will need open reduction and internal xation (ORIF) (see E pp. 176–8). Some undisplaced fractures can be managed conservatively— discuss with your senior.• Mandible fractures are usually open fractures, communicating with either the tooth socket or directly into the oral cavity. IV antibiotics (e.g. benzylpenicillin and metronidazole) are indicated.• Admit the patient, place on the emergency list, and work up for theatre (preoperative bloods etc.), analgesia, IV uids, and nil by mouth(NBM).• Simple bridle wiring of mobile segments can relieve pain (see E p. 233). Take impressions if custom- made arch bars will be needed (e.g. condylar fractures, multiple fractures).• Angle fractures may run through the third molar socket. There is little evidence that infection is more likely if this tooth is left, but if there is a clear indication to remove the tooth (carious, fractured, mobile, preventing reduction of fracture), it must be removed at the time ofORIF. Undisplaced third molars are often left in situ.• You must be adequately trained to take consent. The important points are listed in the following subsections.Special circumstances• Children often fall onto their chin and will not open their mouth. Condylar intracapsular fractures are common, result in intense pain, and are undetectable on plain X- ray. Cone beam computed tomography (CBCT) can show up fractures. Management is generally conservative.• Guardsman fracture— fall onto chin in an adult resulting in bilateral condylar head fracture and midline symphysis fracture. So called because the injury is found in soldiers who faint while on guardduty.Points tonote whenobtaining consent• Fractures are xed with plates and screws; occasionally inter- maxillary xation (IMF; jaw wiring) is required. They may need elastics (small rubber bands) postoperatively.• The approach is usually intra- oral, but sometimes very small incisions need to be made on the face to gain access.• Teeth with a poor prognosis may have to be extracted.• There will be postoperative swelling and trismus.• Numb lip ± tongue is common postoperatively. There is a small chance of lasting paraesthesia, usually when the nerve has been severely damaged by the trauma. 84CHAPTER4 In theemergency department84Zygomatic fractures• Most fractures occur at the junction of the zygoma with other bones (i.e. orbit and maxilla) and so are probably best termed ‘zygomatic complex fractures’. It is possible however, to have an isolated arch fracture.• The classic fracture pattern caused by a direct blow to the prominence of the cheek is the ‘tripod fracture’ with disruption of the zygomaticofrontal suture, depression of the zygomatic arch, and fracture of the infraorbital rim. Some argue that there is a fourth fracture of the zygomatic buttress, which is commonly buckled.• It can be a challenge to assess these fractures because of the marked periorbital swelling.• Very rarely there is an indication for immediate action— RBH is a surgical emergency and requires urgent decompression to preserve eyesight (see E pp. 272–4).• Always fully assess eyes and record results of the Snellen chart in the notes (a handy copy is on the E inside back cover of this handbook).SignsThere is usually a cosmetic ± functional problem:• Loss of prominence of the cheek— best examined from behind the patient looking down onto theface.• Zygomaticofrontal (ZF) tenderness— palpation over the ZF suture (upper outer corner of the orbit) can reveal a step deformity.• Step in the infraorbital rim or zygomaticarch.• Subconjunctival haemorrhage— if the posterior limit cannot be identied, this suggests orbital wall fracture.• Buttress fracture— this is examined intra- orally by sliding a nger along the buccal sulcus above the upper molars. Bruising may be visible in the mucosa.• Trismus— the depressed arch impinges the mandibular condyle (can be confused with mandible fracture).• Infraorbital nerve paraesthesia— usually a neuropraxic injury as it exits the infraorbital foramen, resulting in variable altered sensation to the cheek, side of nose, and upper lip. This can also occur in the absence of fracture.• Unilateral epistaxis— overow from the maxillary sinus as it lls up withblood.• Eye injuries— the globe is relatively protected by the orbital rims, but depending on the mechanism of injury a range of injuries are possible. You must fully examine the eye and refer to Ophthalmology if there are any concerns.0 Always remember to check that the maxilla is stable to avoid missing a Le Fort fracture. ZYGOMATIC FRACTURES85 InvestigationsRadiographsTwo OM views (see E ‘Facial and skull radiography’, p. 56). Assess systematically:• Campbell’s lines— follow a line across both zygomatic arches and another line through both coronoid processes across the maxillary antrum and base ofnose.• Look at the ZF suture and compare with the other side to detect widening.• Check the distance between the coronoid process and the lower border of the arch on each side. It will be reduced in a fracture.• Fluid levels can sometimes be seen in the maxillary antrum, but this can also occur in the absence of a fracture (e.g. from a nosebleed or even acold).Complex fractures require ne cut CT with 3D reformatting (see Fig.4.2).Management• Any eye problems should be referred to Ophthalmology (except RBH which you should manage expectantly and then refer).• Some surgeons advocate early surgical reduction of displaced zygoma fractures. However, most units review a fracture in clinic in 5– 7days and if surgery is indicated plan this for about 2 weeks post injury when swelling has lessened and therefore adequate reduction can be assessed on the operating table (see E pp. 180–2).• 0 Always inform the patient not to blow their nose— this can result in surgical emphysema from the maxillary sinus and upper respiratory tract bacteria may be implanted into the tissues. If this does happen, consider prophylactic antibiotics.• Warn them that diplopia may improve or get worse as the swelling resolves (see E pp. 128–9).Fig.4.2 Axial CT image demonstrates a mildly displaced fracture of the left zygomatic arch, left lateral orbital wall, and anterior and lateral walls of the left maxillary sinus. Reproduced from Abujudeh H ‘Emergency Radiology’ (2016) with permission from Oxford UniversityPress. 86CHAPTER4 In theemergency department86Eye assessment• Ask about diplopia, reduced vision,pain.• Look for swelling, exo/ enophthalmos (posterior displacement of globe), hypoglobus (downward displacement), subconjunctival haemorrhage.• Feel— assess how tense the globe is. There should be some give— feel yourown.• Visual acuity— ideally a full sized Snellen chart at 3 m.Often a mirror is used to double the distance (i.e. at 1.5 m). You must record an objective gure (e.g.3/ 3).• Reexes— red, direct, and consensual (in RBH direct is lost but consensual remains).• Fields— check all movements and record any subjective diplopia and objective restriction in movement.• Fundoscopy and slit lamp examination— this may not be needed if the patient is to be reviewed by Ophthalmology, but it is good practice to check inside the eye. Cells within the anterior chamber can be identied fairly easily.0 Eye examination is often complicated by the patient’s inability to open the eyelid because of swelling. Check that they can perceive light through the lid and look for a consensual reex in the unaectedeye. ZYGOMATIC FRACTURES87 88CHAPTER4 In theemergency department88Orbital floor fractures• Orbital fractures occur as part of zygomatic complex fractures or as isolated orbital oor fractures— blow- out fracture.• Seven bones join to form the orbit, ve of which make up the orbital oor— zygoma, maxilla, palatine, ethmoidal, and lacrimal (the other two are greater wing of sphenoid and frontal).• The outer rim of the orbit is thick, but the orbital oor becomes very thin particularly posteromedially, and hence this is where fractures are most likely to be found. The teleological argument for this ‘design’ is that fractures occur to prevent damage to structures of the globe when orbital volume is suddenly increased (e.g. by a blow to theeye).• The following structures can be involved in oor fractures.• Inferior orbital ssure— contains the maxillary nerve and its zygomatic branch and branches of the pterygopalatine ganglion (parasympa-thetic to lacrimal gland).• Infraorbital canal— contains the infraorbital nerve and vessels and runs under the middle of the orbitaloor.• Most fractures are medial to the infraorbital canal (the optic canal is superior and relatively protected).Orbital oor fractures are usually a result of a direct blow to the eye. Often there is gross swelling and bruising, although sometimes a fracture may be associated with a complete absence ofsigns.RBH, although rare, usually occurs with a zygomatic fracture. However, always think of it as a possibility with any circumorbital trauma.Signs• Diplopia— double vision— it is important to distinguish whether this is due to entrapment of the tissues in the fracture (which can be improved by surgery) or nerve injury causing muscle dysfunction (managed conservatively). Diagnosis is by orthoptic assessment.• Enophthalmos— globe reduced posteriorly— is due to an increase in the volume of the orbit, most noticeable with fractures behind theglobe.• Hypoglobus— globe displaced inferiorly— due to disruption to supporting sling/ bony attachments— check the interpupillaryline.• Subconjunctival haemorrhage— when extending distally or no obvious posterior limit, this suggests orbital wall fracture.• Tenderness/ step of infraorbitalrim.• Infraorbital nerve paraesthesia.Orbital oor fracture inchildrenThese are easily missed so beware. In children, the orbital oor is less brittle, fractures linearly, and ‘snags’ periorbital tissues like a trap door. There is no sub-conjunctival haemorrhage, so this is called the ‘white eye blow- out’. The trapped tissue causes acute pain and restriction in upward gaze, and can be seen as a shadow hanging down into the maxillary sinus radiographically— ‘teardrop sign’. The oculo- cardiac reex is often triggered, with aerent vagal stimulation result-ing in bradycardia, hypotension, and vomiting. This is often confused as signs of a head injury— examine theeyes!! ORBITAL FLOOR FRACTURES89 Urgent surgical intervention is required to prevent muscle necrosis. All children should be followed up long term by ophthalmic surgeons after sur-gical release.Radiology(See Fig. 4.3.) OM views can show a uid level in the sinus and herniation of tissue but visualization of the fracture site (i.e. if for surgical repair) will require ne- cut CT with coronal reformatting.Management• Always admit if a child with suspected orbital oor fracture.• All orbital oor fractures should have ophthalmic surgery review— you should discuss with the on- call doctor. They may elect to see them in clinic if visual acuity is not aected (see E pp. 42–3).• Arrange for a Hess chart and binocular visual orthoptic assessment if there is any diplopia or restricted movement (as an outpatient for adults).• Review in clinic in 3– 5days to assess whether surgery is indicated (obtain CT orbits if you think this is likely).• Instruct patients not to blow their nose, as with zygoma fractures, and to return to A&E if they experience further eye pain. Consider antibiotics.• Swollen eyes can be kept clean with sterile water and cotton wool plus chloramphenicol ointment(1%).Indications forsurgicalrepair• Absolute— muscle entrapment, especially in young patients.• Relative— signicant increase in orbital volume likely to result in hypoglobus, enophthalmos, and diplopia. The surgical dilemma is that diplopia can occur several months later when repair of fracture is dicult. Hence pre- emptive treatment might be required.Fig.4.3 Coronal reformatted CT scan of the orbits showing a right orbital oor fracture with herniation of the periorbital fat and inferior rectus muscle. 90CHAPTER4 In theemergency department90Maxillary fractures• Midface fractures occur along lines of weakness, resulting in the patterns described by Rene Le Fort in 1901 (Fig.4.4).• These are less common than mandibular and zygomatic fractures but can involve both in pan- facial injuries.• The level of fracture might not be the same on both sides and sometimes is incomplete.• Frequently these fractures are associated with major trauma, so check for c- spine and head injury.• When craniomaxillary dysjunction occurs (the bones of the face literally come o the skull), the mobile segment can displace posteriorly and obstruct the airway. It needs to be disimpacted immediately.• Associated laceration of the maxillary artery can result in brisk bleeding, compounding diculty in securing the airway (see E pp. 262–3).HistoryTypically there is a history of major trauma, e.g. road trac accident, but occasionally a Le Fort 1 fracture can be induced from a minor fall in an elderly edentulous patient wearing an upper denture.Signs• Horse face/ dish face— the facial skeleton slides backwards and downwards on the skull base, retruding and lengtheningit.• Posterior gagging— back teeth meet prematurely due to posterior displacement of maxilla with resultant anterior openbite.• Bilateral black eyes (NB:must exclude base skull fracture) and subconjunctival haemorrhage.• Palatal haematoma (can signify midline palatal fracture) and bruising in the buccal sulcus and softpalate.• Mobility of palatal segment and cracked cup resonance on tapping upper teeth. In midline palatal fractures the upper teeth show mobility on compression across thearch.Always look for CSF leak indicating associated cribriform plate fracture (signs of this are ‘tram- lining’ of blood in uid from the nose or a ‘target’ spot of blood on the pillow, and can be checked by sending a sample for β- transferrin measurement).Radiology• Plain lms used for diagnosis are the OM views and lateral cephalogram. The X- rays are systematically examined using the lines described by Campbell and McGregor.• Complex fractures will require CT with coronal/ 3D reformatting.Management• Usually these patients will require admission because of associated injuries. Repair can be complex when there are many comminuted segments and is probably best left until the swelling is resolved. Custom- made arch bars can be used, so take some impressions. (This might be a bit tricky when the maxilla is very mobile!)• Occasionally isolated maxillary fractures can be managed conservatively with a Gunning splint (a type of modied denture). MAXILLARY FRACTURES91 Le Fort IIILe Fort IILe Fort IFig.4.4 Diagram showing Le Fort levels. Reproduced from Mitchell L, Mitchell D, Oxford Handbook of Clinical Dentistry (6th edn), p.461 (Oxford:2014). With permission from Mitchell L and MitchellD. 92CHAPTER4 In theemergency department92Nose, nasoethmoidal, and frontal bone fracturesFracturednose• Nasal fractures are exceedingly common. They often do not need treatment unless the patient complains of a functional or cosmetic problem.• Examine the nose from above and behind, although deviation may be dicult to detect because of swelling. In severe fractures, try to use some LA spray before examining inside the nose. Plain lms are not needed to diagnose nasal fracture, although OM views may be used to rule out associated facial injury.• Epistaxis can be impressive and may require packing (see E p. 230). Do not let it divert your attention from ruling out two important negatives.• Head injury— bilateral black eyes are associated with nasal fracture but can also be a sign of skull base fracture.• Septal haematoma— use a good light and nasal speculum to examine the septum. If it is purple, shiny, and bulging you need to evacuate using a scalpel to prevent cartilage necrosis. You must document that you have checked forthis.• Some advocate manipulating and realigning the nasal bones immediately using the lateral surfaces of both your thumbs to provide traction, or forceps if you happen to have some to hand. This will be eye- wateringly painful for your patient, but may save them a GA. Do not attempt it if you have not been shownhow!• Any patients requiring treatment should be reviewed in clinic in 5– 7days where a decision to perform manipulation under anaesthesia (MUA) can be made (see E p. 187).Nasoethmoidal fracture• This rare injury is caused by signicant blunt trauma across the bridge of the nose and is often associated with a contusion or laceration in this region.• There is a characteristic appearance in prole with attening of the bridge of the nose, which has an upturned tip (think PeterPan).• Traumatic telecanthus increase in distance between the medial canthi is caused by loss of medial attachment of the canthi to the nasal bones and can be dicult to correct. Measure the intercanthal distance, which would normally be half the interpupillary distance, and record both these gures in thenotes.• Other signs include periorbital ecchymosis and telescoping of the nasalbones.• Clean and suture any associated lacerations and obtain detailed 3D CT scans. Surgical treatment can be performed on a semi- electivebasis. NOSE, NASOETHMOIDAL, AND FRONTAL BONE FRACTURES 93 Frontal bone fracture• Essentially this is caused by the same mechanism as for nasoethmoidal fractures but just a few centimetres higher, often with an overlying laceration.• The underlying frontal sinus is highly variable in size and morphology, which can complicate diagnosis of fracture from plain lms. Ahistory of signicant injury in this region requires a CTscan.• Frontal sinus fractures (see Fig. 4.5) can be either:• Anterior wall— depressed fracture will result in poor cosmesis. You may be able to feel a bony step through the foreheadwound.• Posterior wall— when displaced by more than its thickness there is likely to be an associated dural tear. These are treated surgically (by cranialization of the sinus and obliteration of the frontonasal duct) to prevent later complications such as meningitis, brain abscess, and mucopyocele.• Clean and suture any lacerations and prescribe antibiotics.4Fig.4.5. Axial CT image demonstrates a comminuted depressed fracture involving the outer wall of the frontal sinus, with extensive overlying soft tissue emphysema. Reproduced from Abujudeh H ‘Emergency Radiology’ (2016) with permission from Oxford UniversityPress.4 Yavuzer R, Sari A, Kelly CP, et al. (2005). Management of frontal sinus fractures, Plastic and Reconstructive Surg 115:79e– 93e. 94CHAPTER4 In theemergency department94Face and scalp soft tissue injuriesTips forsuccess• Consider mechanism of injury.• Good light for examination and treatment.• Always look for an underlying bony injury.• Don’t forget associated structures that could be involved, including blood vessels, nerves, ducts, or glands (see E p. 31).• Try to close wounds within 24hours.• Ensure haemostasis with bipolar diathermy if required— this may prevent haematoma.• Minimize scarring by thoroughly washing the wound, trimming necrotic tissue, aligning edges correctly, and everting for closure.• If the patient is uncompliant due to alcohol, wash the wound, dress it, and arrange to suture when the patient has soberedup.• Stick within your means— if complex reconstruction is required, discuss with senior.History and assessmentHistoryTake a thorough history including the time and mechanism of injury. Blunt or penetrating trauma? Has a weapon been used? Was broken glass involved? Is there likely to be head injury, C- spine injury, or fractures to the facial skeleton? Medical history, social history, and tetanus status are all important to record.ExaminationCarefully inspect the face and scalp. Record all soft tissue injuries on a dia-gram, including location, size, and nature of all wounds.InvestigationsIf there is any chance of broken glass in the wound, take a soft tissue radio-graph (discuss with radiographers)— most glass and inorganic material is radio- opaque (see E p. 59).Types ofwoundLaceration• Straight— close in layers. Try to evert the edges with skin sutures to aid healing and use minimum sutures to re- appose the edges nicely.• Shelved— consider excising the shelved area to make the wound edges appose at right angles. Thin sections of skin can often ‘retract’, giving the appearance of a worse injury. Ensure that the retracted skin is replaced in its original position.• Crush— gently squeeze out haematoma or congealed blood. Minimally excise any contused or ragged wound edges. Light skin apposition. Can often be swollen. FACE AND SCALP SOFT TISSUE INJURIES95 AbrasionThe epidermis is removed by friction and the dermis is left exposed. This will granulate and heal nicely if thoroughly cleaned, debrided, and dressed with chloramphenicol or white soft paran to keepclean.Beware of ‘tattooing’— grit or dirt literally forced into the tissues by high frictional forces. These wounds must be scrubbed vigorously to lift the grit and prevent permanent marks on the skin/ underlying tissues. Perform under GA if a large surface area is aected.Bite injuriesThese are commonly dog bites, but cat bites and human bites are also seen. Cat and human bites are particularly prone to developing infection. Animal bites to the face are more common in children.5 Early and thorough washout of these wounds is required. Bite wounds are usually polymicrobially contam-inated, so give antibiotic (co- amoxiclav in a patient not allergic to penicillin) prophylaxis for 5– 7days. Give a tetanus booster and consider human teta-nus immunoglobulin (if the wound is highly contaminated or the patient is immunosuppressed). It is possible that viruses can be transmitted via human bites, although the risk is likely to be very small. Arisk assessment of the biter should be made and, if appropriate, hepatitis B vaccine/ immu-noglobulin and/ or HIV post- exposure prophylaxis should be oered. Bite wounds can be closed primarily if thoroughly cleaned, but if in doubt con-sider delayed closure.6Anatomical areas— specictipsEyebrow/ foreheadPreserve the eyebrow’s shape and form. Repair underlying frontalis mus-cle to prevent spreading and further depression of scar. Only minimum debridement of ragged wound edges should be performed— conservation of skin on the forehead is a priority to minimize contracture. Scar revision can be performed at a later date if necessary.EyelidUnless the injuries are supercial, get help— margin involvement or muscle injury needs expert repair. Rule out penetrating injury to the globe. Use ne sutures left long and steri- stripped to the side to prevent sharp suture ends from catching the eye. If the patient is unable to elevate the eyelid, there could be an injury to levator palpabrae superioris. This needs early repair— discuss referral to oculoplastic surgeon with senior.LacrimalThe lacrimal gland and ducts are located superior and lateral to the upper lid margin. The draining superior and inferior canaliculi leading to the lac-rimal duct are located in the medial corner of the eye, above and below the medial canthus. If you suspect injury, do not attempt to close, as careful repair under a microscope is needed.5 Weiss HB, Friedman DI, Coben JH (1998). Incidence of dog bite injuries treated in emergency departments. JAMA 279:51– 3.6 Stefanopoulos PK, Tarantzopoulou AD (2005). Facial bite wounds:management update. Int J Oral Maxillofac Surg 34:464– 72. 96CHAPTER4 In theemergency department96EarsExclude and/ or drain any perichondral haematoma to prevent a cauliower ear from developing— repair in layers, use pressure dressing, and review. Debride ear wounds conservatively. If cartilage sutures are required, use Prolene® 5- 0. Never leave exposed cartilage. Prescribe postoperative co- amoxiclav. For complicated lacerations or ear avulsion injuries, call a senior.NoseEnsure that the nostril borders are re- aligned. If the wound is deep through the nasal mucosa, close the mucosa rst with absorbable 4- 0 sutures and then the skin with 5- 0 sutures. Nasal cartilage should be repositioned by closing the mucosa and skin over it. Anostril splint can beused.CheeksRule out injury to the parotid duct/ gland and facial nerve. Ensure that thor-ough testing of facial nerve is completed before inltrating with LA. If the nerve damage is medial to the lateral canthal line, the facial nerve is prob-ably unrepairable.If the wound involves the gland but not the duct, you can repair the gland in A&E, taking care to re- suture the parotid fascia to avoid development of a sialocoele. If a ductal or facial nerve injury is suspected, the patient must be taken to theatre for a formal exploration and repair within 72hours.Mouth/ lipsThe priority is to re- approximate the vermillion border to avoid a ‘step’ upon healing. Labial mucosa and orbicularis oris should also be precisely apposed and closed with a resorbable suture. Through- and- through lacera-tions should be closed in layers. Good oral hygiene and salt rinses postop-eratively aid healing (see E p. 224). FACE AND SCALP SOFT TISSUE INJURIES97 98CHAPTER4 In theemergency department98Penetrating injuries totheneck• Penetrating neck trauma may involve a sharp object or missile that has penetrated the skin and underlying platysma. This may include puncture wounds, stabbing injuries, gunshot wounds, or impalement.• Apenetrating injury to the neck can potentially inict massive damage to the internal structures that run through the neck and result in catastrophic airway, vascular, or neurological injuries.• Therefore a seemingly small innocuous wound to the skin of the neck can present a threat to the patient’slife.• The neck can be thought of in zones of potential damage (Fig.4.6).7• Zone I— inferior aspect of cricoid cartilage to the thoracic outlet. Contains proximal common carotid artery, vertebral artery, subclavian artery, internal jugular vein (and subclavian vein which sometimes comes above the clavicle), trachea, oesophagus, thoracic duct (left side), and thymus.• Zone II— cricoid to angle of mandible. Contains internal/ external carotid arteries, jugular veins, pharynx, larynx, oesophagus, recurrent laryngeal nerve, spinal cord, trachea, thyroid, and parathyroid glands.• Zone III— angle of mandible to the base of skull. Contains distal extra- cranial carotid and vertebral arteries, internal carotid, and jugular vein and its tributaries.• Management may be observational (if patient is stable), surgical exploration ± adjunctive invasive or non- invasive management.7 Bi WL, Moore EE, Rehse DH, etal. (1997). Selective management of penetrating neck trauma based on cervical level of injury. Am J Surg 174:678– 82.Clinical features• Dysphagia• Hoarseness• Oro/ nasopharyngeal bleeding• Neurologicaldefect• Hypotension• Subcutaneous emphysema• Stridor• Haematoma with neck swelling• Bruit/ thrill• Pulselessness. PENETRATING INJURIES TOTHENECK99 Initial managementATLS approach— primary and secondarysurvey• A:to secure a denitive airway, endotracheal intubation may be required. Get senior anaesthetic help. An emergency cricothyroidotomy may be indicated if unable to intubate through the vocal cords. If the trachea has been lacerated, intubation through the wound may be a lifesaving action, although this would probably be necessary long before the patient gets to hospital.• B:ensure adequate oxygenation and that both lungs have normal airentry.• C:the priority is to get local control of bleeding. Replacing dressings won’t work. Anger stuck into the neck wound may be the only way to control arterial bleeding. Haemostats or artery clips can be used for visible bleeding vessels. Bilateral wide- bore IV access. Fluid resuscitate, although not too aggressively, as the increase in BP may make matters worse in severe bleeding.321Fig.4.6 Zones of the neck in relation to penetrating injuries. Reproduced from Banghu A, Lee C, and Porter K, ‘Emergencies in Trauma’ (2010) with permission from Oxford UniversityPress. 100CHAPTER4 In theemergency department100Possible investigations (discuss withsenior)• Full blood count (FBC), group and save (G&S), cross- match.• Cervical AP and lateral radiograph.• CXR— pneumothorax.• Conventional angiography— for external carotid bleeding. It may even be possible to embolize the vessel at thistime.• Doppler duplex ultrasonography.• Barium swallow.• CT— helical or spiral CT permits multiplanar views and 3D reconstructions. Good for laryngeal injuries.• CT angiography (CTA)— replacing angiography as initial study of choice for suspected vascular injury.• MR angiography (MRA)— time constraints limituse.• Direct laryngoscopy.• Flexible bronchoscopy.• Oesophagoscopy— risk of perforation into neck and introduction of bacteria into neck spaces because of gas insuation used at the time of procedure.Denitive managementAfter primary survey and resuscitation:• Observation or expectant management for those who are stable.• Consider further investigations (only if stable).• Immediate exploration for patients with ongoing signs and symptoms of shock or continued haemorrhage. PENETRATING INJURIES TOTHENECK101 102CHAPTER4 In theemergency department102Intra- oral injuriesOverview• Intra- oral trauma is common in children, particularly toddlers who have a tendency to run and play with objects in themouth.• Good blood supply and the properties of saliva mean that both injuries and incisions in the mouth generally heal quickly.• Intra- oral changes may manifest secondary to bony fractures of the mandible or maxilla.• For anatomy, see E p. 19.AnatomicalareasSoft palate, tonsil, and posterior pharynx• Injuries to these areas are relatively common as they are directly posterior to the opening of themouth.• Penetrating injures can be caused by falling onto a sharp object (particularly toddlers) or stabbing injuries— accidental or otherwise.• Wounds can look innocuous on examination (small puncture wound), but neurological or vascular injury could occur if the object has penetrated deep enough.• Potentially close to internal carotid, cranial nerves IX, X, and XII, sympathetic plexus, and internal jugularvein.• Consider liaising with ENT. May require GA and exploration.• Often managed conservatively.Tongue• Lacerations— if located on the dorsum of the tongue, can normally be managed conservatively. If on lateral border or tip, should be sutured to prevent ssured healing.• Tongue studs can become infected and swell to a phenomenal size. May be risk to airway. Management is to remove the stud and prescribe antibiotics. Studs placed laterally can damage the lingual artery!Lips• Careful approximation of the vermilion border is required (make this the rst ‘marking’ stitch to avoid an uneven pull from stitches on eitherside).• Full- thickness lip lacerations should have layered closure after washout and debridement.• Beware of the labial arteries— if cut and not tied o or coagulated with diathermy can produce signicant labial haematoma or bleeding. They also bleed from bothends!Gingivae• Torn gingivae may mean that there is a fracture of the maxilla/ mandible or alveolarbone. INTRA-ORAL INJURIES103 De- gloving injuries oflowerjaw• Essentially this occurs when the soft tissues have been ripped o the mandible by blunt trauma.• These are dirty wounds and require copious irrigation and closure underGA.• They can often be missed at examination if the tissues are stuckdown.TeethSee E pp. 104–8.General intra- oral injury management• Small wounds do not usually require surgical intervention and will heal quickly.• Salt mouth rinses aid healing and reduce infection risk. Make sure you tell the patient they must clean their teeth as normal with a brush andpaste.• If the wound is dirty and contaminated, antibiotic prophylaxis can be considered.• Intra- oral wounds will initially look yellow and sloughy when healing— this does not mean that they are infected.• Patients with deeper penetrating injuries should be monitored for neurological or vascularsigns.• Foreign bodies— identify with radiographs if possible. Ultrasound (US) may also be useful here, particularly for radiolucent objects (such aswood).• Stitching in the mouth— use absorbable sutures and think about knot placement to increase comfort for patient.• Through- and- through wounds need careful closure in layers to prevent oro- cutaneous/ salivary stula.Non- accidental injury(NAI)Perioral injuries are very common in children when they fall or bump into things at face height. Intra- oral injuries are less common, but do occur acci-dentally. Look out for fraenal tears and palatal injuries, which can occur sec-ondary to objects being forced into mouths. Always take a detailed history of what happened and examine the area in question as well as the rest of the body. If in any doubt about the cause of the injury, discuss with a senior and involve a child safeguarding ocer. 104CHAPTER4 In theemergency department104DentoalveolartraumaThe most important job for you with dentoalveolar trauma in A&E is to avoid unnecessary loss of permanent teeth and to spot alveolar fractures. It can be dicult to manage trauma to teeth in A&E because of the lack of equipment and dental radiographs. Often you just need to do the best you can to stabilize the injuries until the patient can be assessed and treated by their dentist or in the dental hospital.Try to dierentiate between deciduous and permanent teeth in trauma-tized children (see E Table 2.1 and Table 2.2, p. 11). This section is divided into management of deciduous of permanentteeth.Deciduous teeth (‘milk teeth’)As a general rule, you have to do a lot less with injured deciduous teeth although the incidence is common (see Table 4.1). The principles are as follows:• Always exclude NAI (particularly in the non- mobile child).• Alveolar fractures are very rare in children and occur in relation to high- velocity injuries, road trac accident, golf clubs, etc. Occasionally these require surgery.PermanentteethReplace avulsed teeth as soon as you can. This is a dental emergency as the chances of saving the tooth rapidly decrease with the amount of time that it has spent out of the mouth (see E p. 231).Table4.1 Management ofcomplications indeciduousteethComplication ManagementAvulsed deciduous toothYou must account for its whereabouts, see below in tableDo not re- implantNeeds referral to (paediatric) dentist to assess if balancing extractions are required to prevent centre- line shiftIntruded deciduous tooth damaging developing permanent tooth budEmergency removal will not aect the outcome.The tooth can spontaneously re- erupt overtimeThe developing permanent tooth may be bent (dilaceration) which can prevent normal eruption. Surgery may be required to aid eruption later on so GDP must monitor eruption times.Fractured/ damaged teethThese can become non- vital teeth and hence become infected— all dental trauma should be followed up by the GDP or a paedodontist to decide if root canal treatment (RCT) or extraction is required.Unaccounted for avulsed deciduous teethDiscuss with your senior, radiography may be indicated; they could be in soft tissues or aspirated DENTOALVEOLARTRAUMA105 Severely intruded or displaced teeth and fractures of the alveolar bone necessitate follow- up by OMFS. The rest can be managed by the den-tist (many patients are not registered with a GDP which can complicate matters).Make sure that you achieve good anaesthesia before examining the mouth. Most injuries will be ‘luxation injuries’ (loosening). The tooth may not be wobbly per se, but there will have been some damage to the peri-odontal ligament which is identied by blood around the gingival margin. Classication is outlined in Table4.2.Tooth fractureAlso see Fig.4.7.Luxation ‘loosening’ injuriesConcussion/ subluxationA certain amount of force can be absorbed by the periodontal ligament, meaning that the tooth is not grossly displaced. Essentially these two injuries are the same, but are clinically dierentiated as a subluxed tooth has blood around the gingival margin. The tooth can be very tender so a soft diet is recommended. The tooth should be monitored by the GDP as pulpal necrosis can occur and result in a discoloration.Lateral luxation/ intrusion/ extrusionIn these injuries, the tooth is displaced, usually as a result of fracture of the alveolar bone. The area needs to be anaesthetized, any fractures reduced, and the tooth splinted. Severely intruded teeth (>6mm in adults) usually require surgical repositioning and orthodontics. These patients require painkillers, antibiotics, and a mouthwash.Table4.2 Classication offracturesClassication ManagementCrown fractureSimple fracture of enamel ± dentine. It has a good prognosis and is best managed by the GDP. Sensitivity can be avoided by sealing any exposed dentine with bonding agent. Check the lip for intruded fragments (soft tissue X- ray helps)Complicated fractureFractures which expose the pulp— usually require RCT. The situation is complicated in children where the root apex is incompletely formed. The exposed nerve will be acutely painful, so dress it (you may need to inject LA into the pulp). CaOH or Ledermix® can be directly applied and a temporary lling material added on topRoot fracture Splinting + RCT is the mainstay of treatment. Fractures of the coronal third have the worst prognosis and may best be treated by decoronation and crowning (see E p. 106). 106CHAPTER4 In theemergency department106AvulsionThe tooth can be ejected from its socket. This is more common in children, in adults the tooth is more likely to fracture. Advice can be given over the telephone to re- implant the tooth but you must always check the patient yourself (even dentists have been known to replace the tooth the wrong way round). See E p. 231 for the technique but make sure that the tooth is whole before reinserting it. It is advisable to place the tooth in milk while transferring toA&E.MissingteethPatients may ask you what they can do following complete loss of a tooth. Advise the patient that they will need to consult a restorative dentist for a full discussion of their options. However, it is useful if you have some overall understanding what their dentist may oer them (see Table4.3).(a) (b) (c) (d)Fig.4.7 Simple classication of tooth fractures (a)enamel only; (b)enamel and dentine; (c)enamel, dentine, and pulp; and (d)root fracture. Reproduced from Wyatt J etal. ‘Oxford Handbook of Emergency Medicine’ (2012) with permission from Oxford UniversityPress.Table4.3 Options oered byrestorative dentistsCrown If there is enough root left in the socket a dentist can fabricate a crown, which is retained by a post and core. This takes several appointments to makeDenture Can replace one or many teeth. It can be used temporarily to hold the space while a crown or implant is being madeBridge If the adjacent teeth are healthy they can be used to suspend a crown to cover the gap. Various types are available. Temporary bridges can again be used while a crown or implant is being preparedImplant These are expensive and not suitable for everyone. Although they can give an excellent result, the entire process can take months. They are not generally available on the NHS unless part of teaching/ research or following cancer ablative surgery DENTOALVEOLARTRAUMA107 108CHAPTER4 In theemergency department108Dentoalveolar infectionsOverviewToothache without orofacial complications is a dental problem and is not covered in this chapter.Dental infections arise either from within the tooth or from the tissues around the tooth (most commonly the operculum of an erupting wisdom tooth; E p. 245).Pathogenesis• Bacteria invade the pulpal chamber of the tooth leading to pulpitis, and then pulp necrosis. Infection spreads apically from root into bone and then soft tissues (Fig. 4.8), leading to sinusitis, cellulitis, or abscess. However, initial infection may be of the gum (periodontitis) or pericoronal tissues (pericoronitis).• Cellulitis spreading through head and neck tissue planes (see E p. 109) can lead to life- threatening oedema and airway obstruction, septicaemia, cavernous sinus thrombosis, or tracking infection into the mediastinum.• The majority of dentoalveolar infections are mixed anaerobic– aerobic infections and respond to broad- spectrum antibiotics, but pus should never be left undrained.AssessmentTake a history of the toothache and associated symptoms. On examination, look for the following markers of severity:• Airway compromise— can be life- threatening. Look for drooling, stridor, and respiratory distress.• Raised FOM— place gloved nger under tongue to examine for fullness andpain.• Restricted tongue protrusion— can indicate a sublingual space infection.• ‘Hot potato voice’— voice changes are a sign of threatened airway.• Pain on turning the head— may indicate a lateral pharyngeal space infection.• Trismus— suggests submasseteric space infection.• Swelling— describe extent of swelling, is lower border of mandible palpable? (If not, suggests submandibular space abscess.)• Temperature >38.5°C— ‘swinging pyrexia’ with abscess.• Cardiovascular— tachycardia, postural hypotension.• Blood abnormalities— raised white cell count,CRP.• Abscess— localized collection of pus (inammatory exudates, dead white cells). Fluctuant, tense, tender swelling which requires drainage and removal of source of infection.Causes ofswelling• Oedema— swelling of the tissues secondary to uid retention. Common initial change in dentoalveolar infection in children.• Cellulitis— intra- and intercellular oedema with rapid migration of bacteria though tissues— red, hot, and swollen tissue, often well demarcated on face. It can be treated with antibiotics and removal ofcause. DENTOALVEOLAR INFECTIONS109 Management• OPG (occasionally USS or CT is required).• Bloods including WCC, CRP, and glucose. Consider cultures.• IV access and rehydrate.• Commence IV broad- spectrum antibiotics.• Consider corticosteroids in severe swelling.• Admit.• KeepNBM.• If warranted, list for emergency theatre for incision and drainage underGA.• Consent for intra- oral ± extra- oral drainage and extraction of teeth as necessary.PalatalCanineTongueSubmandibularSublingualBuccalFig.4.8 Possible routes of spread of odontogenic infections. Reproduced from the Emergency Medicine Journal, Features of odontogenic infections in hospitalised and non- hospitalised settings, Hwang T etal., 02 November 2010, copyright (2010), with permission from BMJ Publishing GroupLtd. 110CHAPTER4 In theemergency department110AntibioticsAntibiotics can treat cellulitis eectively, but are not eective for abscesses. They are useful to help ‘localize’ abscesses, such that drainage is more straightforward, but beware trying to treat patients with antibiotics alone— the oending tooth must be treated or extracted.DrainageDrain the pus! Infection causing pus formation associated with teeth is rarely treated successfully with antibiotics and analgesics alone. Oedema can also benet from decompression.• Intra- oral drainage— incision in buccal mucosa.• Extra- oral drainage— incision through skin. Allows better drainage by gravity if the infection has tracked below the level of thejaw.Specic infectionsLudwig’sanginaThis is a bilateral cellulitis aecting sublingual and submandibular spaces, such that the whole neck looks swollen. Often the FOM is raised and the tongue pushed up, restricting the airway. This is a life- threatening condi-tion. Inform the registrar/ consultant and get senior anaesthetic help to secure the airway. May require a breoptic intubation or a surgical airway (see E pp. 262–3). Get IV access and arrange emergency decompres-sion/ drainage as soon as possible. Commence IV antibiotics ± steroids in the meantime.Periorbital cellulitisCellulitis generated by rapid migration of bacteria through the tissues around the eye. Often the source is the paranasal sinuses, but it can arise from the teeth, particularly the upper canines. Treat with IV antibiotics, inci-sion, and drainage if pus has collected, and dental extraction if indicated.DrainsAlways obtain consent from patients undergoing incision and drainage for placement of drains. Drains can be manufactured out of most things. The aim is to keep the abscess cavity open, allowing further exudates todrain.Possible materials:• Yates’ drain (corrugated plastic)• Sterile glovenger• Ribbongauze.Secure the drain with a non- absorbable suture. Pulling or ‘shortening’ the drain out in stages postoperatively allows the cavity to gradually close up behindit. DENTOALVEOLAR INFECTIONS111 112CHAPTER4 In theemergency department112Post- extraction complicationsRisks for complications include the following.• Patient factors: ♀>♂, elderly patient, African Caribbean, i BMI, smoking, medical problems (diabetes mellitus, Paget’s disease, previous radiotherapy, bisphosphonates), poor oral hygiene.• Tooth factors: mandible > maxilla, third molars, unfavourable anatomy of tooth (e.g. divergent roots), hypercementosis, brittle tooth (e.g. large restoration),RCT.• Extraction factors: single extraction, dicult extraction, bone removal, junior surgeon.BleedingBleeding can be classied as follows.• Primary haemorrhage— at time of extraction.• Reactionary haemorrhage— up to 24 hours after extraction (usually after the vasoconstrictor has worno).• Secondary haemorrhage— >24 hours after extraction. Indicates infection.Management ofbleedingSee E p. 225.PainMost patients will experience pain and swelling after extraction and regular simple analgesics are recommended. In dicult wisdom tooth extraction, especially those requiring bone removal, pain and swelling can be marked and usually peak at 4 a.m. on the day after the surgery. It can be severe for 2– 3 days; they will need time o work. Non- steroidal anti- inammatory drugs (NSAIDs) often work best and can be used in combination with simple analgesics such as paracetamol.DiagnosisHistoryOnset of pain. Pain immediately after the LA has worn o suggests it is from a traumatic extraction or possibly fracture of adjacent tooth or bone. Dry socket pain typically starts >48 hours post extraction.ExaminationLook for temperature, lymph nodes, halitosis, trismus, and the extent of any swelling. Fibrin in the clot becomes yellow from absorbing saliva so don’t be fooled into thinking it is pus. If you can see bone, suspect dry socket or osteomyelitis.InvestigationX- ray the extraction site to show any retained fragments or fractures. Test adjacent teeth for sensitivity. POST-EXTRACTION COMPLICATIONS113 Causes ofpost- extractionpain• Pain from extraction• Drysocket• Retained root or bone spicules• Damage to adjacent tooth giving pulpalpain• Dislocated mandible• Haematoma• Fracturedbone• Osteomyelitis(late)• Osteonecrosis.Drysocket(For management of dry sockets see E p. 226.)Failure of retention of the clot within the socket because of vigorous rinsing or the action of lytic organisms (but not an infection). The incidence is much increased if the patient smokes, so avoid cigarettes for at least 24 hours after extraction. Contraceptive pill also increases risk. Severe throbbing pain ± lymphadenopathy typically onset 3– 5 days after extrac-tion. Grey– white bone is visible in the bottom of the socket (irrigate to have a look), hence its name alveolar osteitis. Treatment is irrigation with chlorhexidine, packing the socket with obtundent dressing such as Alvogyl®, analgesia, and review in a few days. Antibiotics are usually not indicated. This is a self- limiting condition, but very rarely spreading infection may develop. If it fails to heal suspect osteomyelitis or even malignancy— will need biopsy.SwellingThis is normal after extraction. Trismus may be marked. Haematomas can rapidly form, but most can be left unless they are aecting the FOM or parapharyngeal regions. Once you have checked that there are no signs of infection or airway obstruction, the patient can be reassured. Some advo-cate icepacks.InfectionThis is rare, as the source of infection (tooth) has been extracted; how-ever, delayed swelling, bleeding, and pain are signs. Irrigate the socket, drain any collections, and prescribe antibiotics and hot salt- water mouth rinses. Osteomyelitis can develop, especially in immune compromise, so treat promptly.Oro- antral communicationRoots of the upper molar teeth can extend into the maxillary sinus and when removed may leave a communication between the mouth and nose. Patients complain of uid coming out of the nose when drinking or symp-toms of sinusitis. Examine the extraction site and, if suspected, ask the patient to gently blow out of the nose. You may hear air coming out of the socket. This can be treated by a simple ap electively, but in A&E prescribe antibiotics and arrange follow- up. Packing with Surgicel® and a suture will do no harm. If left, a stula will form which is more dicult totreat. 114CHAPTER4 In theemergency department114Dislocated mandibleThere have been reports of patients being discharged after an extraction with a dislocation (see Ep. 232).Paraesthesia/ anaesthesiaNerves can be damaged by the LA injection as well as by the extraction itself. This is more common in the lower molar teeth. If there is still a feel-ing of numbness long after the LA has worn o, neurapraxia or even more permanent nerve damage (such as neurotmesis) is a possibility. If it was a dicult extraction, the patient should have been warned about this. Most cases resolve spontaneously, albeit slowly (up to 18months). If there is any suggestion that the nerve was severed rather than crushed, referral for re- anastomosis is indicated.Other common problems• Unmet patient expectations— patients may be surprised that they are in pain up to a week post extraction. Asympathetic ear and reassurance that there is no untoward complication may be all that is required.• Suture falling out— if there is no bleeding, no treatment is needed.• Retained root— most require extraction unless planned or too dicult to retrieve (i.e. close to nerve). Roots are sometimes left electively— usually the patient will have been told. Coronectomy has been advocated by some as an alternative to exodontia for third molars.• Displaced fragment— parts of teeth can end up in many spaces in the head and neck. Arrange for follow- up to explore properly.• Osteonecrosis— becoming more of a problem. Historically was seen in radiotherapy elds, but now bisphosphonate osteonecrosis can also occur. The mandible is more commonly aected than the maxilla. Seek senior help. In advanced cases, may need elective resection and re- construction. POST-EXTRACTION COMPLICATIONS115 116CHAPTER4 In theemergency department116Head and neck soft tissue infections• Spreading infection from deeper structures such as teeth, sinuses, salivary glands, and bone is common and must be excluded (see E p. 109).• The surrounding anatomy can become involved, resulting in serious complications such as cavernous sinus thrombosis, airway obstruction (see E p. 231), and even mediastinitis (common cause of death in medieval times!).Localized infectionsCarbuncle/ furuncle/ folliculitisStaphylococcus aureus is the usual cause of infected hair follicles (folliculitis), most commonly in the beard area (sycosis vulgaris— ‘barber’s itch’) and scalp. Hot compresses and antibacterial skin wash may help mild cases; otherwise, systemic antibiotics are indicated. Take a pus sample to conrm the antibiotic choice (usually ucloxacillin). Furuncles and carbuncles are on a continuum of larger and deeper infected nodules and usually require inci-sion and drainage. Look for a precipitating cause (e.g. undiagnosed diabetes, resistant organisms in recurrent infection, e.g. Panton– Valentine leucocidin); random blood glucose is useful as initialtest.ImpetigoSupercial staphylococcal/ streptococcal infection causing golden- crusted pustular lesions. It is common in children and often presents on the face. The sores are highly contagious and very itchy, so meticulous hand hygiene is required. Families should not share towels and bedclothes. Topical fusidic acid ± oral ucloxacillin is usually eective.Infected/ inamed epidermoid (sebaceous)cystCysts originating from the sebaceous glands are commonly found on the face and scalp. Infected cysts are acutely painful until spontaneous bursting or incision relieves the pressure. The cyst can be incised in A&E with ethyl chloride spray to anaesthetize. Wait until the skin suddenly goes white and then incise quickly before sensation is regained (LA is very unlikely to work). Anger from a sterile rubber glove can be secured with a nylon suture or a Penrose drain inserted into the cavity to prevent the cyst from re- forming. Follow- up is required for formal excision of the cyst once infection has cleared (see E p. 170).Chronic drainingsinusChronic periapical infection can lead to pus tracking through alveolar bone and out onto the skin, classically a spot under the chin draining from the lower incisor teeth. There may be no oral pain unless the draining sinus becomes blocked. The skin infection will not respond to topical or systemic antibiotics; the oending tooth needs to be extracted.Spreading infectionErysipelasA bright red painful spreading infection of skin which is raised, rm, and hot to touch. It is usually due to inoculation of a minor wound (e.g. insect bite) with endogenous group A Streptococcus from the nasopharynx. The rash HEAD AND NECK SOFT TISSUE INFECTIONS117 quickly spreads and can progress to blistering and necrosis if severe. Blood cultures are indicated if the patient has a high temperature, and penicillin remains rst- line therapy.Necrotizing fasciitisThis thankfully rare condition has a high mortality, particularly when involv-ing the craniocervical region. The infection is usually polymicrobial, including both aerobic and anaerobic organisms. There is rapid spread along the deep fascial planes and necrosis of the subcutaneous tissues. Prompt surgical debridement and broad- spectrum IV antibiotics (discuss with microbiology as ora will dier between patients (e.g. IV drug users) are the mainstay of treatment. Hyperbaric oxygen has been shown to reduce mortality but is not widely available. Overwhelming sepsis is common, and most patients will be treated on the ITU. Spread to the mediastinum is invariablyfatal.CellulitisFacial cellulitis can develop from infection introduced through a break in the skin (e.g. after a punch to the face) or from infection of deep structures— the so- called fat face associated with dental infections. The source of infec-tion must be addressed to control the cellulitis. The most serious form of this is 2 Ludwig’s angina, where spreading cellulitis in the oor of the mouth can lead to airway obstruction. Patients are often very septic and require urgent anaesthetic involvement to secure the airway followed by surgical drainage of the infection. Always feel under the tongue to assess for swell-ing in the FOM (see E pp. 40–1).Periorbital cellulitisCellulitis can develop around the eye following infection of the upper teeth or, more commonly, sinusitis. It is critical to dierentiate between pre- and post- septal cellulitis. Pre- septal cellulitis is infection limited posteriorly by the orbital septum. Patients have swollen eyelids but no ocular pain or restric-tion in eye movement. This can sometimes be managed by oral, rather than IV, antibiotics. Orbital (post- septal) cellulitis is a surgical emergency. Patients have proptosis, ophthalmoplegia, and diplopia. IV antibiotics are always required to prevent complications such as meningitis, brain abscess, and cavernous sinus thrombosis. Urgent CT is indicated, and denitive treat-ment is usually managed by ENT colleagues who can endoscopically drain the infected paranasal sinuses.Viral infectionsShinglesHerpes zoster infection— reactivation of the varicella (chickenpox) virus— causes severe pain in a dermatome together with vesicles/ blistering. The trigeminal nerve is commonly involved in the head and neck. Infection of the ophthalmic division can result in blistering and subsequent scarring of the cornea, so urgent ophthalmic referral and antiviral therapy is indicated. Post- herpetic neuralgia is severe and more common in the older age group. Zoster normally aects the sensory nerves. The notable exception to this is Ramsay Hunt syndrome where infection of the geniculate ganglion causes paralysis of the facial nerve (look for tell- tale vesicles in the external audi-tory meatus and fauces— the facial nerve has sensory branches to these areas!). Liaise with the medical team about ongoing management. 118CHAPTER4 In theemergency department118Salivary gland diseases• In the emergency setting, most gland problems will be related to infection or obstruction, but you must consider the possibility of a salivary neoplasm or underlying connective tissue disorder. Always review patients once the acute problem has settled.• Painless discrete swellings with associated lymphadenopathy and nerve palsy are red ag signs (and suggest malignancy).• Be extremely careful when suturing mucosa around the salivary ducts. You can inadvertently obstruct them (see E pp. 18–22 and pp. 28–32).• Papillotomy can be performed for stones visible at the submandibular duct opening. Inject a small amount of LA and open the papilla with a No. 11 blade. The stone should pop out, often with a gush of saliva. Leave the incision open and advise chewing gum and hot salt- water mouth rinses in the healing period.• Description is based on old terminology— ‘sialaden’ for salivary gland. Hence inammation is sialadenitis, atrophy is sialectasis, contrast investigation is a sialogram, and stones are sialolithiasis.InfectionBacterialAcute bacterial sialadenitis is an extremely painful infection usually of the parotid or occasionally the submandibular gland. The aected gland is ten-derly swollen and erythematous, and the patient (typically a dehydrated elderly patient, often with poor oral hygiene) may be quite unwell. Pus can be expressed from the duct (swab it and send for microbiology). Staphylococcus aureus is the usual organism. Prompt IV co- amoxiclav and IV uids are required. US scan may reveal an abscess requiring surgical drainage. Chronic infection may necessitate gland excision (see E pp. 192–3).ViralMumps (paramyxovirus) is relatively rare since widespread vaccination, but should be suspected in any acute swelling of the major salivary glands. The swelling is not always bilateral and can aect other organs such as the pancreas and testes (71% infertility). There is a classical mumps voice, and patients complain of arthralgia, lethargy, and headache. Treatment is symp-tomatic. Mumps is a notiable disease in the UK, so serum samples for immunoglobulin (Ig)- G and IgM as well as buccal swabs for mumps virus should betaken.Viral sialadenitis can also be caused by HIV, cytomegalovirus (CMV), Epstein– Barr virus (EBV), and para- inuenzavirus. SALIVARY GLAND DISEASES119 ObstructionSalivary glandstonesThese are most commonly found in the submandibular gland where block-age of Wharton’s duct causes repeated painful swelling of the gland when salivation is induced— ‘meal- time syndrome’. Bimanual palpation of the gland may reveal the presence of a stone, which can be removed if it is at the papilla. The high calcium content of the stones means that 70% are visible on plain X- ray (e.g. lower standard occlusal for submandibular gland stones). Conversely, US scans are not good at showing stones unless they are within the gland. Ascending bacterial infection can result from obstruc-tion and requires admission if severe. However, these patients are usually best managed in the outpatient setting.Mucocoeles and mucous retentioncystsMinor salivary glands in the labial mucosa and FOM can become damaged by minor trauma, resulting in swelling and cyst formation. When found under the tongue these are called ‘ranula’. Although not very painful, they can be worrying when they appear suddenly and prompt a visit to the emer-gency department. The patient can be reassured and excision of the cyst plus gland arranged for an elective locals list. If they are very large, they can be decompressed with a needle as a temporary measure.TraumaThe supercial position of the parotid gland means that it can be relatively easily injured. One particularly charming wound inicted on informers, ‘the telephone’, involves slashing the side of the face with resultant parotid and facial nerve damage. The sublingual and submandibular glands are relatively well protected by the mandible.• Examine for nerve injury before administering LA. All nerve injuries require formal exploration in theatre.• Disrupted ducts need re- anastomosis and stent insertion in theatre. Aplastic cannula sheath inserted into the duct intra- orally can demonstrate a transected duct when it appears in thewound.• Careful closure of the parotid fascia can prevent a salivary stula.• Most salivary stulae will resolve spontaneously with pressure dressings. 120CHAPTER4 In theemergency department120Miscellaneous conditionsFacial nervepalsyThe causes are legion but diagnosis is idiopathic (i.e. Bell’s palsy) in 775% of cases. Don’t forget that this is a diagnosis of exclusion. Check whether the lesion is upper (forehead sparing) or lower motor neuron, unilateral or bilateral. Check the muscles of facial expression, test for hyperacusis (pain on loud noise because of absent stapedius reex), corneal reex, taste, and salivary ow, and examine ears and pharynx for viral lesions. Complete neurological examination is indicated.Causes ofCN VIIpalsyThis is not an exhaustivelist:• Vascular— stroke.• Tumour— CN VII can be compressed anywhere along its length, e.g. intracranial (cerebellopontine angle, acoustic neuromas), cranial base, and parotid tumours.• Trauma— cranial base fracture, facial laceration.• Infective— herpesviruses most commonly, e.g. Ramsay Hunt syndrome (herpes zoster— look for vesicles in the ear). Others include Guillain– Barré syndrome (may be bilateral) and Lyme disease.• Neurological— multiple sclerosis and other degenerative conditions, e.g. amyotrophic lateral sclerosis.• Inltrative— sarcoid, leukaemia.• Bell’s palsy— can be considered if the above conditions are excluded. Unilateral lower motor neuron lesion in an otherwise well patient. Possibly a viral trigger and is usually self- limiting.• Rare syndromes, e.g. Heerfordt syndrome— uveitis, fever, parotid swelling.• Iatrogenic— damage due to surgery.Management• Exclude serious cause— CT or MRI may be indicated.• Protect the eye— warn the patient, eye drops, patch (not longterm).• Studies have shown that prescription of 50 mg prednisolone daily for 10 weeks can reduce the time to recovery if commenced within 24 hours of onset of symptoms. The use of aciclovir is more controversial, but is certainly indicated if there is evidence of viral infection.BleedinggumsThe most common cause of bleeding gums is gingivitis, ‘gum disease’. Bleeding occurs when the gums are touched and is usually noticed by the patient when they spit out blood- stained toothpaste. Improving oral hygiene will improve gingivitis.Spontaneous bleeding of the gums may reect a more serious condition suchas:• Acute necrotizing ulcerative gingivitis (ANUG), also known as ‘trench mouth’ as described in the frontline soldiers in the First World War. Acombination of poor oral hygiene, stress (or any cause of immune suppression), and smoking can predispose to infection by multiple MISCELLANEOUS CONDITIONS121 anaerobes, giving symptoms of painful necrotic bleeding gums, halitosis, lymphadenopathy, and fever. If untreated this can progress to a chronic destructive infection called noma/ cancurum oris. Treatment is oral metronidazole and chlorhexidine mouthwash, although the condition can resolve without treatment. Oral hygiene must be reviewed once the acute symptoms have settled, together with smoking cessation and investigation of immune suppression (e.g.HIV).• Clotting disorder— inherited or acquired. Check medications and alcohol use, and perform clotting screen.• Leukaemia— classically, acute myeloid leukaemia (AML) causes sudden gingival enlargement (inltration with leukaemic cells) with bleeding (d platelets). Ablood lm should reveal the diagnosis. Severe gingival bleeding can be tamponaded by taking a conventional impression.PericoronitisThe gum overlying a partially erupted lower wisdom tooth is prone to pain-ful inammation dueto:• trauma from opposing upper wisdomtooth• infection from organisms trapped under the gum ap, an ideal breeding ground for anaerobes.Spreading infection is rare but there can be severe pain, swelling, trismus, and lymphadenopathy.Management• Irrigate under the operculum (gum ap) using a Monoject™ syringe (has a curved tapered nozzle) lled with chlorhexidine mouthwash. Show the patient how to do it so they can continue athome.• Analgesia.• Prescribe metronidazole (see E p. 280).• Look for spreading infection especially into pharynx (see E pp. 108–10 andp. 235).• Send back to GDP who may wish to refer for extraction(s) in accordance with local policies.• In the acute situation, extraction of the opposing tooth may relievepain.EarringtearThe lower pole of the ear lobe can be completely torn through, result-ing in an unsightly forking of the lobe. If the injury presents immediately, repair is simple with direct closure of the skin on both surfaces of the lobe. Unfortunately, if patients present more than a few days after the injury, the surfaces will be epithelialized and simple suture will not be possible. The scar tissue must be removed and the bleeding surfaces opposed. However, in these days of funding cuts it is a treatment that may not be available on theNHS. 122

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