On the ward 










199
Chapter7
On theward
OMFS on the ward 200
Trauma patients 204
Dentoalveolar patients 206
Head and neck oncology patients 208
Flap monitoring 212
The tracheostomy patient 214
Orthognathic patients 218

200
CHAPTER7 On theward
200
OMFS ontheward
Since OMFS is a small specialty with relatively few inpatients, it rarely
has a dedicated ward and often shares with ENT or another small
surgical specialty.
Sometimes the whole OMFS team attends the ward round, and may
include ‘special services’ (e.g. Macmillan nurse, SALT, dietician,etc.).
There are a large number of young short- stay patients (trauma/
orthognathic) with no medical problems.
There are a small but increasing number of long- stay patients with many
medical problems— it is really important that you get good exposure to
medical rms during your training, ideally in the ITU as well, to manage
these sick patientswell.
OMFS ward round essentials
Be ontime and know thepatient’s background history
Pen torch, spatulas, gloves, orthodontic elastics, skin marker- pen.
Stethoscope.
Hand- held Doppler for ap patients available.
Review appointment cards if applicable.
Snellen charts for measuring visual acuity (see E inside back cover of
this handbook).
Radiographs/ investigations
It is important to ensure that radiographic imaging is available to be viewed
on the ward round with the corresponding reports if completed. This is usu-
ally done via digital images on PACS (Picture Archiving and Communication
System), often before the ward round. Be ahead of the game and have cor-
rect up- to- date images ready for the patient. Think about their interpreta-
tion and signicance for management, as it is likely that you will be asked for
your input. Furthermore, the latest blood, microbiological, and pathological
results should also be known and presented to the ward round; you will get
used to the usual questions:CRP, WCC, glucose for the abscess patients,
for example.
OMFS wardwork
A select few patients will take up the majority of your time (normally the
oncology cases) as they require more regular investigations and postop-
erative monitoring (see E pp. 212–13). Get to know who in the hospital
controls the appointments for investigations, e.g. ultrasound, lung function,
ECHO. The faster a patient is worked up for surgery the better for them
and you may save the hospital a huge ne for a breach in missing treatment
deadlines.
If you need to perform a procedure on the ward, try to make use of
a side- room or ENT treatment room where you are likely to have more
space, more light, and more equipment available than by the bedside.
Ensure that you know the location of, and have had a play with, any equip-
ment that you might need in an emergency. Take the opportunity to extend
your role doing minor procedures and endoscopy.

OMFS ONTHEWARD
201
Nurses
As ever, a good working relationship with the nurses is essential for a happy
and harmonious working environment. Muck in and be helpful, and you will
receive the same in abundance. Communicate well, share knowledge, and
learn what the roles of the nurse involve—they have seen many like you
come and go and have a wealth of knowledge.
Ward protocols
These are generally in place to follow in specic clinical situations. Some
examples are given as follows.
Tracheostomy
Tracheostomies are used to protect the airway— but they can kill if not
cared for properly. Our patients have dicult airways and should have plans
in place if the airway is inadvertently lost. You should be knowledgeable
about tracheostomies, so nd and review the protocol (often in place for
the nurses) for tracheostomy care. These guidelines relate to tracheostomy
tube care, suctioning, humidication, care of the cu, fenestrated tubes,
speaking valves, decannulation, tracheostomy emergencies, and resuscita-
tion (see E pp. 214–18). Extra reading of the NICE guidelines is amust.
1
Carotid blow- out
Ensure that you familiarize yourself with this, as the protocol is in place to
decrease stress for both the patient and sta in what can be a seemingly
horric situation. The three approaches to carotid blow- out are preventa-
tive, active resuscitation, or palliativecare.
Preventativeprevent dehydration, infection, and wound breakdown;
nutritional support; reduce physical and emotional stress.
Active resuscitationsecure airway; prevent aspiration; control
haemorrhage; prevent hypovolaemic shock; relieve anxiety; morphine/
diamorphine/ midazolam.
Palliative carerelieve anxiety; compassion and support; assist the dying
patient.
Alcohol withdrawal
This will be appropriate for a signicant proportion of OMFS patients,
particularly cancer and trauma patients who may be heavy drinkers. Look
for your hospital’s protocol; it is designed to prevent delirium tremens and
Wernicke’s encephalopathy by administering a reducing regimen of chlor-
diazepoxide and giving vitamin B parenterally. Your hospital will often have
an alcohol withdrawal team aswell.
Likely ward referrals
Occasionally, OMFS receives a ward referral to review an inpatient under
a dierent team. You are a representative of our specialty and accept
the referral graciously even if they seem trivial— you may need a favour
backsoon!
1 M https:// www.evidence.nhs.uk/ search?q=Tracheostomy+guidelines

202
CHAPTER7 On theward
202
If appropriate, get a DPT done before you see them; if possible, get them
down to a clinic for optimal assessment and if you are not going to see
them on your shift make sure you hand their details over so they are not
forgotten.
Cardiothoracic/ cardiologyto screen for dental sources of infection,
e.g. pre- CABG or stent, or if the patient has developed infective
endocarditis.
Neurosurgeryinfective source of meningitis, brain abscesses.
Any specialtytoothache referral. If you are not dentally qualied,
know how to take a dental pain history, how to examine, and which
special tests to organize before discussing the case with a dentally
qualied member of the team. But remember, toothache referrals are
not something OMFS particularly wants to get involved in and you may
nd the patient had toothache since well before they arrived in hospital
and actually they can be prescribed painkillers and see their own dentist
after theyleave.

OMFS ONTHEWARD
203

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199 Chapter7On thewardOMFS on the ward 200Trauma patients 204Dentoalveolar patients 206Head and neck oncology patients 208Flap monitoring 212The tracheostomy patient 214Orthognathic patients 218 200CHAPTER7 On theward200OMFS ontheward• Since OMFS is a small specialty with relatively few inpatients, it rarely has a dedicated ward and often shares with ENT or another small surgical specialty.• Sometimes the whole OMFS team attends the ward round, and may include ‘special services’ (e.g. Macmillan nurse, SALT, dietician,etc.).• There are a large number of young short- stay patients (trauma/ orthognathic) with no medical problems.• There are a small but increasing number of long- stay patients with many medical problems— it is really important that you get good exposure to medical rms during your training, ideally in the ITU as well, to manage these sick patientswell.OMFS ward round essentialsBe ontime and know thepatient’s background history• Pen torch, spatulas, gloves, orthodontic elastics, skin marker- pen.• Stethoscope.• Hand- held Doppler for ap patients available.• Review appointment cards if applicable.• Snellen charts for measuring visual acuity (see E inside back cover of this handbook).Radiographs/ investigationsIt is important to ensure that radiographic imaging is available to be viewed on the ward round with the corresponding reports if completed. This is usu-ally done via digital images on PACS (Picture Archiving and Communication System), often before the ward round. Be ahead of the game and have cor-rect up- to- date images ready for the patient. Think about their interpreta-tion and signicance for management, as it is likely that you will be asked for your input. Furthermore, the latest blood, microbiological, and pathological results should also be known and presented to the ward round; you will get used to the usual questions:CRP, WCC, glucose for the abscess patients, for example.OMFS wardworkA select few patients will take up the majority of your time (normally the oncology cases) as they require more regular investigations and postop-erative monitoring (see E pp. 212–13). Get to know who in the hospital controls the appointments for investigations, e.g. ultrasound, lung function, ECHO. The faster a patient is worked up for surgery the better for them and you may save the hospital a huge ne for a breach in missing treatment deadlines.If you need to perform a procedure on the ward, try to make use of a side- room or ENT treatment room where you are likely to have more space, more light, and more equipment available than by the bedside. Ensure that you know the location of, and have had a play with, any equip-ment that you might need in an emergency. Take the opportunity to extend your role doing minor procedures and endoscopy. OMFS ONTHEWARD201 NursesAs ever, a good working relationship with the nurses is essential for a happy and harmonious working environment. Muck in and be helpful, and you will receive the same in abundance. Communicate well, share knowledge, and learn what the roles of the nurse involve—they have seen many like you come and go and have a wealth of knowledge.Ward protocolsThese are generally in place to follow in specic clinical situations. Some examples are given as follows.TracheostomyTracheostomies are used to protect the airway— but they can kill if not cared for properly. Our patients have dicult airways and should have plans in place if the airway is inadvertently lost. You should be knowledgeable about tracheostomies, so nd and review the protocol (often in place for the nurses) for tracheostomy care. These guidelines relate to tracheostomy tube care, suctioning, humidication, care of the cu, fenestrated tubes, speaking valves, decannulation, tracheostomy emergencies, and resuscita-tion (see E pp. 214–18). Extra reading of the NICE guidelines is amust.1Carotid blow- outEnsure that you familiarize yourself with this, as the protocol is in place to decrease stress for both the patient and sta in what can be a seemingly horric situation. The three approaches to carotid blow- out are preventa-tive, active resuscitation, or palliativecare.• Preventative— prevent dehydration, infection, and wound breakdown; nutritional support; reduce physical and emotional stress.• Active resuscitation— secure airway; prevent aspiration; control haemorrhage; prevent hypovolaemic shock; relieve anxiety; morphine/diamorphine/ midazolam.• Palliative care— relieve anxiety; compassion and support; assist the dying patient.Alcohol withdrawalThis will be appropriate for a signicant proportion of OMFS patients, particularly cancer and trauma patients who may be heavy drinkers. Look for your hospital’s protocol; it is designed to prevent delirium tremens and Wernicke’s encephalopathy by administering a reducing regimen of chlor-diazepoxide and giving vitamin B parenterally. Your hospital will often have an alcohol withdrawal team aswell.Likely ward referralsOccasionally, OMFS receives a ward referral to review an inpatient under a dierent team. You are a representative of our specialty and accept the referral graciously even if they seem trivial— you may need a favour backsoon!1 M https:// www.evidence.nhs.uk/ search?q=Tracheostomy+guidelines 202CHAPTER7 On theward202If appropriate, get a DPT done before you see them; if possible, get them down to a clinic for optimal assessment and if you are not going to see them on your shift make sure you hand their details over so they are not forgotten.• Cardiothoracic/ cardiology— to screen for dental sources of infection, e.g. pre- CABG or stent, or if the patient has developed infective endocarditis.• Neurosurgery— infective source of meningitis, brain abscesses.• Any specialty— toothache referral. If you are not dentally qualied, know how to take a dental pain history, how to examine, and which special tests to organize before discussing the case with a dentally qualied member of the team. But remember, toothache referrals are not something OMFS particularly wants to get involved in and you may nd the patient had toothache since well before they arrived in hospital and actually they can be prescribed painkillers and see their own dentist after theyleave. OMFS ONTHEWARD203 204CHAPTER7 On theward204Trauma patients• Most of these patients will be waiting for either surgery or discharge. Occasionally you may have a multiply injured patient under another team that you keep under review.• Continue to monitor airway, breathing, and circulation, as the status can change. FOM swelling caused by mandible fractures can develop late and you denitely do not want your patient to lose their airway on your ward. Do not just admit and forget about these patients— it has happened!• Patients requiring neurological observations are not normally accepted by the OMFS team, so check with your senior before admitting to theward.• Occasionally, depending on your hospital’s circumstances, you may need to explain to these patients who are on a trauma list that they are treated according to risk of life and limb and that order is out of the hands of the surgicalteams.Preoperative• Make sure that your patient is put on an emergency list and consented. Getall imaging (remember two views for a fracture) and prosthesis such as splints and arch bars. Arch bars may need to be custom- made if there are multiple missing teeth (will need impressions).• Remember always to review the patient as other injuries come to light once distracting pain is removed or alcohol has worno.• The xation of facial fractures comes quite low down the ‘urgency ranking’ of emergency operations. You need to warn these patients (who are not infrequently heavy drinkers and/ or drug users) that it is likely that their operation will be delayed. Do what you can to keep them comfortable (e.g. withdrawal medications, methadone) and try to avoid self- discharge. You would be well advised to check liver function tests (LFTs), haemoglobin, and coagulation tests in these patients.• Children usually have priority, and simple lacerations can be sent home from A&E to be brought back starved rst thing in the morning for theatre (often they close suciently overnight to not require suturing!). Liaise with theatre and the paediatric ward to ensure that space is made available.• IV uids are essential, especially if the fracture was the result of a drunken brawl. It cannot be pleasant to be NBM with a hangover! Dextrose saline is a good choice.• Think about the situation in which the injury occurred. Is there a possibility of domestic violence? If so, this is a good opportunity to get help for the victim.• Soft tissue injuries should ideally be sutured within 24 hours. You may need to press this point with the emergency theatreteam. TRAUMA PATIENTS205 Postoperative• Most simple fractures can be discharged on the same or the followingday.• Postoperative radiographs should be checked and a record made that they were checked, prior to discharge.• Analgesia is usually in the form of NSAID + paracetamol/ codeine.• Antibiotics may not be required unless there is a compound fracture or delayed xation although your hospital will have a policy, usually two postoperative IV dosesonly• Facial lacerations severe enough to require GA will usually need review in clinic. They may need further surgery, such as scar revision, in the following months (advise patient this might be up to 1year post injury).Mandible• The occlusion should be the best indicator of adequate xation. If there are obvious gaps between the teeth, let your seniorknow.• Reassure the patient that numbness to the lower lip is normal and will usually resolve (document any pre- surgery numbness).• Advise soft diet and avoidance of contact sports for 6weeks.• Oral hygiene is important. Brush teeth gently and use hot salt water and/ or chlorhexidine mouthwash 2– 3 timesdaily.• Intra- oral sutures are resorbable. If an extra- oral approach has been adopted, make arrangements for suture removal (e.g. with GMP nurse).• Review in clinic in 2 weeks and then after 6 weeks unless the patient requires elastics, in which case review may be needed sooner.• They may require elastic IMF, and this may require adjusting before discharge.Maxilla andzygoma• Reassure the patient that it is normal to have a little blood from the nose. They should avoid blowing their nose for at least 2 weeks (wipeonly).• If a coronal ap has been raised, drains will be inserted in theatre and usually remain for 24 hours postoperatively.• Always monitor for retrobulbar haemorrhage in zygoma fractures, both pre- and postoperatively (see E pp. 262–3).• Uncomplicated fractured zygomas are usually reviewed once at 2 weeks postoperatively.OrbitEye observations should be continued for 24 hours— the rst 8 hours are critical. Look out for the three Ps of increasing Pain, Proptosis, or Pupillary defect, along with reduction in visual acuity which would indicate a retro-bulbar haemorrhage.DentoalveolarMany patients with facial injuries will have damaged teeth and it is impor-tant that they are reviewed by a dentist once they are discharged. Give the patient a copy of any pertinent radiographs and a letter outlining their treatment to take to theGDP. 206CHAPTER7 On theward206Dentoalveolar patients• Most elective dentoalveolar operations are performed as day- case surgery. Patients who are not suitable for this (for medical or social reasons) may come under your care on the ward (e.g. warfarinized patients, haemophiliacs, and children).• Even if you are not dentally trained, it is inevitable that you will receive some ward referrals as the ‘hospital dentist’ and you will pick up the basics fairly quickly. Although you will not be able to replace lost or broken dentures, you should be able to assess a simple toothache!• Abscesses in the head and neck region require a little more attention than elsewhere in the body, especially in children.TraumaInjuries to the primary dentition may require admission and GA as patients are generally too young to tolerate treatment under LA. Early loss of a pri-mary tooth sometimes means that a balancing extraction of the same tooth on the other side has to be performed. This is to prevent asymmetric move-ment of the remaining teeth causing a shift of the centre- line and crowding which can hinder eruption of the underlying adult tooth. In the adult patient, teeth are frequently damaged during trauma and these are best followed up by the patient’s own dentist. It is polite to phone or at least write to the GDP and to provide some radiographic evidence of the treatment. Do not try to re- implant lost primaryteeth!AbscessesTreat the cause as quickly as possible (i.e. emergency surgery as a priority case) as antibiotics alone will not arrest the infection (unless it is at the cel-lulitic stage before any pus has formed). These patients usually stay on the ward for a couple of days postoperatively and should have inammatory markers checked daily. The swelling can worsen after theatre and some advocate the use of preoperative steroids if cellulitis is present. Check the drains (sometimes these are intra- oral) and chase any microbiology. Through- and- through drains will drain saliva as well as pus. The operating surgeon should make a decision on drain removal and shortening (warn the patient that it can be painful!). Sometimes patients need to return to theatre if they are not improving, particularly if there is a mouth full of rotten teeth, as it can be dicult to isolate the source. These patients, especially children, should receive some education in dental hygiene to reduce the chances of future infections.Inpatient referralsSome patients require dental review as part of their ongoing medical care. Examples are given in Box7.1. DENTOALVEOLAR PATIENTS207 Assessment• History— sharp, poorly localized pain elicited by hot/ cold/ sweet food and lasting for a few seconds only can indicate pulpitis, which may be reversible if the cause (i.e. caries) is removed. Sensitivity on cold alone may be due to exposed dentine, resulting from over- zealous brushing. Pain which is spontaneous or lasts for a long time after the trigger is removed and is well localized usually means that the pulp is irreversibly damaged and should be treated by root canal treatment or extraction.• Extra- orally, look for lymphadenopathy or facial swelling— not all patients with facial swelling need admission.• Intra- orally, look for level of oral hygiene. Are there multiple restorations or obvious cavities? Are the teeth mobile?• If the pain can be localized, it makes your diagnosis easier. Otherwise tap the teeth rmly (e.g. with a tongue depressor) and see if the patientjumps.• Look for swellings and sinuses in the gingivae, buccal sulcus, and palate.• OPGs are not very good for diagnosis of tooth pathology; a periapical is much better. If there are lots of crumbling teeth, OPG may be a lower- radiation choice (see E pp. 48–54).Box 7.1 Patients requiring dentalreview• Endocarditis— assess if dental source of bacteria.• Extractions prior to major surgery (e.g. cardiac valves, transplants, IV bisphosphonates).• Cerebrovascular accident (CVA) of infective cause— assess if fromteeth.• Extractions prior to radiotherapy to the head/ neck to prevent osteoradionecrosis (sterile necrosis of bone due to d vascularity).• Investigation of pyrexia of unknown origin. 208CHAPTER7 On theward208Head and neck oncology patients• Approximately 50% of head and neck oncology patients develop a complication after surgery,2 so they need considerable postoperative monitoring care on theward.• The patients are often unhealthy— malnourished and may be heavy smokers or drinkers.• Expect the worst. As ever, prevention is thekey.Preoperative• Make it your job to ensure that the preoperative work- up/ investigations are complete and highlight any abnormalities well in advance.• Check the clinic letters, initial assessment, staging, MDT discussion, proposed surgical plan, and pre- assessment investigations to gain a good overall knowledge of the case (see E pp. 160–1).• Consider PEG/ RIG for postoperative feeding— often done before surgery.In particular, ensure that the following have been completed:• Cross- matched blood— check local transfusion protocols.• Special free ap investigations.• Radial ap— Allen’s test (Doppler more sensitive). Record any pre- existing nerve dysfunction.• DCIA ap— previous abdomen surgery (hernia repair/ appendix)?• Fibula ap— duplex run- o at the knee, CTA or MRA bothlegs:• Hip or knee problem on one side— use thatside.• Preoperative nerve dysfunction— foot dropetc.• If reconstructing right mandible, left bula is usually used because of its shape, although bone is usually osteotomized for bestt.• Mark perforators— pen and hand- held Doppler usually done by registrar.• Ensure that the anaesthetist is aware that the patient is admitted.• Imaging and histology available; have you booked frozen specimens with thelab?• Consent completed.• Laboratory work prosthesis available.• Fluids prescribed, if appropriate.• Alcohol withdrawal (consider using chlordiazepoxide) and nicotine withdrawal prescribed. See your local protocols.• Laxatives prescribed (especiallyDCIA).• Thromboembolic prophylaxis prescribed.• Gastric ulcer prophylaxis prescribed (may be on steroids).• Is the patient having a tracheostomy? Make sure that an ITU bed is booked.• Get a family contact so that you know who to call if there are any urgent changes in the patient’s condition• SALT/ dieticians should see patient preoperatively.• Conrm postoperative feeding requirements.2 McGurk MG, Fan KF, MacBean AD, etal. (2007). Complications encountered in a prospective series of 182 patients treated surgically for mouth cancer. Oral Oncol 43:471– 6. HEAD AND NECK ONCOLOGY PATIENTS209 PostoperativeImmediate— rst 24hours• Likely to be on ITU for rst day so get to know how to interpret the blood gas and physiological parameters (e.g. mean BP, urine output).• Flap monitoring (see E pp. 212–13)— you will be called if nurses have concerns. Know what a healthy and a not healthy ap looks like. Always err on the side of caution and call seniors— better to have a false alarm than miss a salvage.• Drains, volume and content, serous, bloodchyle?• Pain control.• SALT/ dieticians— PEG/ RIG or NGT. For intra-oral aps, patients will be fed exclusively via NGT for at least the rstweek.• Routine postoperative bloods including CRP daily— LFTs twice weekly.• If on enteral feeds, can often get vomiting/ diarrhoea/ constipation— liaise with dietician, a change of feed mayhelp.Short term— rst7days• Regular observations and systems examination.• Check for spikes in temperature, if raised think ‘wind, wound, water, walk’— respiratory tract infection, wound infection, urinary tract infection, DVT, and check for these— ‘septic screen’.• Tracheostomy— although protective of airway there are risks such as blocking from mucous plugs. In hospital, deaths occur every year that can be avoided. All should be on humidied oxygen nebulizers to loosen secretions. Aim to remove once the surgical swelling has subsided (see E p. 216). Patients also improve psychologically once they have their voice back— you will be surprised how many patients struggle with communication through writing.• Monitor ap healing— look for infection, dehiscence, stula, delayed healing.• Monitor neck dissection wound healing— look for infection, haematoma, seroma, salivary collection (clear uid send for amylase), chyle leak (milky uid from damage to thoracic duct—check uid for triglyceride/ chylomicrons).• Drains— most can be removed when <30 mL in 24 hours but local policy mayvary.• Monitor donor site healing— look for infection, dehiscence, delayed healing.• Try to remove indwelling urinary catheter, central line, and IV cannula as soon as indicated.• Routine postoperative bloods— LFTs twice weekly.• Early mobilization.• Chest physiotherapy.• SALT/ dietician review of swallowing and feeding requirements. 210CHAPTER7 On theward210Longer term (>7days)• Head and neck patients can be on the ward for a longtime.• Common problems— alcohol and/ or nicotine withdrawal, complications of malnutrition, chest infections.• Keep bowels going— a regular laxative may be required.• Remove stitches or clips depending on anatomicalsite.• Consider arrangements for any adjuvant treatment.• Social arrangements for discharge can prolong inpatient stay— nd out about the patient’s home circumstances and try to make early arrangements as required. Many delays in discharge can be anticipated— it is vital that assessments are promptly lled in so that funding for out- of- hospital care can be arranged. Although it might seem like mundane work, it is increasingly vital that hospital stays are kept as short as possible to prevent hospital- acquired infection and to keep the beds for those that really need expert medicalinput.Drains• Are they still working (check the vacuum is still active)? What’s in them and how much? How much is too much?— Check with senior.• Monitor the volume output overtime.• Look for blood, saliva (amylase), or creamy coloured chyle (triglycerides).• If the drain is removed too soon, a collection will form which will require intervention— this is usually seroma and can be drained with a needle but be careful if near the ap pedicle!• Sometimes drains ‘fall out’ too soon— they may need radiological re- insertion, never blindly reinsert adrain.• Surgeons have their own preferences about shortening or removing drains. Make sure that you know what they are! If in doubt, ask before removing.• If you take a drain out, ‘de- vac’ it before pulling to prevent discomfort.Donorsites• Radial— monitor nerve and perfusion, check the ngers. Some use a Bradford Sling® to elevate the arm and reduce swelling.• Composite radial— as above and X- ray for the plate and a lightweight cast may be required for 6 weeks if there are concerns about the remainingbone.• Fibula— splint, ankle at 90°, liaise with physiotherapist, usually partial weight bearing progressing to full prior to discharge. The donor site is notorious for wound breakdown and delayed healing.• Neck— shoulder physiotherapy to prevent shoulderdrop.• DCIA— blood loss in drain is often high postoperatively due to bleeding from cut bone edges. Bowel ileus may develop postoperatively (can breach the peritoneum), check for abdominal tenderness and distention. LA in an epidural catheter into the wound will help with mobilization (this is often the most painful area after surgery). HEAD AND NECK ONCOLOGY PATIENTS211 212CHAPTER7 On theward212Flap monitoring• The purpose of ap monitoring is to identify a failing ap (usually a free ap, although pedicled aps can also become compromised) at the earliest possible stage, to give the best chance of salvage.• Flaps that return to theatre within 24 hours of surgery have a higher chance of salvage.3• Pedicled aps, such as the pectoralis major ap, may become compromised due to compression of the pedicle by the clavicle, soft tissue, or surrounding oedema or haematoma, or by torsion of the pedicle at the time of surgery.• Most causes of free ap failure occur at the anastomosis:venous engorgement (majority) or arterial occlusion.• External and systemic causes are also possible— e.g. haematoma occluding venous drainage, low blood pressure, hypovolaemia, or arrhythmias.• If there is no plan to return the patient to theatre if the ap fails, close ap observations are not required.• Composite aps take longer to raise, and there may also be greater blood loss during ap harvest.• DCIA aps classically fail slowly.• Any concerns, inform seniorearly.How tomonitoraap• Look for colour— free ap colour- monitoring charts can help. Ideally see the ap immediately post surgery to have a baseline. Things can deteriorate quickly so if you are not sure, come back and reassess in 5 minutes.• Palpate for temperature and texture, often the skin is from a non- sun exposed area, e.g. inner wrist, hip, thigh and will be paler than surrounding skin, therefore capillary rell is a very important sign (should be <3 seconds).• Doppler assessment:• External hand- held Doppler can monitor blood ow at the pedicle or main perforators within the ap. These may have been marked at the time of surgery. Afailing ap can still have a good Doppler in the early stages so don’t be falsely reassured.• Some units have sterilizable metal probes for monitoring the ap intra- orally, or will have placed an implantable probe at the time of surgery.• Prick the ap with a needle to look at the rate of blood ow and its colour (ask for senior help before doing this— generally only done to prove that the ap is failing). Profuse dark blood suggests venous congestion, no bleeding suggests arterial occlusion.• Microdialysis— sampling of tissue uid for pH, lactate, pyruvate, and glucose using a probe inserted into the ap. Rarely used as it is expensive.• There are many new and exciting ap monitoring developments including laser speckle imaging. It is well known that technology (when it works) is better at predicting early ap failure than clinical judgement alone.3 Brown JS, Devine JC, Magennis P, etal. (2003). Factors that inuence the outcome of salvage in free tissue transfer. Br J Oral Maxillofac Surg 41:16– 20. FLAP MONITORING213 Monitoring regimen• Skin mark or stitch to mark anastomosis.• Check ap hourly for 24 hours— colour and Doppler signal.• Check ap every 4 hours for next 48hours.• Check with designated nurse that they are happy with the surgery that has been done, the normal colour of the ap, and where to place theprobe.• Do not be afraid to call a senior if you have doubts.Maintain good ap conditions• Drains should have been placed to prevent collections in the neck. Do not clamp a drain in theneck.• Maximize perfusion by keeping MAP at 80– 100mmHg— ITU may suggest inotropes to maintain BP, usually these are avoided to prevent eect on capillary ow unless Doppler is compromised— this is a seniorcall.• Ideal haematocrit is30%.• Ideal haemoglobin concentration is >8g/ dL.• May require pushing of IV uids.• Keep patientwarm.• Avoid tranexamic acid. Low- molecular- weight heparin in DVT prophylactic dose is usually prescribed unless unusually oozy during surgery.• No neck or ap compression with tight tracheostomy or neckties.• Try to prevent the patient coughing.DangersignsFirst 48hours• Haematoma in neck— bad.• Dark, blue, or mottled ap or very pale ap— bad.• Dark ap with Doppler signal— bad.• Immediate ow of dark blood on prick ap with needle— bad.• Pale with Doppler— OK.• Very pale with no Doppler and/ or no bleeding on pricking ap— bad (rare).Action required• Patient resuscitation.• Urgent exploration in theatre.• Flap salvage— re- running of anastomosis.• May require replacement local or pedicledap.• Venous engorgement can be treated with leeches.• Close monitoring of haemoglobin and electrolytes.After 48hours• Wound healing or breakdown around edges of ap— determines when a patient can start taking things by mouth, or when to take patient back to theatre to prevent communications between mouth andneck.• The sequence that must be avoided is breakdown in the mouth around ap edges rst, then sumping of saliva in neck, ap dies, and the neck burstsopen.Action required• More sutures, pack,NBM. 214CHAPTER7 On theward214The tracheostomy patient• OMFS patients sometimes require tracheostomies, either electively for major head and neck procedures where the airway may be compromised or as an urgent operation if a surgical airway is required (although in an acute emergency, a cricothyroidotomy would usually be done rst).• Ablocked or dislodged tracheostomy tube can kill a patient.• Ensure that tracheostomy tube care is performed at regular intervals and that the tube is checked at every visit to the bedside to avoid sudden frightening blockages in the middle of thenight.• Tracheostomy emergencies (see E pp. 264–6).• Many hospitals have a dedicated tracheostomy nurse or conduct tracheostomy ward rounds, which are useful.Types oftracheostomytube(See Fig. 7.1.) Can be a combination of the following:Cued• Inatable cu to prevent aspiration pasttube.• Used for all newly placed tracheostomies and for ventilated or unconscious patients.• The cu should have low pressure and high volume to prevent pressure necrosis to the trachea wall. Recommended cu pressure is <25mmHg, and 5– 7 mL of air is usually enough to inateit.• When deating the cu, suction the oropharynx rst to clear any secretions which may have pooled ontop.Uncued (plain)• Used if no risk of aspiration, not ventilated.Fig.7.1 Diagram of tracheostomy tubes. (a)Cued fenestrated tube; (b)non-cued, non- fenestrated tube; (c)paediatric tube. Reproduced from Corbridge R and Steventon N, ‘Oxford Handbook of ENT and Head and Neck Surgery’ (2009) with permission from Oxford UniversityPress. THE TRACHEOSTOMY PATIENT215 Fenestrated• See Fig.7.2.• There is a hole in the back of the tube which enables inhaled air to pass from the mouth into the trachea as well as through the tube placed in the neck. It can help a patient return to normal breathing or wean o a tracheostomy. It can also facilitate and improve speech.• Must not be used if risk of aspiration.Fig.7.2 Diagram of tracheostomy tube position (note fenestration). Reproduced from Corbridge R and Steventon N, ‘Oxford Handbook of ENT and Head and Neck Surgery’ (2009) with permission from Oxford UniversityPress. 216CHAPTER7 On theward216Inner cannula• Should be used with all tracheostomy tubes. The inner tube can be removed easily, facilitating the clearance of secretions.• Prevents having to change the tube asoften.• Regular suctioning and humidication should still be performed.Adjustableange• Used for patients with fat or swollen necks or a deep- set trachea.• The ange can be adjusted to give the desired tube length to allow for variation in the distance from trachea toskin.AccessoriesDecannulationcapUsed in weaning. The cap is placed on a fenestrated uncued tracheostomy tube to close it o, prompting the patient to breathe through their mouth. If the patient is managing to maintain O2 saturations with this arrangement, decannulation is possible.SpeakingvalveThis valve allows air in through the tracheostomy tube, but not out. Therefore the patient can direct expired air up and out though the vocal cords and phonate. To prevent sputum blockage, do not leave on overnight.TracheostomycareAims are to maintain a patent airway, maintain skin integrity, prevent infec-tion, and prevent tube displacement.• Ensure the inner tube (if present) is being checked and cleaned regularly.• Regular suction is required to prevent secretions from blocking the tracheostomy tube. Encourage the patient to take deep breaths before and after suctioning to maximize clearance from thelungs.• Use a size 12 catheter to suction. About half the length of the catheter will reach the carina (often the patient coughs at this point) and then suction should be applied, withdrawing the catheter at the sametime.• Small volumes of sterile water can be syringed in to break up dried secretions or blockage, with immediate suction.• All patients with tracheostomies should receive humidication of inspired gases via a heated humidier, a heat moisture exchange lter, or nebulized normal saline.Tracheostomy weaning• Amultidisciplinary approach should be adopted to assess the patient’s gag and swallowing reexes, dependence on suctioning, and physiotherapy to decide the best time to wean. There may be a ward or departmental protocol to follow forthis.• Absolute weaning requirements include a patent upper airway, a spontaneous cough, and the ability to clear secretions. THE TRACHEOSTOMY PATIENT217 • Weaning methods normally involve increasing periods of cu deation, use of fenestrated tubes and speaking valves, downsizing the tube, or capping o the tracheostomy prior to nal decannulation.• Generally, increasing periods of cu deation until the patient has tolerated ‘cu- down’ for 24 hours are followed by capping o for 24 hours. If this is not tolerated, the cu should be re- inated, and the trachea should be scoped to look for blockages. 218CHAPTER7 On theward218Orthognathic patients• Most orthognathic patients will be t and healthy and in their late teens or early twenties so they usually recover fairly quickly.• Generally this sort of surgery is well tolerated, and the preoperative planning and counselling is extensive so that patients will know what to expect.• Swelling is inevitable, so nurse patients sitting up. Ice packs around the jaws and steroids can also help. They may be on the HDU for the rst night (although in many units patients return to the ward) because of the risk of bleeding/ swelling compromising the airway, so take any calls about this seriously. Nurses are used to looking after these patients.• They may be in elastic IMF and this may need adjusting depending on the postoperative occlusion. Elastics can be tight or loose. Class 2 elastics are placed more anteriorly on the upper arch. Class 3 elastics are placed more anteriorly on the lowerarch.• If placing elastics, arm yourself with eye protection, plenty of elastics, and preferably two instruments including a surgical clip and a pair of tweezers. Getting icked in the eye with the patient’s saliva, or indeed the elastics themselves, is not pleasant.• The swelling can take some months to go, so warn the patient that the nal result will not be apparent untilthen.• As with any fracture around the jaws, the patient should maintain strict oral hygiene and a soft diet for 6weeks.• Acouple of doses of IV antibiotics and steroids will generally be prescribed peri/ post surgery, although regimens dier with the surgeon.• If there are drains, they should be removed after 24 hours if there is no excessive drainage.• Patients will generally feel more sorry for themselves after the postoperative steroids are stopped. Generally, the best place for them to recover at this point is at home with good painkillers.• The patient is followed up by the surgeon and the orthodontist, as the next stage involves ‘detailing’ post- surgical orthodontics, generally at 6 weeks postoperatively.

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