Management of isolated mandibular body fractures in adults

Objective@#The mandible is the most common fractured craniofacial bone of all craniofacial fractures in the Philippines, with the mandibular body as the most involved segment of all mandibular fractures. To the best of our knowledge, there are no existing guidelines for the diagnosis and management of mandibular body fractures in particular. General guidelines include the American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAOHNSF) Resident Manual of Trauma to the Face, Head, and Neck chapter on Mandibular Trauma, the American Association of Oral and Maxillofacial Surgeons (AAOMS) Clinical Practice Guidelines for Oral and Maxillofacial Surgery section on the Mandibular Angle, Body, and Ramus, and a 2013 Cochrane Systematic Review on interventions for the management of mandibular fractures. On the other hand, a very specific Clinical Practice Guideline on the Management of Unilateral Condylar Fracture of the Mandible was published by the Ministry of Health Malaysia in 2005. Addressing the prevalence of mandibular body fractures, and dearth of specific guidelines for its diagnosis and management, this clinical practice guideline focuses on the management of isolated mandibular body fractures in adults.@*Purpose@#This guideline is meant for all clinicians (otolaryngologists – head and neck surgeons, as well as primary care and specialist physicians, nurses and nurse practitioners, midwives and community health workers, dentists, and emergency first-responders) who may provide care to adults aged 18 years and above that may present with an acute history and physical and/or laboratory examination findings that may lead to a diagnosis of isolated mandibular body fracture and its subsequent medical and surgical management, including health promotion and disease prevention. It is applicable in any setting (including urban and rural primary-care, community centers, treatment units, hospital emergency rooms, operating rooms) in which adults with isolated mandibular body fractures would be identified, diagnosed, or managed. Outcomes are functional resolution of isolated mandibular body fractures; achieving premorbid form; avoiding use of context-inappropriate diagnostics and therapeutics; minimizing use of ineffective interventions; avoiding co-morbid infections, conditions, complications and adverse events; minimizing cost; maximizing health-related quality of life of individuals with isolated mandibular body fracture; increasing patient satisfaction; and preventing recurrence in patients and occurrence in others.@*Action Statements@#The guideline development group made strong recommendationsfor the following key action statements: (6) pain management- clinicians should routinely evaluate pain in patients with isolated mandibular body fractures using a numerical rating scale (NRS) or visual analog scale (VAS); analgesics should be routinely offered to patients with a numerical rating pain scale score or VAS of at least 4/10 (paracetamol and a mild opioid with or without an adjuvant analgesic) until the numerical rating pain scale score or VAS is 3/10 at most; (7) antibiotics- prophylactic antibiotics should be given to adult patients with isolated mandibular body fractures with concomitant mucosal or skin opening with or without direct visualization of bone fragments; penicillin is the drug of choice while clindamycin may be used as an alternative; and (14) prevention- clinicians should advocate for compliance with road traffic safety laws (speed limit, anti-drunk driving, seatbelt and helmet use) for the prevention of motor vehicle, cycling and pedestrian accidents and maxillofacial injuries.The guideline development group made recommendations for the following key action statements: (1) history, clinical presentation, and diagnosis - clinicians should consider a presumptive diagnosis of mandibular fracture in adults presenting with a history of traumatic injury to the jaw plus a positive tongue blade test, and any of the following: malocclusion, trismus, tenderness on jaw closure and broken tooth; (2) panoramic x-ray - clinicians may request for panoramic x-ray as the initial imaging tool in evaluating patients with a presumptive clinical diagnosis; (3) radiographs - where panoramic radiography is not available, clinicians may recommend plain mandibular radiography; (4) computed tomography - if available, non-contrast facial CT Scan may be obtained; (5) immobilization - fractures should be temporarily immobilized/splinted with a figure-of-eight bandage until definitive surgical management can be performed or while initiating transport during emergency situations; (8) anesthesia - nasotracheal intubation is the preferred route of anesthesia; in the presence of contraindications, submental intubation or tracheostomy may be performed; (9) observation - with a soft diet may serve as management for favorable isolated nondisplaced and nonmobile mandibular body fractures with unchanged pre - traumatic occlusion; (10) closed reduction - with immobilization by maxillomandibular fixation for 4-6 weeks may be considered for minimally displaced favorable isolated mandibular body fractures with stable dentition, good nutrition and willingness to comply with post-procedure care that may affect oral hygiene, diet modifications, appearance, oral health and functional concerns (eating, swallowing and speech); (11) open reduction with transosseous wiring - with MMF is an option for isolated displaced unfavorable and unstable mandibular body fracture patients who cannot afford or avail of titanium plates; (12) open reduction with titanium plates - ORIF using titanium plates and screws should be performed in isolated displaced unfavorable and unstable mandibular body fracture; (13) maxillomandibular fixation - intraoperative MMF may not be routinely needed prior to reduction and internal fixation; and (15) promotion - clinicians should play a positive role in the prevention of interpersonal and collective violence as well as the settings in which violence occurs in order to avoid injuries in general and mandibular fractures in particular.

Intravascular lymphoma of the inferior turbinate: An unusual rhinologic presentation of a rare neoplasm

Objective: To present a unique case of intravascular lymphoma of the inferior turbinate because of its rarity, unusual clinical presentation and difficulty in establishing a diagnosis. Design: Case Report Setting: A tertiary hospital Patient: A 66-year-old male admitted to the hospital due to intermittent high grade fever of six months duration. Result: The patient presented with fever of unknown origin, and exhaustive laboratory, ancillary procedures and biopsies to rule in/out infectious, autoimmune and oncologic causes were performed to arrive at a diagnosis. Nasal endoscopy revealed an enlarged, hypertrophied and violaceous right inferior turbinate with watery to mucoid discharge and septal deviation to the right confirmed by CT scans of the paranasal sinuses. Functional Endoscopic Sinus Surgery (FESS), septoplasty and turbinoplasty with biopsy revealed intravascular lymphoma. Chemotherapy was deferred due to the deteriorating medical condition and the patient expired seven months after the initial onset of symptoms. Conclusion: Patients who present with fever of unknown origin should undergo a thorough otorhinolaryngologic examination to exclude primary ENT conditions and ensure proper management. Given its rarity and multiplicity of presentation, it is extremely difficult to make a diagnosis of intravascular lymphoma. A high index of suspicion of intravascular lymphoma is necessary so that timely acquisition of tissue biopsy of any lesion involved will make a definite diagnosis. (Author)

Oto-drill (A prototype surgical drill unit)

OBJECTIVE: To design and produce a high quality, inexpensive surgical drill using locally available electronics. DESIGN: Descriptive (Instrument Design) SETTING: University based tertiary hospital MATERIALS AND METHODS: The surgical drill apparatus will use high quality electronics readily available locally which will make it cheaper than the other available units. This prototype unit was designed and tested by the author in collaboration with the Santo Tomas University Hospital Biomedical Engineers. The drill units schematics and specifications where patterned from the RAM Microtorque II drill unit which is produced in the U.S.A. RESULTS: The prototype is a cost effective alternative to the expensive drill units available in the market. It was given a 24 hour durability test which it passed with no loss of power or drilling efficiency proving that it can be used for major surgeries especially in the field of Otolaryngology and Neurosurgery. CONCLUSION: The OTODRILL is a cheap alternative and of comparable quality to expensive surgical drills available in the market which can be used in major surgeries in the field of Otolaryngology and other surgical fields. (Author)

Suture ligation technique in hemangioma of the head and neck

Intra-operative bleeding is what most surgeons want to avoid in any surgery. Excessive blood loss and compromise of vital structures are possible morbidities when this happens. This paper presents a method that will minimize intra-operative bleeding during excision of hemangiomas. "Suture ligation technique" is the application of simple interrupted overlapping sutures using silk 2.0 with an atraumatic needle around the hemangiomas prior to the skin incision. Although a number of cases have been done three were documented. It was observed that the technique provides a less bloody and clearer operative fields hence resulting in a faster and less stressful operation with lesser complications. (Author)