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.

Otorhinolaryngology Out-Patient Practice in the “Post”-COVID-19 Era: Ensuring a Balance Between Service and Safety

Objective@#To review available resources and provide evidence-based recommendations that may optimize otorhinolaryngologic out-patient health care delivery in the “post”-COVID-19 era while ensuring the safety of our patients, healthcare workers and staff.@*Data Sources@#Relevant peer-reviewed journal articles; task force, organizational and institutional, government and non-government organization recommendations; published guidelines from medical, health-related, and scientific organizations.@*Methods@#A comprehensive review of the literature on the COVID-19 pandemic as it pertained to “post”-COVID 19 out-patient otorhinolaryngologic practice was obtained from peer-reviewed articles, guidelines, recommendations, and statements that were identified through a structured search of the data sources for relevant literature utilizing MEDLINE (through PubMed and PubMed Central PMC), Google (and Google Scholar), HERDIN Plus, the World Health Organization (WHO) Global Health Library, and grey literature including social media (blogs, Twitter, LinkedIn, Facebook). In-patient management (including ORL surgical procedures such as tracheostomy) were excluded. Retrieved material was critically appraised and organized according to five discussion themes: physical office set-up, patient processing, personal protection, procedures, and prevention and health-promotion.@*Conclusion@#These recommendations are consistent with the best available evidence to date, and are globally acceptable while being locally applicable. They address the concerns of otorhinolaryngologists and related specialists about resuming office practice during the “post”-COVID-19 period when strict quarantines are gradually lifted and a transition to the “new” normal is made despite the unavailability of a specific vaccine for SARS-CoV-2. While they target practice settings in the Philippines, they should be useful to ENT (ear, nose & throat) surgeons in other countries in ensuring a balance between service and safety as we continue to serve our patients during these challenging times.

Nasopharyngeal Tuberculosis in a Philippine Tertiary General Hospital

Objectiv@#This study aimed to determine the prevalence of nasopharyngeal tuberculosis among patients who were initially assessed to have a nasopharyngeal mass and subsequently underwent biopsy in a Philippine Tertiary General Hospital from 2013 to 2015. @*Methods@#Design: Case Series. Setting: Tertiary National University Hospital. Participants: All patients with nasopharyngeal mass identified from January 2013 to December 2015 from a hospital wide census who underwent biopsy were investigated using chart and histopathology review. The prevalence of tuberculosis, malignancies and other findings were determined.@*Results@#Among 285 nasopharyngeal biopsies done between 2013 and 2015, 33 (11.6%) were histologically compatible with nasopharyngeal tuberculosis, 177 (62.1%) were different types of nasopharyngeal carcinoma, 59 (20.7%) were chronic inflammation, 4 (1.4%) were lymphoma, 5 (1.8%) were normal, and 7 (2.5 %) had diagnoses other than those above. @*Conclusion@#This study suggests a relatively high prevalence rate (11.6%) of nasopharyngeal tuberculosis in patients who have a nasopharyngeal mass. This indicates that nasopharyngeal tuberculosis should always be a differential when confronted with a mass in the nasopharynx especially in tuberculosis endemic areas.

Nasopharyngeal Tuberculosis in a Philippine Tertiary General Hospital

@#<p><strong>OBJECTIVE:?</strong> This study aimed to determine the prevalence of nasopharyngeal tuberculosis among patients who were initially assessed to have a nasopharyngeal mass and subsequently underwent biopsy in a Philippine Tertiary General Hospital from 2013 to 2015.</p><p><strong> </strong></p><p><strong>METHODS:</strong>?</p><p><strong>Design</strong>:           Case Series</p><p><strong>Setting</strong>:           Tertiary National University Hospital</p><p><strong>Participants</strong>: All patients with nasopharyngeal mass identified from January 2013 to December 2015 from a hospital wide census who underwent biopsy were investigated using chart and histopathology review. The prevalence of tuberculosis, malignancies and other findings were determined.</p><p><strong> </strong></p><p><strong>RESULTS</strong>:? Among 285 nasopharyngeal biopsies done between 2013 and 2015, 33 (11.6%) were histologically compatible with nasopharyngeal tuberculosis, 177 (62.1%) were different types of nasopharyngeal carcinoma, 59 (20.7%) were chronic inflammation, 4 (1.4%) were lymphoma, 5 (1.8%) were normal, and 7 (2.5 %) had diagnoses other than those above.</p><p><strong> </strong></p><p><strong>CONCLUSION:</strong> This study suggests a relatively high prevalence rate (11.6%) of nasopharyngeal tuberculosis in patients who have a nasopharyngeal mass. This indicates that nasopharyngeal tuberculosis should always be a differential when confronted with a mass in the nasopharynx especially in tuberculosis endemic areas.</p><p> </p><p><strong>KEYWORDS:</strong> nasopharyngeal tuberculosis; prevalence; censuses; tertiary care centers; Philippines; carcinoma; nasopharynx; biopsy; tuberculosis; lymphoma </p><p> </p>