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.

Tracheal diameter estimates using age-related formula versus radiographic findings: Which approximates the actual tracheostomy tube in pediatric patients?

@#<p style="text-align: justify;"><strong>OBJECTIVE: </strong>To compare actual tracheostomy tube sizes with estimated endotracheal tube sizes using age-related formula and tracheal diameter from preoperative radiographs among pediatric Filipino patients aged 0-18 years old undergoing tracheostomy.</p><p style="text-align: justify;"><strong>METHODS:</strong></p><p style="text-align: justify;"><strong>          DESIGN:</strong> Review of records</p><p style="text-align: justify;"><strong>          SETTING:</strong>           Tertiary Private University Hospital in Dasmarinas, Cavite, Philippines</p><p style="text-align: justify;"><strong>          PATIENTS:</strong>         Pediatric patients regardless of gender, aged 0 to 18 years old, with a preoperative radiograph of the trachea, and who subsequently underwent tracheostomy anytime from January 1, 2007 to                December 31, 2016 were considered for inclusion. Radiographs were measured, endotracheal tube sizes were computed using age-related formula, and recorded tracheotomy tube sizes were retrieved.</p><p style="text-align: justify;"><strong>RESULTS: </strong>Twenty-two patients (12 males, 10 females) aged 10 months to 18-years-old (median age: 11 years) were included in the study. Mean tube sizes were 6.46mm (+/- 1.492 SD) for age-related formula, 5.67mm (+/- 1.1849 SD) for radiograph-based estimation, and 5.0 for actual tracheostomy tube inserted in each patient. The Bland-Altman plot showed the bias estimate at 0.7913 and the lower and upper limits of agreement at -1.3598 and 2.9423 (confidence level 95% or 2 standard deviations away from the mean).</p><p style="text-align: justify;"><strong>CONCLUSION: </strong>The average value derived from radiograph-based estimation is less than the corresponding average value from age-related formula. There is a significant difference between age-related formula-based estimation and actual tracheostomy tube inserted. Since the range of differences between the two estimation methods is high, these results imply that the bias or the difference between measures from the two methods is not consistent, with the two methods exhibiting very poor agreement.</p><p style="text-align: justify;"><strong> </strong></p><p style="text-align: justify;"> </p>