Regarding repair of a through-and-through laceration involving the pinna of the ear, which ONE of the following statements is TRUE?
Answer: D: All lacerations involving the pinna of the ear should be repaired after achieving meticulous control of bleeding to prevent haematoma formation. All cartilage should be covered with skin to prevent infection of the cartilage. If the cartilage cannot be covered due to avulsed skin the patient should be referred to plastic surgery. Significant debridement at the skin edges should not be done as there will not be adequate skin to cover the cartilage. In a through hand-through laceration, approximation of the skin ideally with the perichondrium is sufficient to promote healing of the cartilage and to preserve the shape of the pinna. There is a risk of haematoma formation a few days after the repair and if unattended this may lead to deformity of the pinna (‘cauliflower ear’) due to the pressure it exerts on the cartilage. With a haematoma, the patient may present with swelling and increasing pain. Sutures should be removed to completely drain the haematoma and haemostasis should be achieved; the laceration should be repaired again. To prevent haematoma formation, after repair of any significant laceration it should be covered with a properly placed pressure dressing. The skin sutures should be removed in 4–5 days.
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Regarding Ludwig’s angina, which ONE of the following statements is FALSE?
Answer: C: Ludwig’s angina is a rapidly spreading infection in the submandibular space, and has a dental origin in majority of cases. It is potentially lethal as the rapidly increasing infection in the submandibular space causes elevation of the floor of the mouth and swelling of the tongue, tightly closing the airway. It may cause trismus, further compromising the ability to secure the airway. It is essential to evaluate the airway immediately upon the patient’s presentation to the ED. Some of the features of a compromised or threatened airway are:
Appropriate other specialties such as anaesthetics and ENT should be involved early in the assessment and management of the airway as this is a potentially hazardous exercise.
Any actual or potential airway compromise requires consideration for urgent tracheal intubation. In one Australian study, eight out of 29 patients that presented with Ludwig’s angina required emergent securing of the airway. Fibre optic nasal intubation was attempted in all of these patients and seven were successful. The patient with failed fibre optic nasal intubation required emergent tracheostomy.20 Attempts at securing the airway should be done in the operating theatre.
The anterior wall of the submandibular space is formed by the taut investing layer of deep cervical fascia running between the under surface of the mandible and hyoid bone. The mucous membrane of the floor of the mouth forms the roof of the submandibular space. The non-distensible nature of the investing layer of deep cervical fascia causes any swelling in the submandibular space to upwardly displace the floor of the mouth and tongue, compromising the airway.
Any attempt at obtaining a CT without thoroughly evaluating and securing the airway where necessary is a potential hazard to the patient and is not useful in immediate patient management. However, in patients with Ludwig’s angina who present with hard induration of the suprahyoid region, it may be difficult to clinically differentiate an abscess with liquefaction requiring drainage from induration and phlegmon. In these patients, once the airway is evaluated and/or secured, CT may be helpful.
Regarding an avulsed tooth, which ONE of the following statements is TRUE?
Answer: C: An avulsed tooth is a true dental emergency if it involves a permanent tooth. In the majority of cases presenting to the ED, the tooth will not survive for a number of reasons. One of the main reasons is the lack of placement of the tooth in a suitable transport media and the amount of time that has elapsed outside the oral cavity. The survival once implanted depends on the viability of the periodontal ligament of the tooth. Periodontal ligament necrosis occurs within 60 minutes if the tooth is not placed in a suitable transport medium. By placing the tooth in milk, it can preserve the periodontal ligament for 4–8 hours. Saliva is another acceptable transport medium. (Commercially available transport media will preserve it for 12–24 hours). In a pre-hospital situation where a suitable transport media is not generally available, the most appropriate step is to rinse the root, taking care to touch the crown of the tooth only, and replacing it into the socket. However, primary teeth and fractured teeth should not be replaced. Also, when there is associated significant maxillary/ mandibular trauma (e.g. alveolar ridge fracture) the avulsed tooth should not be replaced. An avulsed primary tooth if replaced can fuse to the alveolar line and can distort the eruption of permanent tooth.
Additionally, it also increases the risk of infection. Between ages 6–12, children have both primary and permanent teeth, therefore identification of the type of the avulsed tooth is important.
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Regarding a patient presenting to the ED with continued bleeding from the tooth socket after extraction, which ONE of the following is the LEAST appropriate management?
Answer: D: Patients often present to the ED with persistent bleeding from the socket post extraction. Displacement of the clot from the socket is generally the cause. The tooth socket should be carefully examined and any remaining clot in the socket kept intact. The clotted blood from the surrounding area should be removed with suction and the area can be rinsed with saline. Direct pressure should be applied to the bleeding socket with firmly clenched teeth using gauze carefully packed into the socket; this direct pressure should be maintained for at least 15 minutes. Gauze impregnated with a vasoconstrictor such as adrenaline may help to stop the bleeding. Local infiltration of lignocaine with adrenaline into the surrounding gingiva can cause vasoconstriction as well as anaesthesia for adequate application of direct pressure. If the bleeding doesn’t stop, suitable coagulation sponge material can be applied to the tooth socket and these can be kept in place by loosely suturing the gingiva over the socket. Tight suturing of the gingiva is not recommended because it may cause necrosis of the gingiva.
Regarding tongue lacerations, which ONE of the following statements is FALSE?
Answer: C: In adults most repairs of tongue lacerations can be done in the ED under local anaesthetic infiltration or with a lingual block. To achieve both anaesthesia and haemostasis, lignocaine with adrenaline can be used on the tongue. In a large gaping laceration, the edges should be approximated when the laceration is repaired. If such a laceration is not repaired properly, the subsequent epithelial coverage over the gap may result in a grooved or a bifid tongue. Other lacerations that need primary repair are flap-shaped lacerations and lacerations at the edge of the tongue, as well as deep lacerations that involve the muscle and that are causing significant bleeding. When the laceration penetrates both the mucosa and the muscle, it can be sutured using non-absorbable stitches that penetrate both into the mucosa and the muscle. Absorbable sutures can be used as well.
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