visual acuity is ~120 min. Medical management with acetazolamide, mannitol, and hydrocortisone might buy some additional time but the eye will still require urgent surgical decompression.Oral and maxillofacial surgery: in clinic
Oral and maxillofacial surgery: in the emergency department
Oral and maxillofacial surgery: in theatre
Oral and maxillofacial surgery (OMFS) specializes in the diagnosis and treatment of diseases affecting the mouth, jaws, face, and neck. OMFS requires qualification in both medicine and dentistry, treating conditions that require expertise from both backgrounds.
The mouth has over 500–1000 different bacteria orally, particularly anaerobes and Gram-negative bacteria. Therefore broad-spectrum antibiotics are commonly required both as cover for elective procedures and infections. Familiarize yourself with basic dental anatomy and that of the head and neck.
Abnormal mucosal patches may indicate dysplastic or cancerous change and any suspicious features warrant investigating and biopsy to confirm diagnosis and exclude neoplastic change.
Affects ~1% of the population worldwide. It is an itchy, non-infectious rash that usually occurs in adults over the age of 40 and is believed to be autoimmune related. An oral component affects the buccal mucosa and gingiva in 50% of people who have cutaneous lesions. Patients complain of burning or stinging in the mouth when eating or drinking spicy foods, citrus fruits, and alcohol. A white, lace-like pattern is often seen on the tongue and buccal mucosa, occasionally with surrounding erythema or ulceration. There is a 0.5–2% risk over a period of 5 years of undergoing cancerous change. Treatment: topical or oral corticosteroids, antiseptic and analgesic mouthwash.
Acute pseudomembranous candidiasis is the oral candidiasis commonly referred to as thrush. It is common in the immunosuppressed or those on antibiotics. Although usually painless, it can cause a burning sensation so should be excluded in patients in whom burning mouth syndrome is being considered. Treatment: oral antifungal drops, e.g. nystatin.
Is a chronic disease of the oral mucosa with inflammation and fibrosis of the submucosal tissues. The main presenting feature is a progressive inability to open the mouth (trismus) due to oral fibrosis and scarring, pain, and burning on consuming spicy food. It has ~8% malignant transformation potential to SCC. The condition is particularly associated with areca nut chewing (prevalent on the Asian subcontinent).
Is a common condition characterized by recurrent small, round, well-circumscribed ulcers with erythematous margins and yellow or grey slough. There are three subtypes: minor, major, and herpetiform. It is worth noting that they are not infectious and herpetiform implies it has some similarities to HSV infection in appearance only.
Have many potential causes and suspicion for oral carcinoma warrants biopsy (e.g. painless, non-healing ulcers with raised borders, cragginess, surrounding dysplasia, hardness, induration, or persistence >3 weeks). Common sites for oral cancer are the lateral aspect of the tongue, floor of the mouth, and soft palate. Commonest causes of recurrent oral ulceration are local trauma, cessation of smoking, stress, food sensitivities (coffee, nuts, strawberries, tomatoes, etc.), hormones, deficiency (vitamin B12, folate, and iron), infection (HSV type 1) and irradiation.
The commonest neoplastic mass in the parotid is a secondary from a skin cancer within the head/neck. The most common primary tumour is a pleomorphic adenoma whereas the commonest malignant salivary gland tumour is the mucoepidermoid tumour.
Pleomorphic adenoma: ‘rule of 80s’
• 80% of salivary gland tumours occur in the parotid gland.
• 80% of parotid tumours are pleomorphic adenomas.
• 80% of parotid pleomorphic adenomas are in the superficial parotid.
• 80% of salivary pleomorphic adenomas are in the parotid.
Less commonly have malignant masses, the commonest malignant tumour in the submandibular gland is adenoid-cystic carcinoma. Though the submandibular glands are more commonly affected by sialoliths or strictures causing sialadenitis and painful swelling of the gland, either pathology can occur in any gland.
Tends to occur in elderly patients usually due to a reduction of salivary flow secondary to medical or pharmacological causes. Treatment: is rehydration and antibiotics.
Can commonly be palpated in a bimanual fashion along the length of the duct. Patients can complain of facial swelling in thinking about or consumption of food (meal time syndrome). Subsequent salivary stagnation can predispose to sialadenitis. It is important to consider imaging to help exclude oncological causes as they may cause similar symptoms through duct compression. Imaging: this can either be done by indirect visualization through US, sialography, MRI, or by direct visualization via sialendoscopy. Treatment: initially, treat by rehydration and antibiotics. Once the infection has settled, options include sialendoscopy, ultrasonic lithotripsy, gland resection, or enucleation of the stone by gland-preserving surgery.
Always exclude head injury, loss of consciousness, and cervical spine (C-spine) injury. Upper facial injury assessment must exclude retrobulbar haemorrhage.
Rarely cause tissue loss, but may appear to due to maceration, in folding of skin and swelling. Infiltrate local anaesthetic with a vasopressor (e.g. lidocaine 2% with 1:80,000 adrenaline (epinephrine)) for haemostasis and allow assessment of the wound. If unable to tolerate, use an infra-orbital or mental block. Match the vermillion of the lips (where mucosa meets skin) before closing the skin. Perform a layered closure with absorbable sutures for deeper structures and mucosa, and non-absorbable sutures for superficial closure. Leave sutures in for 7 days.
Clinically ask about mechanism of injury to help you rule out other injuries such as head or C-spine injury. Fully assess both intra- and extra-orally and document the cranial nerves examined. If the midface is involved, exclude globe injury, retrobulbar and septal haematoma. Check that damaged teeth have not been aspirated. These fractures are treated with miniplates and screws. Usually they can be placed with all the cuts inside the mouth or hidden in skin creases.
This commonly breaks in two places (like a polo mint) so always check for a second fracture. A direct blow to the chin can result in a classic fracture pattern called a guardsman’s fracture with a symphyseal and bilateral condylar fractures. Patients regularly complain of altered occlusion and numbness. The latter is due to damage to the inferior alveolar nerve, and it is important that you document if sensation is present in the lower lip, as well as the tongue. Look for the standard features of a fracture (pain, swelling, bruising, deformity). Look inside the mouth for haematoma on the floor of the mouth, laceration in the gingiva, step in the line of the teeth, or bleeding from around the teeth. Commonly, teeth around a fracture are mobile, so feel for movement. Imaging usually used to assess a mandible fracture is an orthopantomogram (OPG) and a PA mandible X-ray. Treatment is usually antibiotics, followed by surgery (miniplates) and a soft diet for 6 weeks.
Any orbital trauma or surgery can result in bleeding behind the globe, due to the confined space an orbital compartment syndrome can develop. This is an OMFS emergency due to the threat of blindness.
• Paralysis of ophthalmic muscles.
• Loss of pupillary responses.
• Blindness (colour vision goes first).
• Tense eye (firmer and painful on ballottement).
Fundoscopy: pale disc and pulseless retinal arteries.
Urgent decompression using lateral canthotomy and cantholysis is essential as the window for visual recovery from the onset of visual acuity is ~120 min. Medical management with acetazolamide, mannitol, and hydrocortisone might buy some additional time but the eye will still require urgent surgical decompression.
It is important to exclude entrapment, retrobulbar haemorrhage and globe injury.
Epistaxis, bony tenderness, step deformity on orbital rim, paraesthesia over maxilla (infraorbital nerve), and subconjunctival haemorrhage are all suggestive of orbital floor fracture. Check for visual acuity, that the pupils are equal and reactive to light, and accommodation, full range of eye movements, and exclude diplopia. Look for hypoglobus (the pupils sit at different vertical heights) and enophthalmos (where the eye sinks back into the socket). Tissues can become entrapped, especially in children due to the greater flexibility in their bone causing the fracture to spring back up like a trap door. This entrapment can cause a ‘white eye blowout’ where on looking upwards, one eye remains fixed. In paediatric cases it can stimulate the oculocardiac reflex associated with hypotension, N&V. In extremis, it can induce a potentially life-threatening bradycardia or arrhythmia. If tissues are left entrapped this can 
muscle necrosis and permanent disturbance in eye movements.
Facial view X-ray or CT orbits. Look for the black eyebrow sign of air in the orbit (Fig. 37.1), tear drop sign of entrapped tissue, and fluid level (blood within the maxillary sinus) as suggestive features. If the patient has eye signs and the fracture is minimally displaced, then it can be treated conservatively. Large orbital floor defects are reconstructed using alloplastic (titanium mesh, Medpore®, etc.) or autogenous (bone) materials. Patients must avoid nose blowing, be covered with antibiotics, and reviewed with orthoptics in clinic 7–10 days after the injury/surgery. Numbness is common over the maxilla due to the position of the infraorbital nerve.
Fig. 37.1 CT right orbital floor fracture. Reproduced with permission from Cyrus Kerawala and Carrie Newlands, Oral and Maxillofacial Surgery, 2014, Oxford University Press.
Involve trauma to the upper, middle, and lower facial bones. Because of the force necessary to create such severe facial injuries they are commonly associated with multisystem injury as well as head and C-spine trauma. Hence, they’re manage initially through standard ATLS® algorithms. Le Fort fracture patterns are worth knowing but it is best to describe the fracture relative to the anatomy. Sometimes no primary repair is done and the bones are allowed to heal in an abnormal position and a corrective osteotomy planned for later.
This is a tracking cellulitis of the floor of the mouth that occurs in association with dental infections. It is life-threatening if left untreated as it can cause airway obstruction. Usually there is a history of preceding dental pain or dental work. There is submandibular and submental swelling with a raised floor of the mouth crossing the midline. The patient has difficulty talking and swallowing their own saliva. They may have a ‘hot potato’ like voice. Commonly there is erythema over the anterior neck, which can track all the way down to the sternum. The patient can deteriorate very quickly so early anaesthetic review and OMFS referral is essential. In the intervening period they should be placed in the resuscitation bay, nursed vertically, and placed on monitoring. Treatment is with antibiotics (IV co-amoxiclav) ± steroid (IV dexamethasone) and early surgery to decompress the submandibular and submental spaces. Patients may require a tracheostomy or prolonged intubation depending on severity.
Always exclude head injury and enquire about any loss of consciousness and the mechanism of injury. Ask about disturbance in their bite, as there may be a luxation injury, or an associated dentoalveolar or jaw fracture. Dental injuries are treated conservatively (antibiotics, analgesia, and soft diet for 2 weeks) with early dental review within 24 hours. Very mobile subluxed teeth, extrusions, lateral luxations, and any associated dentoalveolar fractures are treated with reduction, splinting, and a soft diet in addition to this. Ensure you account for the tooth if avulsed.
Types of dental injury
• Concussed: injury to the tooth and supporting structures without 
mobility or displacement. Pain occurs on percussion.
• Subluxed: mobility without displacement.
• Laterally luxated: displacement of the tooth other than axially.
• Extruded: partial displacement of the tooth out of its socket.
• Intruded: displacement of the tooth into the alveolar bone.
• Infraction: crack in the tooth with no loss of substance.
• Fractured: loss of tooth structure. It can be described as being enamel only, dentine and enamel, enamel with dentine and pulp, and root fracture.
Oral cancer makes up to 4% of all cancers in the Western world and are on the rise, but can be as high as 40% in the Indian subcontinent. 85% of oral cancers are mucosal SCC. Commonest sites are floor of mouth, tongue, and retromolar trigone (behind the wisdom tooth). Risk factors: smoking, drinking alcohol, chewing paan/ghat (can also cause submucosal fibrosis which is pre-cancerous). Treatment: resection with or without reconstruction. Adjuvant radiotherapy is occasionally used if margins on the resection are close, as is chemoradiotherapy. Risk of a second head and neck primary is in the region of 35% over a lifetime.
These commonly close surgical and traumatic defects as well as mould and model tissues. A graft draws its blood supply from the recipient area, relying on ingrowth of new vessels whereas a flap arrives in the recipient area with its own blood supply.
(Also known as a Wolfe graft.) Commonly used to reconstruct larger skin lesion defects in the head and neck. Usually taken from the supraclavicular area or behind the ear as an ellipse of the full thickness of skin with a small cuff of underling fat, this facilitates primary closure of the donor site. The flap is then thinned with a knife by removing the fat. It is important to note that the recipient area must be covered by soft tissue (and not on bone) as it draws its blood supply locally.
Used for additional cover of muscular flaps or donor site defects unable to be closed primarily. Usually taken from the thigh using a dermatome, a partial thickness of skin to include a partial thickness of dermis. The residual dermis allows the donor site to regenerate epidermis.
Various types of flaps are used, from pedicled, where their own blood supply is not disrupted, to free flaps, where an anastomosis of blood vessels is required. The most common way to describe them is in terms of their composition (e.g. musculocutaneous, composite (mixture of bone, muscle and skin)). The major workhorses of flap reconstruction in the head and neck are the radial forearm, fibula, and deep circumflex iliac artery (DCIA) free flaps, along side pectoralis major and latissimus dorsi pedicled flaps.
These are when you borrow tissue from the adjacent area to fill a defect, such as following the excision of skin cancer. They can be rotational, advancement, or transposition flaps and various designs exist (e.g. rhomboid, bi-lobed, nasolabial, V-Y closure, and O-Z closures). They are relatively robust and do not require rigorous monitoring. They can be done under local anaesthetic, and the patient can go home on the same day.
Tracheostomies are placed for a number of reasons such as protecting the airway pre-emptively, to secure an airway in an emergency following upper airway obstruction, or to aid ventilation in patients who are intubated for long periods of time. It is important to find out why they have one. They can become blocked through secretions, blood, or displacement into the soft tissues; therefore, they must be secured at all times. Most have an inner tube that slides out to facilitate cleaning. This inner tube can be fenestrated to allow speech, or a complete tube. If a patient loses their airway, then the inner tube should be removed and high-flow oxygen applied over the tracheostomy site. If there is no improvement, consider letting their cuff down on the tracheostomy and giving additional oxygen via the mouth and nose. The UK National Tracheostomy Safety Project has excellent advice on the management of tracheostomies (
www.tracheostomy.org.uk).
As a flap brings its blood supply with it there is potential for it to be compromised, therefore postoperatively it is important the flap is monitored. No one feature should be taken in isolation but they help build the picture of the health of the flap and patient factors such as whether they are warm and well perfused or inotropes should also be considered. The things commonly looked for in flap observations are as follows:
• Colour: a pale flap suggests not enough blood supply, a dark or blue tinted flap implies a compromised venous return.
• Capillary refill: a delayed capillary refill means poor arterial supply, a brisk refill can mean poor venous return.
• Texture: a boggy flap may be oedema, however it may be an underlying collection; a hard flap may be a large tense haematoma underneath.
• Temperature: a cool flap indicates poor perfusion.
• Doppler signal: though not always tested, it is useful to test patency of the arterial supply.
The observations should be done regularly and when handing over a patient with a flap it is important for both parties to see the patient together so that they can see and confirm what the flap looks like to establish a baseline. You do not want the first time you see a flap to be at 3 am with the nurse saying ‘They think it’s a little blue’. It is worth noting that oral flaps have a tendency to be paler than other flaps. When reviewing the flap ensure the patient is optimized; with a sufficient mean arterial pressure (70–80 mmHg), Hb >80, lactate <2 adequate urine output (>0.5ml/kg/hr), that the pedicle is not stretched (e.g through hyper extension), and there is no pressure over the pedicle (such as from tracheostomy straps).
Tailor your examination to the patient’s presentation (e.g. deformity vs oncology vs trauma). Adopt a systematic approach and break it down into extra-oral and intra-oral components of the examination.
In trauma, always exclude head and C-spine injury first, then break the examination of the face down into thirds, work from upper, to middle, to lower third using the ‘look, feel, and move’ approach. Look specifically for signs of base of skull fracture:
• Battle’s sign (bruising of mastoid).
• Panda/raccoon eyes (periorbital bruising).
• New irritant cough (leaking CSF down their throat).
Review C-spine for tenderness on bony prominences and guarded neck movements. Commonly imaging is performed in at-risk cases to aid diagnosis. You should then specifically assess for the following:
• Facial asymmetry: examine from above the patient’s head, front, side, and below, thinking of the face in 3D assessing in AP, vertical, and horizontal planes. Use your fingers to help you assess the symmetry of bony prominences and their projection.
• Scars/lacerations/ecchymosis: should all be looked for, past OMFS scars can be very well hidden, look especially closely around the pre-auricular area and skin creases.
• Eye: if there is any possibility of orbital injury look specifically for proptosis, hypoglobus, enophthalmos, limitation in eye movement, acuity, reaction to light, and accommodation. Seek an ophthalmology opinion if any abnormality or globe injury cannot be excluded. Restriction of upward gaze suggests entrapment of soft tissues, such as inferior rectus; if left, this can cause a permanent visual defect as the muscle will become ischaemic and fibrose. This is an emergency in children in whom it is more common due to the orbital floor fracture green-sticking and forming a trap door to spring shut on the muscle.
• Nose: deviation in upper, mid, and lower thirds should be documented, with septal deviation and haematoma excluded. The latter is crucial—it can lead to an ischaemic septal cartilage.
• Mouth opening: look for deviation to one side, limitation (normal is >4 cm), and check for pain on lateral excursion. Assess for any lock, click, crepitus, and pain on movement.
• Palpate: for steps, feel along the bony prominences of the face for step deformities and spot tenderness. Feel for crepitus in the soft tissues, and palpate the lymph nodes systematically.
• Move the midface: check for movement at Le Fort 1 (base of the nose), 2 (medial orbit), and 3 (lateral orbit) levels. To do this, place one finger on the hard palate and pull the mid face in an AP direction while looking and feeling with the other hand over the mid face at the three Le Fort regions.
• Cranial nerves: these should be formally assessed and documented, especially cranial nerves V and VII. Classically, malignant parotid tumours affect cranial nerve VII but benign do not. Weakness of the tongue also suggests a malignancy. Altered sensation in lip and chin is regularly seen following a fracture jaw, and numbness over the maxilla common following and orbital floor fracture.
• Roof of mouth (hard and soft palate).
• Floor of mouth: if it is raised where infection is suspected then it may be a Ludwig’s angina, an OMFS emergency that can compromise the airway. With fractures of the jaw it is common to get bruising, so look specifically for a sublingual haematoma.
• Buccal aspects: a dental mirror or tongue depressor and torch are particularly useful here to retract the tissues so you can specifically inspect the sulci.
• Tongue: look over lateral, dorsal, and ventral areas. As many cancers occur proximally, ensure the patient sticks out their tongue as far as possible; to aid this, a dry piece of gauze can be used to pull the tongue forwards and at the same time you can feel the tongue for abnormalities. Cancers tend to feel hard and craggy.
• Oropharynx and tonsils: these are best viewed by getting the patient to say ‘ahhhh’.
• Gingivae: commonly lacerated over fracture lines.
• Teeth: when reviewing teeth look at them individually (quality, quantity) and how they meet together (occlusion) and establish if this has changed. On individual teeth, check for caries, cavities, and fractures. Feel for sharp or jagged edges that can cause ulcers, then assess mobility and tenderness to percussion. If tapping on a tooth with an instrument causes pain it is suggestive of apical inflammation, likely secondary to trauma or an abscess. Account for any missing teeth in trauma, if any concerns perform CXR to exclude inhalation or lateral facial view to exclude avulsion into soft tissues.
• Glands: commonly missed, they are important, as the parotid is the most common site for head and neck skin cancer secondaries. Bimanually palpate the parotids and submandibular glands, try to milk out saliva from ducts (opposite the upper first molars for the parotid and either side of the lingual frenulum for the submandibular gland). Dry the area using a gauze swab, to aid in visualization before milking the gland.
• Muscles of mastication: palpate for tenderness, common with bruxists (excessive teeth grinding or jaw clenching).
• Lumps and bumps: if you do find any masses, or lesions in glands or intra-orally, describe them in the usual fashion such as site, size, shape, symmetry, surface, scars, colour, consistency, compressibility, temperature, tenderness, transillumination, fixation, etc.