Golden hour intervention by maxillofacial surgeons in the emergency room: a case report

Introduction

Maxillofacial trauma is amongst the commonly encountered case to maxillofacial surgeons. These injuries can occur isolated or associated with other parts of the body such as head, chest, abdomen and extremities (1). Maxillofacial trauma has a multi-factorial aetiology predominantly due to road traffic accidents (RTAs) (2) followed by accidental falls, assaults, industrial mishaps, sports injuries, and firearm injuries. The severity and pattern of the trauma depend on the anatomic site, the magnitude and direction of the force delivered to the face (3).

The primary evaluation of a trauma patient needs to be a rapid, reproducible physical examination to sort emergency cases from others. The secondary survey involves complete head to toe examination of the trauma patient which includes complete history taking, physical and radiological examinations and some laboratory studies (4). Errors are most often noted at this stage owing to the low-intensity, non-emergent scenarios and communicational errors (5).

This report highlights the importance of early diagnosis and timely management in the field of maxillofacial traumatology. We present this case in accordance with the CARE reporting checklist (available at https://jxym.amegroups.com/article/view/10.21037/jxym-24-6/rc).

Case presentation

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). The patient was informed regarding the procedure and proceeded upon approval. The patient also approves publication of the case with no disclosure of personal information or images. A copy of the written consent is available for review by the editorial office of this journal.

A 33-year-old female patient had reported to the Emergency Unit with complaint of bleeding from nose and mouth associated with facial and neck pain. Sudden discomfort in the throat was also reported. History of an alleged assault at home was informed during which she sustained injuries to the face. Clinical examination revealed multiple fractured teeth of the maxillary and mandibular anterior region along with a bilateral maxillofacial fracture. The patient reported of avulsion of two teeth at the site of the incident while intraorally multiple teeth were fractured. Computed tomography (CT) scan of head and neck performed was confirmatory of the bilateral maxillofacial fractures (Figure 1) and also revealed a focal, hyperdense hazy structure on the lateral wall of the nasopharynx (Figure 2). Based on the history presented and clinical findings, a diagnosis of maxillofacial fractures with implanted tooth in the pharyngeal wall was sought. The patient was immediately shifted for emergency procedure under general anaesthesia to retrieve the foreign structure and simultaneously treat the maxillofacial injuries.

Figure 1 Computed tomography scan showing maxillofacial fractures.

Figure 2 Implanted foreign body in the pharyngeal region (red arrow).

After the patient was administered muscle relaxants and sedated, the foreign body implanted in the lateral wall of oropharynx was visualised and removed using a long straight artery forcep (Figure 3). Patient was later intubated and fracture fixation was done using mini-plating system. An additional intraoperative abdominal scan was performed to rule out any teeth ingestion (Figure 4). The patient was prosthetically rehabilitated two weeks post-operatively.

Figure 3 Implanted foreign body specimen.

Figure 4 Intraoperative computed tomography abdominal scan.

Discussion

Maxillofacial traumas include damages of soft and hard tissues structures and proper evaluation during the secondary survey of emergency care must be done. It is during this stage most errors are encountered leading to wrong diagnosis, improper treatment planning and impaired care for patient. There have been several articles showing the increased number of dental traumas owing to changing trends in the nature of maxillofacial trauma (6).

Assaults account for 39% maxillofacial trauma (7,8) with interpersonal violence edging over domestic violence. Cases of domestic assault tend to often less spoken or reported and hence proper clinical evaluation along with thorough knowledge on the nature of force and its damage to the facial skeleton is needed for proper diagnosis.

Tooth fracture or displacement is a common finding in maxillofacial trauma. After trauma, teeth missing from the oral cavity or a foreign body can be displaced along three paths: (I) expulsion, (II) aspiration, and (III) ingestion (6). Thin pointed teeth have higher risk of perforation and pneumothorax than those with a smoother shape. Delayed removal of a foreign body beyond 24 hours may be associated with increased morbidity and longer hospital stay. Chronic retention of a foreign body can lead to formation of granulation tissue, inflammatory polyps around the foreign body, and obstruction of the bronchus (9). Hence the role of maxillofacial surgeons in such scenarios is vital.

Conclusions

Treatment of maxillofacial trauma requires a multi-disciplinary approach. In our case presentation, the proper secondary survey with timely identification of the tooth structure in the oropharynx aided in early intervention and management of patient’s concerns.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have complete the CARE reporting checklist. Available at https://jxym.amegroups.com/article/view/10.21037/jxym-24-6/rc

Peer Review File: Available at https://jxym.amegroups.com/article/view/10.21037/jxym-24-6/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jxym.amegroups.com/article/view/10.21037/jxym-24-6/coif). M.K.R. owns a clinic and has a patents planned (a maxillofacial instrument). The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Patient was informed regarding the procedure and proceeded upon approval. Patient also approves publication of the case with no disclosure of personal information or images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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