A 30-year old patient came to the Oral and Maxillofacial surgery department with a penetrating facial injury after a road traffic accident. The surgeons were confronted with a wooden log passing through the left lateral side of the patient’s face; the log was seen protruding through the mouth of the patient, just below the angle of the mandible or gonial angle. The doctors made a diagnosis of a comminuted fracture, a break or splinter of the bone into more than two fragments. Fractures of this degree occur after high-impact trauma, such as a road traffic accident.
On examination, the patient was seen having difficulty breathing with signs of moderate bleeding. However, there was no neurological deficit reported with the bleeding. A neurologic deficit refers to abnormal functioning of a body area. This altered function is either because of a weaker function of the brain, spinal cord, nerves or muscles. Examples of neurologic deficit include weakness of arms or legs, problem walking, vision changes, memory loss, loss of balance, decreased sensation, an inability to speak and abnormal reflexes.
Additionally, moderate trickling of blood was noted from the entry site of the wooden log. The pulse rate of the patient was 110/min, the heart typically beats 60 to 70 times in a minute, if the heart rate is elevated then the heartbeat is faster than normal. Furthermore, the blood pressure of the patient was 140/90 mm Hg. Blood pressure numbers less than 120/80 mm Hg are considered to be within a normal range. The management of the patient was done following the advanced trauma life support (ATLS), a training program for medical providers developed by the American College of Surgeons for the management of acute trauma cases. The airway, breathing and circulation of the patient were assessed. Airway management was a challenge for the surgeons in such a penetrating injury. Moreover, because of the long wooden log stuck behind the neck, the patient was unable to lie down in a supine (flat) position. In addition, penetrating facial injuries are potentially dangerous and there is a high chance of aspiration (a passage of materials from pharynx into the trachea) of blood and saliva, the aspirated materials can originate from the nose, mouth, esophagus or stomach. Therefore, to secure the airway, the patient was planned for a tracheostomy. Tracheostomy is a temporary or permanent medical procedure, it involves creating an opening in the neck, through which a tube is passed into the patient’s windpipe to allow air to enter the lungs. The tube is inserted through a cut in the neck, right below the vocal cords.
The wooden log was shortened near close proximity to the jaw of the patient. Anesthesia was administered through a tracheotome1, a medical instrument used for performing an incision in the trachea or windpipe. The wooden log was then removed after adequate exposure, there were no other foreign body seen during the surgery. After identifying the lingual and facial artery, they were ligated (a surgical procedure of tying a ligature around a blood vessel) with a silk suture. A suture is used for stitching up a wound or incision. There was no other injury reported in the nerves and great vessels of the neck. The bleeding was stopped, and area was cleaned with betadine saline wash. The broken pieces of the mandible were put into place using stainless steel mini plates and screws, holding the broken bone together. Nonetheless, after securing the suction drain, the wound was closed in layers.
Evaluation after the surgery was completed revealed no injury to the facial or lingual nerve. The patient was discharged on the 10thday after the surgery and the tracheostomy tube was removed. Despite the uneventful post-operative period, the patient showed no major aesthetic or functional problems after 1 month. Fortunately, the patient recovered with a favorable outcome.
References
- Reindert, B. (1968). U.S. Patent No. 3,384,087. Washington, DC: U.S. Patent and Trademark Office.
