Chapter 25. Otolaryngology (ENT)

A headrest for head and neck surgery can be fashioned from foam packing material (Styrofoam) or a piece of foam cushion or mattress. Use a 25-cm × 25-cm × 10-cm piece of the material and hollow out the middle so that it is only one-third of the original depth. This space is for the patient's head. The foam material will provide traction to keep it on the operating room (OR) table.1 This headrest can also be used as a sleeping pillow if the individual needs, or wants, to be only on their back.

Most of the regional nerve blocks useful for ear, nose, and throat (ENT) procedures are discussed in Chapter 23, Dental: Diagnosis, Equipment, Blocks, and Treatment.

To relieve most or all orofacial pain in adults, use a simple paravertebral block. This is an extremely safe procedure, since the injection is made with a 1.5-inch-long, 25-gauge needle. Inject 1.5 mL of 0.5% bupivacaine into the paravertebral musculature on both sides, 1 inch lateral to the seventh cervical spinous process. Bupivacaine provides good pain relief within 15 minutes for adults with toothache (odontalgia), mandibular fractures and dislocations, temporomandibular joint (TMJ) syndrome, ocular pain, facial pain from a variety of other causes, and headaches.2,3

Otoscope

If an otoscope is not available, use an ophthalmoscope to look through any type of speculum into the ear canal. Objects that can substitute for a speculum include a pen casing (cut the tapered point off a little and smooth it), a 1-cc syringe barrel with the end cut off and smoothed, a nasal speculum (be careful not to put it in too far), and similar objects. Note that many late-19th century otoscopes looked no different than modern nasal speculums. They used a direct or an indirect (head mirror) light source.4

Foreign Body/Cerumen Removal

Knowing how to remove foreign bodies from an ear can save time and resources. There is no evidence to support choosing one method over another in most cases, and many different techniques are available. It is also useful to know which cases may need to go to the OR to have foreign bodies removed under sedation. The most difficult foreign bodies to remove from an ear are spherical objects, those in contact with the tympanic membrane, and those that have been in the ear for more than 24 hours.5 Most foreign bodies can be removed from the ear using irrigation, dissolution, suction, glue, or by other physical means. Removing insects and metal objects are special cases.

Anesthesia

Current sedation techniques (see "Procedural Sedation" in Chapter 15, Sedation and General Anesthesia) make it safe to administer sedation to both adults and children before undertaking painful, or what may be prolonged, attempts at foreign body removal. Anesthetizing the ear can gain the patient's cooperation, although good anesthesia in the ear canal is difficult to achieve. Topical anesthetic can be dropped into the canal (if the foreign body is neither vegetable matter nor a button battery), although it usually has only a modest effect.

Irrigation

Irrigation is the least traumatic way to remove cerumen and smaller foreign bodies close to the tympanic membrane (TM). If the TM is not perforated, irrigate the ear with clean water at body temperature. (Cold water produces emesis.) For earwax, it may help to put in a softening agent for a few days before trying this.

Use a small piece of tubing connected to a syringe; the catheter from an IV or the tubing from a butterfly cannula—with the needle cut off—works well. An alternative is to use a bulb syringe or a turkey baster. With both, low-pressure volume, rather than a directed stream of water, works better. Other methods that have been used successfully include using oral jet irrigators (this may have too high a pressure, depending on the state of the batteries),6 a recreational water gun,7 and mouthfuls of water instilled (by the patient's nurse-wife) through a cocktail straw.8 Aim the fluid stream at the superior aspect of the ear and, if possible, pulse the fluid for best results. Alternatively, direct the stream along the wall of the ear canal and around the object, flushing it out.

Do not irrigate the ear to remove hygroscopic objects such as vegetables, beans, and other food matter as these may swell. More common in noses than in ears, button batteries should not be irrigated out. That only accelerates the tissue necrosis. Also, avoid nasal and otic drops in these patients.

Dissolve

Styrofoam is a common foreign body found in the ear. It is often compressed and tightly impacted in the ear canal. The friable substance tends to fragment if grabbed with forceps. The best removal method is to instill acetone or ethyl chloride, both organic solvents. This results in rapid and near-complete dissolution of the Styrofoam without any patient discomfort.9

Suction

Objects that are light and move easily can often be quickly removed with suction. Use a small soft-rubber suction catheter (e.g., pediatric feeding tube), a standard metal suction tip (e.g., Frazier tip), or a specialized flexible tip. It takes 100 to 140 mm Hg (or higher) negative pressure to attach an object, so using your mouth to suck on a tube won't work.

Mechanical Removal

Mechanically removing an object involves grabbing the object and pulling it out of the ear. This is most commonly done with cerumen, but can often be done with compressible objects by using tiny (alligator) forceps. Alligator forceps are best for grasping soft objects like cotton or paper.

To remove cerumen and small, visualized foreign bodies, fashion improvised spoons by bending the end of a paper clip into a very tiny "U" shape. Don't do this with your fingers—use pliers or a similar tool. This can also be used for removing foreign bodies from the nose.10 If the foreign body is at all irregularly shaped and is not made of organic material, it can often be grasped with any available forceps or hemostat and removed.

Metallic objects, such as the appropriately feared button batteries, can sometimes be removed from the ear using a magnetized screwdriver.11 (Ask your maintenance staff for one to use.) Note that batteries must be removed immediately to prevent corrosion or burns. A delay of only an hour or two, or a missed diagnosis of a battery in a nose or an ear, may lead to a particularly severe outcome. Upon contact with most tissue, this type of alkaline battery is capable of producing a liquefactive necrosis extending deep into tissues. Do not crush the battery during removal. Avoid nasal and otic drops. These electrolyte-rich fluids enhance battery corrosion and leakage, the generation of an external current, and local injury. After removing the battery, irrigate the canal to remove any alkali residue.

Glue

If the object is dry and smooth, put a tiny amount of cyanoacrylate (Super Glue) on the wooden end of a tiny swab (e.g., Q-tip) and touch the object. It will dry in about 15 seconds and then both can be extracted. The danger is gluing the stick to the patient. If so, don't fret—it can be removed with acetone or simply by waiting several hours.12

Removing Insects

Insects are a special case of organic foreign body. They are the most frequent ear foreign body in adults. Generally, they are alive, and often panic the patient because of both the pain and the noise they generate.

Kill the insect before attempting to remove it. Quickly drop in any liquid that will not injure the ear canal (e.g., mineral or cooking oil, lidocaine, liquid soap, alcohol, etc.) to kill the insect—and to restore the patient to relative calm. Plain water or normal saline usually is ineffective. Most insects die in less than 3 minutes after liquid is put in the ear.13

Improvised Ear Wick

Patients with edematous otitis externa need a method of getting the medication into the ear canal. This usually requires an ear wick. To improvise an ear wick, use thin ribbon gauze, impregnated at the bedside with antibiotic/anti-inflammatory ointment. This can be removed by patients, is inexpensive, and requires fewer visits than when patients use ear wicks.14

Alternatives to Otic Medications

Acetic acid (10% vinegar) is an amazing, nontoxic, inexpensive, and widely used preventive and treatment for most cases of external otitis. Scuba divers routinely use it. Mix one part acetic acid (vinegar) with nine parts water. Instill enough to fill the ear canal as often as needed. The only side effect is a streak of white where it drips out of the ear. Simply wipe it off. One caveat: diabetic patients and individuals whose ear canals have swollen shut need additional treatment; the latter can be treated with this medication if an ear wick is inserted. While patients with diabetes may be able to temporize with acetic acid, they should also have the appropriate antibiotics or antifungals instilled, if these are available. A mixture of 50% rubbing alcohol, 25% white vinegar, and 25% distilled water can also be used for external otitis. This should only be used QID.15

Myringotomy

A myringotomy may need to be done if the patient is in pain from otitis and no analgesic, decongestant, or antibiotic is available. If a myringotomy is necessary, nearly any local anesthetic drops will anesthetize the tympanic membrane if you wait 10 minutes after they are put in. For example, use one spray of 10% lidocaine aerosol directed into the clear external meatus onto the tympanum.16 Another option is to put in 1 drop (only!) of 10% phenol. If phenol is used, start the procedure immediately, since the anesthetic effect lasts only 10 minutes. (Phenol also can anesthetize other areas, such as pilonidal cysts.) To do the myringotomy, insert an 18-gauge needle into the anterior-inferior part of the tympanic membrane. To take a culture, attach a TB syringe. Avoid puncturing the membrane posteriorly. (David Merrell, MD, oral communication, October 2006.)

Nose Drops and Washes

Nose drops and washes are reasonably benign ways to make "stuffed up" patients feel better and, in some cases, to "clear the way" for other medications. There are a variety of recipes that you can prescribe for patients to make at home, if the commercial varieties are not available.

• Recipe #1: Mix ½ teaspoon salt in 8 oz warm water and store the solution in an empty spray bottle. Make a new solution after 2 days.17,18
• Recipe #2: Add 2 to 3 heaping teaspoons of table salt and 1 rounded teaspoon of baking soda to 1 quart of boiled tap or bottled water. Store it in a 1-quart glass jar. If the mixture is too strong, reduce the salt to 1 to 2 teaspoons. If the patient's nose is dry, add 1 tablespoon of corn syrup to the mix. Stir or shake before each use and store in the refrigerator; mix a fresh batch weekly.

For adults, use two to three times daily. Instill with a bulb, ear, or medical syringe. Warm the solution to body temperature and have patients stand over the sink or in the shower as they squirt toward the back of each nostril. Avoid contaminating the stock solution. For children, instill 3 drops as often as necessary in each nostril while they are supine with their head turned to one side. Have them blow their nose after 1 minute or, for younger children, use a suction bulb to remove mucous.18

Anesthesia

Using intranasal anesthetic gains a patient's cooperation for any manipulation. Good intranasal anesthesia can be obtained in several ways. Use 1 to 3 sprays of 10% lidocaine aerosol in the nose. Or spray the nose with 2 to 3 mL 4% lidocaine plus 1 drop (0.05 mL) of 1:1000 epinephrine. Then pack the nose with gauze soaked in the same solution.16

To anesthetize the entire nasal cavity, hyperextend the head and pour 20 mL of 1.25% lidocaine with 0.25 mL of 1:1000 epinephrine into each nostril; allow it to remain there for 3 minutes. (Before instilling the liquid, warn the patient to close his glottis by forming but not saying a "ggg" sound while the liquid is in his nose.) The patient then blows their nose.16 A less traumatic method is to attach a standard face mask to a nebulizer containing the solution and have the patient breathe through the nose.19 A variation is to connect wall oxygen to an atomizer using oxygen tubing with a lateral hole cut in it. By intermittently occluding the hole with a fingertip, a spray of lidocaine is produced from the atomizer nozzle. Held at the nostril, the nozzle can deliver 2% lidocaine throughout inspiration and produce dense anesthesia of the airway from the nose to the trachea in less than 5 minutes.20

Nasal Speculum

A nasal speculum provides an excellent view when examining the nose and is vital when doing procedures, including packing the nose for epistaxis or draining a septal hematoma. The problem is finding the right-size speculum when it is needed. There are at least two methods to improvise a speculum, depending on the available resources.

If disposable otoscope specula are available, simply snip off the end of one to get the size you need, put it on an otoscope, and you have a speculum adequate to examine the nose.21

For a speculum that approximates the standard instrument, snip the corner off a wire hanger and bend the ends to the size you need (Fig. 25-1). Note that the loops bend inward so that the handle can be oriented toward the cheek (Fig. 25-2). Be careful to bend the V-shaped "corner" of the wire so that it exerts less pressure than you might need if making this into a self-retaining retractor.

Epistaxis

Epistaxis is one of the most common complaints. It can be either remarkably simple to treat or a life-threatening event. Nasal bleeds are either anterior, posterior, or a combination of the two. While many clinicians use prepackaged materials to stop nasal bleeds, these are usually not available in austere situations.22

Adding a vasoconstrictor to an intranasal anesthetic stops up to 65% of anterior bleeds. A number of different, often readily available, anesthetics work well. Cocaine 4% is safe when used appropriately. Use a maximum of 200 mg (4 mL) or 2 to 3 mg/kg. Try to avoid using it in patients with coronary artery disease.22 Lidocaine 4% plus phenylephrine has an effect equivalent to that of cocaine.23 The maximum dose of lidocaine is 4 mg/kg. If using the injectable form, use up to 7 mg/kg lidocaine plus epinephrine. Tetracaine 1% plus 0.05% oxymetazoline (Afrin) works as well as lidocaine plus phenylephrine.24 It also lasts longer, up to 60 minutes. The maximum adult dose of tetracaine is 50 mg.

Anterior Bleeds

Direct Pressure

The vast majority (90%) of nosebleeds arise from the mucosa in the anterior part of the septum (Little's area, Kiesselbach's Plexus). Ask the patient to blow their nose to remove any inadequate clots and then press their anterior nose for 10 minutes without stopping. Show them how to press directly over the ala nasi (the soft part of the nose nearest the nares). Use a clock or a watch to time it or they will stop too early. This technique stops nearly all anterior bleeds. (Do not press over the nasal bones, as even experienced personnel often do.24) Alternatively, make a nasal pressure device by tightly taping two tongue depressors together at one end. The non-taped end can be spread apart and placed on either side of the nares to apply pressure.

These techniques work even better if you first insert cotton or gauze with a small amount of oxymetazoline (Afrin), phenylephrine (Neo-Synephrine), or other vasoconstrictor into the anterior nose before applying the pressure. For patients with von Willebrand's disease or with other clotting problems, David Merrell, MD, says that packing fresh (uncooked) liver or bacon in the nose often helps because of the clotting factors they contain. (Oral communication received October 2006.)

Iced Lavage

If neither vasoconstrictors nor direct external pressure stops the bleeding, try an iced normal saline lavage of each nostril, with the patient leaning forward. This may help decrease or stop the bleeding and allow better assessment of bleeding sites. The patient must be seated during both the examination and the therapeutic procedures to lower his blood pressure.25

Packing

Anterior packing is almost a lost art among many clinicians. Lubricating a vaginal tampon and slipping it into the nose can make an improvised "prepackaged" anterior pack. (David Merrell, MD, oral communication, October 2006.) As with anything else inserted into or through the nose, insert the tampon straight back along the floor of the nose.

If other measures do not stop the bleeding, an actual anterior pack may be required. For this, you need a cooperative patient, a petroleum gauze strip, a long forceps or hemostat, a nasal speculum, and a strong arm. Having a support behind the patient's head, even if only a wall, is helpful to stop the patient from continually backing away from you—the natural response. (See Fig. 23-4 and how to make a dental/ENT chair in Chapter 23, Dental: Diagnosis, Equipment, Blocks, and Treatment.)

After anesthetizing and vasoconstricting the nasal cavity, sit the patient upright in a chair with a headrest. While lighting is not vital, using a headlight or a head mirror is useful. Sit facing the patient and insert the nasal speculum with the handle pointing away from the nasal septum. It often helps to have an assistant hold the petroleum gauze so that you can easily pick it up at each step of the packing process. You will use only one long piece of gauze. If the piece you have is not long enough to fill the nose, tie another piece onto the first one and continue. Never use more than one piece in each side; they will get lost in there.

Pick up one end of the ribbon gauze and insert it as far back as possible. Try not to let it drop into the nasopharynx, but it should be almost there. The most common error in doing anterior packs is that they don't extend far enough back into the nose. Then, pick up the gauze at a point about twice the distance that the first portion went in (Fig. 25-3). Try to push this back in the nose as far as the first piece went, layering the gauze. Continue this process—forcefully—until absolutely no more gauze can fit into the nose. Cut off any remaining gauze. Have the patient return in 2 to 3 days to have the packing removed. Many of these patients will need analgesics.

Posterior Bleeds

Without a fancy balloon designed to stop posterior nasal bleeding, two options, aside from surgery, are available: a balloon-tipped urethral (Foley) catheter and a posterior nasal pack.

Foley Catheter Method26

1. If possible, anesthetize the nose and posterior pharynx.

2. If a flow-control roller clamp from an IV infusion set is available, slide it over a large (14 Fr) urethral (Foley) catheter with 30-mL balloon.

3. Trim the distal tip of the catheter; do not cut the balloon.

4. Slide the well-lubricated large catheter through the nares that is bleeding the most. Pass it along the floor of the nose until it is visible in the nasopharynx (~8 to 10 cm).

5. Fill the balloon with 15 to 30 cc of water.

6. Pull the balloon back until it firmly seats against the posterior nasal opening (choana).

7. If an intravenous roller clamp was placed on the catheter, put a gauze pad against the nares for protection and, while holding gentle traction on the catheter to apply pressure to the posterior bleeding site, slide the roller clamp to the nares and lock it in place.

8. Otherwise, pad the nose, pull the catheter tight against the back of the nose, and secure it with tape, a safety pin, or a nasogastric or umbilical clamp.

9. Pack the anterior nose, as in section above, around the catheter.

10. If significant bleeding continues, repeat the entire process on the other side. If it still continues, consider surgery.

11. Place the patient (irrespective of age or medical condition) on oxygen, since they are nearly always going to be hypoxic.

Posterior Nasal Gauze-Pack Method27

1. Fold two 4 × 4 pieces of gauze or, if not available, a similar quantity of clean cloth into a small ball. Tie them securely at the middle of a very long piece of heavy thread or silk suture. Wrap the ties around the cloth several times in each direction. You will use these strings later to secure anterior nasal packing.

2. If possible, anesthetize the nose and posterior pharynx.

3. Pass a small-gauge urethral catheter or an infant feeding tube through the nares that is bleeding the most. When it is visualized in the posterior pharynx, grasp it with an instrument and pull it out through the mouth (Fig 25-4).

4. Tie the free end of the heavy thread to the mouth end of the catheter (Fig. 25-5) and pull it out through the nose, bringing the thread with it through the nares. Cut the string connecting the catheter and discard the catheter.

5. Gently pull on the string and, with the other hand, guide the cloth pack tightly up into the nasopharynx until it firmly lodges against the posterior nasal opening (choana) (Fig. 25-6).

6. Have your assistant hold traction on the thread while you pack the anterior nose (as described earlier).

7. Place a small piece of gauze or a cloth against the anterior nose and tightly tie the ends of the thread connected to the nasopharyngeal pack. This secures both the anterior and posterior nasal packs.

8. If significant bleeding continues, repeat the entire process on the other side. If it still continues, consider surgery.

9. Place the patient (of any age or medical condition) on oxygen, since they are nearly always going to be hypoxic.

Foreign Body Removal

Foreign bodies in the nasal passages are common and occur almost exclusively in children. The danger of working on a nasal foreign body is that it might accidentally get dislodged into the airway. Try to position the patient in a sitting or lateral position so that this is less likely. Vasoconstrictors are immensely helpful, including the otherwise little-used 4% cocaine solution. (Be careful of toxicity from using too much.) Oxymetazoline (Afrin) or phenylephrine hydrochloride (Neo-Synephrine) can also be used. Patient cooperation may be gained by using anesthetics, such as spraying 4% lidocaine (or cocaine). Anesthesia is the same as discussed earlier in this chapter under "Epistaxis."

Mechanical Removal

If a nasal foreign body can be seen, it can sometimes be retrieved by getting behind it using an ear curette, a right-angle ear hook, or the tip of a paper clip or calcium alginate swab (Calgiswab) whose metal-shaft has been bent to a 90-degree angle. With the paper clip, bend it by clamping the tip between the handle end of bandage scissors; the swab shaft is thin enough to easily bend by hand.28

Small malleable objects close to the anterior nares can often be grasped with bayonet or alligator forceps. Harder objects may be retrieved with hemostats.

Magnetic metallic objects, such as the dreaded button battery, may be retrieved with a magnetic screwdriver or other tool, or by using metal forceps and a magnet. Place a magnet on the outside of the nose and touch the magnetized forceps to the foreign body. Place the magnet against the nasal skin and slide toward the tip of the nose. The metallic object is often attracted to the magnet and can be easily removed without pain.29

Suction

Suction, as in the ear, may work. However, the other methods usually work so well that suction is not needed. If it is used, turn the suction to 100 to 140 mm Hg, touch the foreign body with a thin rigid suction catheter (Frazier) tip, and withdraw the catheter and, hopefully, the foreign body with it.

Glue

Also not often needed, cyanoacrylate glue can be used on the end of a wooden or plastic applicator stick. Press it against the foreign body for approximately 1 minute and then remove it, trying not to also glue the stick to the patient's nasal mucosa. However, since the nasal mucosa is moister than the ear canal, if the patient is inadvertently glued to the stick, it comes off faster.

Catheter

A fast, reliable method is to pass a well-lubricated catheter with a balloon (urethral, vascular, or cardiac catheter) behind the foreign body. A vascular catheter is stronger and stiffer than a urethral catheter, and may pass by the object more easily. Use the smallest diameter available. Don't try to visualize or guide the catheter—just gently let it find its own passage around the object. Once the catheter enters the nasopharynx, inflate the balloon with 2 to 3 cc of air (not liquid!). Take the syringe used to inflate the balloon off the catheter before removing it from the nasopharynx. One common mistake is that the balloon inflation is not maintained during catheter removal. To avoid this, "lock" the inflation by removing the syringe or by clamping the catheter with a hemostat before it is removed from the nose.

Positive Pressure

Positive pressure behind the nasal object has also been shown to be an effective removal method. If a child is cooperative, first ask the child to blow his nose while you, the parent, or the child occludes the other nostril. Sneezing, which can be stimulated with pepper, may also work.

If that doesn't work, a parent can forcefully do one or two breaths of mouth-to-mouth breathing on a child with the opposite nostril occluded. The method is to tell the child that the parent will be giving him or her "a big kiss." Have the child sitting, standing, or, if supine, in the Trendelenburg position. Reassure and calm the patient, then have the parent firmly seal the child's open mouth with theirs, as in mouth-to-mouth resuscitation, and give a short, sharp puff of air. This usually results in the foreign body being blown onto the parent's cheek. When it doesn't work the first time, reposition the parent and child and try again.30 If the parent is not willing to do "the kiss," a bag-valve-mask can be used in a similar manner.31

An easy method is to use air pressure from wall oxygen or an air outlet, if that is available. Connect a tubing (Christmas tree) adapter to the end of oxygen tubing. Spray phenylephrine in both nostrils and lay the child on his side, with the foreign body side down. Make sure the other side is unobstructed. Hold the child securely, with one person keeping control of the head. Turn the oxygen flow meter to 15 L/min or slightly higher. Quickly place the tubing connector into the nostril without a foreign body (Fig. 25-7). Usually within several seconds, the offending object blasts out of the other nostril. (Don't stand in the line of fire.) It's postulated that, startled by the air blast, the child temporarily lifts his soft palate, forcing the air to flow out of the opposite nostril.32 Dr. David Merrell suggests that if the patient is cooperative, have them say "K, K, K" to close the soft palate while doing this. (Letter to author, September 3, 2008.)

Anesthesia

Local anesthesia of the oral cavity, pharynx, larynx, and trachea can be obtained using a standard nebulizer fitted with a mouthpiece to administer 4 mL of 4% lidocaine at 8 L/min oxygen flow over 3 minutes.33

To anesthetize the tonsil, after applying topical anesthesia, inject 1 mL of 1% lidocaine with 1:250,000 epinephrine above the tonsillar fossa, followed by 1 mL infiltration of both the posterior and the anterior pillar, followed by 1 mL injected through the anterior pillar into the tonsillar bed to "float" the tonsil forward.16

Direct Laryngeal Exam

Direct laryngoscopy is a relatively easy way to examine the larynx and vocal cords. The only tools needed are a laryngoscope and topical local anesthetic for the oral mucosa, tongue, oropharynx, and larynx.

Topical anesthesia can be as simple as spraying lidocaine and having the patient gargle with 4% lidocaine viscous to anesthetize the oral cavity and pharynx. The vocal cords can then be sprayed under direct vision when the laryngoscope is inserted. An alternative method of anesthetizing the vocal cords, if that is necessary to remove a foreign body, is to spray or syringe 2 mL 4% lidocaine into the nose. Then insert a nasal airway coated with lidocaine ointment, apply cricoid pressure, and spray or inject 4 to 5 mL of 4% lidocaine down the tube directly at the larynx.16

If topical anesthetic is not available, an oral block that includes the tongue, such as the Gow-Gates block (see the section on blocks in Chapter 23, Dental: Diagnosis, Equipment, Blocks, and Treatment), may be used.

Carefully explain the procedure to the patient: You need their full cooperation. Stand at the patient's head as you would when intubating. Have suction available, as well as long blunt (Magill) forceps if you suspect a foreign body. Lay the patient nearly flat with his head on a level with your mid-chest. Then, carefully insert the laryngoscope into the patient's mouth, trying not to touch any non-anesthetized structures. Ask the patient to pant, say "E," and do the other maneuvers to have the vocal cords move or to otherwise evaluate the larynx, and to visualize and remove a foreign body.

Peritonsillar Abscess

After anesthetizing the mouth and pharynx, use a laryngoscope to provide exposure when draining a peritonsillar abscess. The patient should be sitting and the laryngoscope handle should point down toward the patient's waist.

Possibly less intimidating to the patient than the laryngoscope, the bottom half of a disposable, clear plastic gynecologic speculum, with a light source attached, can be used to depress the tongue and illuminate the pharynx.34 Another option is to tape a penlight to the proximal end of a tongue blade—this provides direct vision and allows the practitioner to have one hand free to do procedures.

Pharyngitis

Patients' sore throats can be relieved with a variety of solutions, including warm saltwater gargles, a topical anesthetic, lozenges, and so forth. Not often used is gargling with a suspension of two crushed, regular-strength aspirin tablets dissolved in a small amount of warm water. Relief usually lasts for several hours. However, using coated or buffered aspirin does not work; neither does acetaminophen.35

Oral Mucositis Analgesia

Patients on chemotherapy and radiation therapy often have intractable pain from oral mucositis. Ketamine provides effective analgesia if used as an oral rinse. To make a rinse, mix 0.2 mL ketamine 100 mg/mL (20 mg) with 5 mL of artificial saliva. Have the patient swish it around his mouth and expectorate after 1 minute. The artificial saliva (1% sodium carboxymethylcellulose and 3% sorbitol) helps local irrigation and mucosal retention. Repeat this every 3 hours as needed, for months if necessary.36

General Principle

As described by Dr. Sir Harold Gillies during World War I, patients with maxillofacial trauma die if their airways are not protected.37 His method was to sit patients up or put them on their side with their face down. If a patient with a severe maxillofacial injury has no neck injury or is awake and cooperative so that he can protect his spine, the patient will be best served by sitting him up or putting him in the "recovery" position.

Nasal Fractures

To reduce brisk bleeding from a nasal fracture, intermittently pack the nose with adrenaline-saline gauze.

Most nasal fractures do not need to be immediately reduced, and when swelling exists, there is no good way of determining the proper orientation. If a nasal fracture does need reduction, stabilize the septum with metal scalpel handles or major artery forceps wrapped in gauze or with rubber tubes slipped over their blades. "Grasp the nose septum and wings: Mobilize the fragments by traction and careful twisting. Model the nose into normal configuration."38 Then pack both sides of the nose for 1 week.

Midface Fractures

Midface fractures, if displaced backward, may occlude the airway. If this is suspected, simply grab the midface and pull it forward. If it is unstable, maintain manual traction on the nose to keep the segment forward.39 If necessary (and if the patient is unconscious or chemically paralyzed), one or two fingers can be introduced behind the soft palate to pull it forward. If this works, use heavy sutures placed around stable anterior teeth as a handle to continue traction.

Lacerations

Tongue Lacerations

Suture any tongue laceration >1 cm long or that splits the tongue anteriorly. Also suture any laceration large enough to trap food particles. Anesthetize the tongue using a Gow-Gates or an inferior alveolar block (see the section on blocks in Chapter 23, Dental: Diagnosis, Equipment, Blocks, and Treatment), which may need to be done bilaterally. Alternatives are to do a lingual nerve block or, if the laceration is small, apply gauze soaked in 4% lidocaine to the wound for 5 minutes.

To perform a lingual nerve block, insert a 25- or 27-gauge needle just posterior and medial to the most distal molar. After aspirating, inject ~1 mL of local anesthetic with epinephrine. The needle should be inserted 0.5 cm in children and 1 cm in adults.

Before suturing begins, secure the tongue by having an assistant (or the patient, if cooperative) hold the tip with gauze. An alternative is to place a suture, towel clamp, or safety pin vertically through the tip (as shown in Figs. 8-2, 8-3, and 8-4). Irrigate the wound and close it with 4-0 or 5-0 absorbable sutures. (You don't want to have to take these stitches out!) Pass the suture through at least one-half of the tongue's thickness with each stitch. Tie the sutures loosely, since the tongue tends to swell. Tying the knots over an instrument or the wooden end of a cotton swab lying on the laceration helps keep the sutures loose enough. Put 4 to 6 knots in each suture or they will unravel when the patient talks, eats, or just fiddles with the sutures. Applying cold (e.g., ice, Popsicles) to the tongue for the next day or so helps relieve the swelling and pain.

Lip Lacerations

The most difficult part of treating lip lacerations is carefully approximating the vermillion border. Anesthetizing the lip with an infraorbital block makes it easier to do this since it does not distort the tissues. This block is also effective for the anterior maxillary teeth and the external anterior nose.

While an infraorbital block is actually a regional block for the upper (maxillary) incisors, the lip, and the side of the nose (Fig. 25-8), the procedure is a simple extension of a supraperiosteal infiltration. It often has to be performed bilaterally, especially for lacerations involving the middle third of the upper lip.40 The needle, inserted over the upper canine tooth, needs only to advance about 2 cm so that the needle tip is over the most prominent part of the cheek (malar eminence) (Fig. 25-9). Experience shows that injecting 2 to 3 cc of 2% lidocaine with or without epinephrine works nearly 100% of the time.

Gingival Mucosa

To close a laceration at the juncture of the upper lip and gingiva above the upper incisors, pass a 4-0 or 5-0 absorbable suture through one piece of the mucosa of the avulsed lip, completely around the adjacent tooth to the inside of the mouth and then out. When it is on the other side of the tooth, pass it through the avulsed tissue flap again and tie it. Repeat this process at the level of each tooth that abuts the laceration. Remove these sutures, even if absorbable, in 1 week. If the teeth are so tight that the sutures cannot be passed between them, insert them using a flossing action.41

Mandible

Mandibular Dislocations

Always attempt to reduce temporomandibular joint (TMJ) dislocations using standard methods and local or general anesthetics. In austere situations, patients may not present for some time after the dislocation occurs. Mandibular dislocations that have been out for more than 48 hours may be difficult to reduce. In difficult cases, try one of the following methods.

In either difficult cases or when no anesthetic is available, a TMJ dislocation can be gradually reduced by first placing as many tongue depressors as possible, stacked one on top of the other, into the existing space on the side with the most prominent dislocation. Then insert new tongue depressors, one at a time, into the stack. The TMJ spasm should gradually relax enough for the joint to relocate.42 If that doesn't work, try placing splints on the upper and lower teeth (see Chapter 24, Dental: Fillings, Extractions, and Trauma for splinting techniques.)

Mandibular Fractures

The first screen for a mandible fracture is to ask the patient if their teeth or, even better, their dentures fit like they used to. The absence of malocclusion virtually rules out a mandible fracture. A remarkably accurate test (96% sensitive, 65% specific) for mandibular fractures is to put a tongue blade between a patient's teeth (or have them do it) and ask them to bite down on it, bend it, and try to break it. People with normal mandibles are able to do it. Mandible fractures can be treated with soft diets and splints, as described in Chapter 24, Dental: Fillings, Extractions, and Trauma.