PANCE Blueprint EENT (7%)

Oropharyngeal trauma

Patient will present as → a 20-year-old presents 30 minutes after being struck by a hockey puck in the mouth. On physical examination, a central incisor is missing from its socket. The patient has the tooth wrapped in tissue paper and the root appears intact

What is the treatment of choice for an avulsed permanent tooth?
The patient should be transported to the dentist for reinsertion of the avulsed tooth and it should be placed back in the socket ideally within 15 minutes and up to one hour
What about an avulsed primary tooth?
Avulsed primary teeth should not be reimplanted because of the potential for injury to the developing tooth bud

An avulsed tooth is a medical emergency and should be replaced immediately

  • The likelihood of survival of the tooth depends on the length of time that the tooth is out of the socket and the degree to which the periodontal ligament is damaged

Luxation injuries -  involve the supporting structures of the teeth, including the periodontal ligament and alveolar bone.

  • Concussion – The tooth is neither loose nor displaced; it may be tender with the pressure of biting because of inflammation of the periodontal ligament
  • Subluxation – The tooth is loose, but not displaced from its socket; the periodontal ligament fibers are damaged and inflamed
  • Intrusion – The tooth is driven into the socket, compressing the periodontal ligament and fracturing the alveolar socket
  • Extrusion – The tooth is centrally dislocated from its socket; the periodontal ligament is lacerated and inflamed
  • Lateral luxation – The tooth is displaced anteriorly, posteriorly, or laterally; the periodontal ligament is lacerated, and the supporting bone is fractured
  • Avulsion – The tooth is completely displaced from the alveolar ridge; the periodontal ligament is severed, and fracture of the alveolus may occur

Fractures — Trauma to the teeth may cause fractures of the teeth and/or damage to the supporting alveolar bone and periodontium. Fractures of the crown are classified as follows:

  • Infraction – Infracted teeth are intact but display surface cracks on the enamel, which are best appreciated by shining a bright light onto the crown of the tooth.
  • Uncomplicated crown fracture – Uncomplicated crown fractures consist of two types:
    • Enamel only  – The affected tooth is chipped. Pain is typically absent but may be elicited with manipulation.
    • Enamel and dentin – The chipped tooth has exposed dentin. The tooth is sensitive to touch and temperature.
  • Complicated crown fracture  – Complicated crown fractures have associated exposure of the pulp. These injuries have an increased risk of infection.
  • Root fracture – Fractures of the root may or may not also involve the crown (crown-root fracture). If the crown is not involved, a root fracture is suggested by mobility of the crown. Dental radiographs are necessary to confirm a root fracture. Root fractures may be horizontal, vertical, or oblique.
  • Alveolar fracture – Fracture of the alveolus causes dislocation of multiple teeth that move together with palpation.

Tooth fractures may involve enamel, dentin, or pulp and may occur in the crown or the root.

Radiographs

  • Children who have dental pain, fractures, luxation, discoloration, or abscess should have dental radiographs taken to assess the severity of displacement or the occurrence of a root fracture, bony fracture, or permanent tooth bud displacement

Avulsed teeth

  • Avulsed permanent teeth should be reimplanted immediately by the first capable person (eg, the injured child, a parent, teacher, coach, or primary care provider)
  • Remove debris by gentle rinsing with saline or tap water; do not attempt to sterilize or scrub the tooth
  • The tooth should be placed back in the socket ideally within 15 minutes and up to one hour (or longer if stored in cold milk)
  • Avulsed primary teeth should not be reimplanted because of the potential for injury to the developing tooth bud
Reimplantation procedure and storage solutions

The reimplantation procedure is as follows:

  • Handle the tooth carefully by the crown to prevent damage to the periodontal ligament
  • Remove debris by gentle rinsing with saline or tap water; do not attempt to sterilize or scrub the tooth
  • Manually reimplant the tooth in the socket
  • Keep the tooth in place by having the child hold it or bite on a gauze pad or clean towel
  • Refer the child to a dentist with pediatric expertise as soon as possible

Storage solutions

  • The vitality of periodontal ligament cells may be preserved by storing the tooth in culture media (Viaspan or Hank’s Balanced Salt Solution)
    • HBSS may be purchased in an avulsed tooth preservation system called “Save-A-Tooth”
    • The use of such a system, even for several hours, increases the likelihood of survival of the periodontal ligament
  • Cold milk is the best alternative storage medium for avulsed teeth if cell culture media are not available.
    • The avulsed tooth should be placed in a container of milk that is packed in ice, which maintains the cold temperature without diluting the milk and decreasing its osmolality.
  • Saliva is an alternative if milk or cell culture media are not available immediately. The tooth should be placed into a container of the child’s saliva. Holding the tooth in the child’s mouth is not advised because it can be further traumatized, swallowed, or aspirated
  • Tap water should not be used because its low osmolality will cause the cells to rupture within minutes

Dental management of injuries to primary and permanent teeth

Description Primary dentition Permanent dentition
Concussion/subluxation Observe, soft foods for 1 week, dental radiograph to rule out root fracture Observe, soft foods for 1 week, dental radiograph to rule out root fracture
Luxation Reposition tooth or extract, do not splint Dental radiograph, reposition tooth, splint for 4 weeks
Extrusion Reposition tooth or extract, do not splint Dental radiograph, reposition tooth, splint for 2 weeks
Intrusion Dental radiograph, observe and allow to reerupt, extract if alveolar plate is compromised Dental radiograph, observe and allow to reerupt, surgical or orthodontic repositioning, root canal treatment
Uncomplicated crown fracture Restore tooth, smooth sharp edges, dental radiograph to rule out root fracture Restore tooth, smooth sharp edges, radiograph to rule out root fracture
Complicated crown fracture Dental radiograph, pulp treatment, restore or extract tooth, observe for infection Dental radiograph, pulp treatment, restore tooth, observe for infection, may require root canal treatment
Root fracture Dental radiograph, extract if root fracture is in middle or cervical third of root Dental radiograph, splint, may require root canal treatment; if in cervical third, may need to extract
Avulsion Do not replant, dental radiograph to rule out intrusion if tooth is not located Do not handle the root, replant within 30 min or place in recommended transport medium (balanced salt solution, cold milk); dental radiograph, replant and splint as soon as possible; systemic antibiotics, soft diet, chlorhexidine, close follow-up

Question 1
A 16-year-old women's lacrosse player is struck in the mouth with a ball. Several of her front teeth are knocked out of the socket. An emergent dentist appointment is made. What additional steps in initial management are recommended?
A
Rinse the teeth in saline and place them in ice
Hint:
See C for explanation
B
Scrub the roots with saline and reimplant them back in the sockets
Hint:
See C for explanation
C
Rinse the teeth in saline and place them in milk
D
Scrub the teeth with a brush and place them on ice
Hint:
See C for explanation
E
Scrub the teeth with a brush and place them in milk
Hint:
See C for explanation
Question 1 Explanation: 
Tooth avulsion is a medical emergency. Survival of the tooth partially depends on the length of time that the tooth is out of the socket. Water or saline can be used to gently rinse off debris, but the teeth should not be brushed as this may damage the root. During transport, the tooth must be kept moist. An avulsed tooth can be transported in whole milk, saliva, sterile saline solution, or commercially available kits with physiologic buffer solutions.
Question 2
A 42-year-old intoxicated man is brought to the emergency department by his friends after a bar fight. He complains of mouth pain and difficulty swallowing. Physical examination reveals swelling and dried blood inside the mouth, with lacerations extending from the right soft palate to the posterior pharynx.Besides overt bleeding, which of the following is the most immediate concern during the initial assessment and stabilization of this patient?
A
Risk of an abscess of the parapharyngeal space
Hint:
While oropharyngeal infections (due to breaks in mucosa) can spread to deeper structures, it usually wouldn't manifest immediately or present as acutely as airway issues.
B
Possibility of tooth fragment aspiration
Hint:
Loose teeth/fragments are indeed a concern but generally less urgent than ensuring a patent airway.
C
Impaired airway protection
D
Development of acute otitis media
Hint:
While infections/complications can develop later, immediate focus centers on managing airway and life-threatening bleeding.
E
Transmission of bloodborne pathogens
Hint:
Important as universal precautions for healthcare teams and determining a patient's exposure risk, but a patient's urgent oxygenation/ventilation needs supersede such considerations initially.
Question 2 Explanation: 
Airway evaluation and protection are paramount in significant facial/oral trauma. Blood, secretions, and swelling associated with oropharyngeal injuries present a risk for airway compromise due to aspiration and difficulty in managing it.
Question 3
A 16-year-old boy fell onto a wooden pencil point first while running. It pierced his soft palate near the uvula. The mother promptly removed the pencil, and the bleeding stopped spontaneously. Other than some mild pain, the patient has no specific complaints. Following a thorough physical exam to rule out active bleeding or structural complications, the next most appropriate step in management is:
A
Tetanus prophylaxis and antibiotic prescription
B
Oral rinse with salt water
Hint:
Maintaining good oral hygiene can certainly assist, but antibiotic and tetanus protection take priority over it.
C
Plain film X-rays of the head and neck
Hint:
X-rays aren't indicated here, primarily unless concern for broken tooth/foreign body fragments exist that weren't immediately identifiable.
D
CT scan of the head and neck
Hint:
Imaging might be used later if complications arise, but initial stabilization/infection control outweigh routine imaging needs.
E
Urgent ENT referral
Hint:
If exam revealed severe injuries, lacerations requiring repairs, or inability to control bleeding, ENT would be appropriate but doesn't supersede infection/tetanus management for a basic penetration scenario presented here.
Question 3 Explanation: 
Oropharyngeal penetrating trauma like this carries a high risk of infection given the bacterial colonization within the mouth. Antibiotic prophylaxis and careful follow-up (given wound location) are essential components of managing such injuries.
Question 4
A 35-year-old man was hit in the jaw during an altercation. He initially was seen at an urgent care center, where he was diagnosed with a simple jaw contusion and sent home. Two days later, he presents to the emergency department with increasing pain, swelling of the tongue, and difficulty speaking and swallowing. Which of the following complications likely explains this patient's presentation?
A
Ludwig's Angina
B
Retropharyngeal Abscess
Hint:
Retropharyngeal abscess, while serious, presents more commonly with fever, neck pain, and torticollis (abnormal head posture). While it should be considered, the tongue swelling and rapid progression here support Ludwig’s.
C
Mandibular Fracture
Hint:
Fractures cause immediate pain and often malocclusion (teeth displacement). This patient shows delayed progression and a focus on oral cavity findings.
D
Temporomandibular Joint (TMJ) Dislocation
Hint:
TMJ dysfunction can be painful, but lack of trismus (inability to open mouth) and the focus on floor of mouth involvement point toward another process.
E
Airway Foreign Body
Hint:
If an initial aspiration took place during the trauma, acute presentation would be expected, not 2 days later.
Question 4 Explanation: 
Ludwig's angina is a rapidly progressing cellulitis involving the sublingual and submandibular spaces. It usually arises from dental infections or oral trauma, resulting in floor of mouth elevation, tongue swelling, and potential airway compromise. This timeline and worsening symptoms raise strong suspicion for the condition.
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References: Merck Manual · UpToDate

Parotitis (ReelDx) (Prev Lesson)
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