Epistaxis

Bleeding from the nose.

Material
Wick of vaseline gauze

Fine dissecting forceps

Urinary catheter (sound) with n° 12 balloon

Technique

Figures 69, 70

First, introduce the vaseline gauze, not more than 2 cm, as far into the nose as possible, with dissecting forceps, and try to fold the gauze in pleats from behind forwards.
Pack the bleeding nasal cavity and hold it in place with an adhesive tape.

If bleeding continues despite the pack, posterior bleeding is occuring: introduce a Foley catheter (n°12) as far as the oropharynx, inflate the balloon with 10 to 15 ml of air (Figure 69), and pull back until it abuts on the posterior pharyngeal wall. Then, introduce the vaseline gauze as before. Maintain the catheter and the gauze mesh with an adhesive tape (Figure 70).

If bleeding continues, it is coming from the other nostril.

The pack must remain for at least 3 days.

FIGURE

Ear drainage

Incision of the tympanic membrane.

Indication

Acute otitis with fever, intense pain, and an inflamed distended non-perforated tympanic membrane.

Material

Drainage needle

Otoscope with a light or a speculum with a head-light.

Technique

Figures 71, 72

While viewing the membrane, and without anesthesia, make a radial incision in the posterior-inferior quadrant with a stylet or a special lancet.

Aspirate the pus with a soft catheter, gently removing the serous fluid and pack gently with cotton.

Antibiotic therapy

Systemic:

Ampicillin if less then 5 years of age: 100 mg/kg/day PO x 3 -10 days

Phenoxymethyl penicillin / Penicillin V older than 5 years of age:

Adult : 3 x 2 tablets/day (tablets of 400.000 U)
Child : 50 to 100.000 U/kg/day x 5 to 10 days, or procaine penicillin or PPF

FIGURE

100.000 U/kg/day x 3 days, followed by penicillin V during 4 to 6 days.

Erythromycine for those allergic to betalactamines:

Adult : 1 g in 3 divided doses/day x 10 days
Child : 50 mg/kg/day in 3 divided doses/day x 10 days

Dental extraction

Always remember that a tooth is not "pulled" but gently extracted ! It is a surgical procedure and therefore strict surgical etiquette must be followed to prevent serious complications (fractures of the bone or teeth, hemorrhage, infection).

Pre-operative examination

General history and examination of the patient

Search for potential contra indications to anesthesia.

Examination of the mouth

The teeth are numerous, but each is an important individual structure, and each must be preserved if possible. The decision to extract a tooth must be taken for immediate therapeutic or curative reasons.

Teeth possibly requiring extraction:

· acute (toothache) or chronic inflammation of the pulp,
· necrosis of the pulp,
· infection (abcess, cellulitis),
· teeth with dead roots.

FIGURE

Premedication

Required for each general anesthetic.

In cases with associated cellulitis: prescribe an antibiotic for 6 days and an antiinflammatory (ampicillin: 2 g/day in 3 doses and indomethacin: 75 mg in 3 doses/day for an adult). Do not extract the tooth until the following day, this will allow the inflammation to subside making the anesthetic more efficaceous.

Operation technique

Preparation of the patient

Position of the patient:

- Sitting, for lower teeth.
- Lying, for upper teeth.
- Always place the head on a firm surface to prevent movement.

Surgical drapes: A clean drape around the neck is recommended.

Position of the operator: - Facing the patient for the upper teeth and for teeth on the lower left side. - Behind the patient's head for teeth on the lower right side.

Anesthesia

Material

A cartridge syringe (carpule) with plunger, to avoid intravascular injection.

Sterilized needles for cartridges type S. Neved: - short n°17/23 for local injection - long n°17/42 for local regional injection

Cartridge without vasoconstrictor - scandicaine 3 % (no allergic reactions) - lidocaine 2 % (more toxic than scandicaine)

Maxilla

Conduct a local anaesthetic opposite the tooth of interest in the following order:

Anesthetise the palatine mucous membrane, 1 cm from the gingival margin. (Gently inject without making the membrane blanche, 1/4 of the cartridge will suffice.)

Dental nerve block: inject into the vestibular sulcus and anesthetise along the nerve root as far as the bone, then inject 3/4 of the cartridge after aspirating for blood with the syringe at 30° to the axis of the tooth.

After several minutes, ensure good anesthesia: no sensation in the mucous membrane and the patient describes a "dead" feeling on percussion of the tooth.

FIGURE

Mandible

It is necessary to know the innervation of the inferior dental nerve:

A local/regional anesthetic or nerve block of the inferior dental nerve at the level of its entrance into the dental canal at the spine of Spix, in sight of the internal branch which climbs above the mandible.

Classical technique: with the patient's mouth wide open, the edge of the left index finger is placed on the lower molars, with the tip of the finger palpating the border of the ascending branch of the nerve. The needle is introduced 10 to 15 mm behind the point of the index finger, then advanced 10 to 15 mm along the nerve, the body of the syringe situated at the level of the canines or the opposite pre-molars. After aspirating, slowly inject 3/4 of the cartridge into the entrance of the dental canal.

Variation: with the patient's mouth wide open, use the left thumb to palpate the junction of the ascending anterior branch and the horizontal branch of the dental nerve. The index finger is placed on the external auditory canal and the other finger on the posterior angle of the mandible. These 3 fingers delineate the summit of the triangle. The body of the syringe rests on the canines or opposite pre-molars, advance the needle along the nerve root in the direction of the bisection of the angle of the triangle, which represents the geometric line of the entrance of the dental canal. After aspirating, inject 3/4 of the cartridge.
In children, the entrance of the dental canal is lower, the body of the syringe will be in contact with the canines or the opposite upper pre-molars.

To extract a molar, always anesthetise the buccal nerve. Advance the needle obliquely and behind into the entrance of the vestibular sulcus, opposite the second or third molar, until bone is reached, and inject 1/4 of the cartridge.

In cases with persistent sensation of the lingual innervation of the gum, anesthetise the lingual nerve, as for palatine anesthesia.

For movable and decaying teeth, limit local anesthesia (vestibular and lingular) as for the maxilla. It can be completed with an intraligamentary anesthetic. Advance a short needle vertically to the vestibular side, between the root of the tooth and the alveolar bone, then slowly inject 1/5 of the cartridge.

FIGURE

FIGURE

Extraction

Consists of:

2 steps: one dental, the other alveolar
3 movements to remove the tooth:

- syndesmotomy
- elevation or luxation
- avulsion

Dental step

Syndesmotomy Consists of separating the attached epithelium and the alveolar-dental ligaments by inserting the point of the syndesmotome hook between the tooth and the gum, and then the alveolar bone. The syndesmotome should be held like a pen and supported on the adjoining teeth to prevent slippage.

FIGURE

Elevation or dislocation of the tooth

The elevators are levers which act to mobilise and dislocate the tooth from its socket. This is a critical part of the extraction. The teeth should not be forced or juggled because this can produce a fracture of the tooth or bone. A single elevation procedure, properly followed, will produce an effective extraction in 70 to 90 percent of extractions and is a unique and practical way of extracting a tooth with its roots.

- Instruments:

Use:

· a bayonnet elevator for the upper teeth.
· a right and left elevator for the lower teeth and the upper molars.

FIGURE

- Technique:

With the assistance of a gauze compress, the fingers of the left hand surround the tooth for extraction, serving as a guard in case of slippage of the instrument.

The surface of the thin plate should always be in contact with the tooth, the elevators are inserted in the alveolar-dental space by gentle lateral movements. Then the tooth is mobilised by rotation and eventually (especially for the molars) by see-saw movements towards the vestibule (exterior) without pushing on the adjoining tooth.

The external bone (vestibular) at the level of the superior maxilla is particularly fragile, especially at the level of the anterior teeth. Work on the palatine side and opposite the tooth.

At the level of the mandible it is the internal bone (lingual) which is particularly fragile and contains the lingual nerve. Use the elevators on the vestibular side and on the side of the teeth (proximal side)

A characteristic sign of good mobilisation is the "suction" noise which occurs when air enters between the tooth and the tooth socket.

FIGURE

Avulsion or removal with dental forceps If the steps have been followed, removal is often a simple "plucking out" of the tooth. The only exception is with the molars which often have wide roots limiting elevation and dislocation.

- Instruments: dental forceps

FIGURE

FIGURE

- Technique:

The index finger should be placed between the two handles of the dental forceps to abut in case of slippage and sudden closure of the prongs of the instrument. The movement is one of traction in the axial plane of the tooth.

In the case of molars in which simple luxation will not be possible, it is necessary to "work" at the tooth with the appropriate davier before trying to remove it. Use see-saw and rotatory movements, without forcing the tooth in order to avoid fracturing the roots or the bone.

The extracted tooth should be examined to ensure that the roots have not been fractured.

Alveolar step

Once a tooth has been extracted, carry out a systematic review of the tooth socket.

· Examine the border of the mucus membrane: ensure that it has not been torn by the different instruments, and does not require suturing.

· Examine the alveolar bone and the tooth socket, looking for a fracture which may require ablation of a sequestrum, to avoid pain, infection and scar formation.

· Examine the base of the tooth socket and curette to remove the debris, granulation tissue, and especially a granuloma or cyst, and also to prevent the risk of hemorrhage, infection and the formation of scar tissue.

FIGURE

· Compress the borders of the socket between the thumb and index finger and ask the patient to bite hard on 1 or 2 compresses for 30 minutes to produce hemostasis and coagulation.

· Prescribe mouth washes for 24 hours to check for hemorrhages.

· Recommend a semi-liquid diet for the first day.

Complications

Hemorrhage

In most cases this is due to poor inspection and debridement of the tooth socket (leaving a granuloma or a cyst in place). after local anesthetic, clean the socket with a curette, then bite on a compress.

Alveolitis

Due to anoxia of the bone or an alveolar sequestration left in place, producing severe lancing pain 2 to 3 days after the intervention. Clean the socket, then introduce a wick with gentian violet end leave for at least 3 or 4 days. Prescribe analgesics and antibiotics in case of infection.

Infection

May exist before but usually occurs after extraction, due to an error in aseptic technique, sequestered bone, a residual nerve root or a non curetted cyst. Inspect and clean the socket under local anesthetic and prescribe an antibiotic for 6 to 8 days, with or without an anti-inflammatory (ampicillin: 2 g/day for an adult).