Grand Rounds

Dr. Benito Pacho

Dr. Ellison Alcala
Dr. Jose Lynetto Matela
Dr. Blaize Marc Baldebrin
GENERAL DATA
• N.B.
• 12 years old
• Male
• Child
• Filipino
• Roman Catholic
• Bayawan, Negros Oriental
Chief Complaint
• Extrusion of Kirschner wire
 History of Present Illness
• 13 months prior to admission:
• Patient was admitted at this institution:
• GSW, POEn, Menton; POEx, Submental area with Multiple Metallic Foreign body in situ,
submental area; submandibular area, bilateral; anterior neck midline; anterolateral
neck left
• Fracture, Mandible, Open, Comminuted, Body, Right to Body, Left secondary to Gunshot
Injury
• Avulsed wound, 6x4cm, menton to submental area secondary to Gunshot Injury
• Wound debridement, Partial removal of multiple metallic foreign body, application of
Kirschner Wire, and Repair/GA was done

• Length of hospital stay: 27 days

• Patient was discharged improved
 History of Present Illness
• 9 months PTA
• A portion of the Kirschner wire was noted to have extruded at the menton
area
• Follow up at VSMMC ENT-OPD was done and patient was given unrecalled
antibiotics
• Patient was also advised of possible removal of the Kirschner wire

• Interim
• Progressive extrusion of Kirschner wire, associated with serous discharge
from postoperative site.
• No follow up consults were done and condition was tolerated
 History of Present Illness
2 weeks PTA
• Yellowish discharge was noted to be draining from the postoperative site
prompting to seek consult
• Patient was then advised admission
 Past Medical History
• September 2017 – VSMMC
• GSW, POEn, Menton; POEx, Submental area with Multiple Metallic Foreign body in situ,
submental area; submandibular area, bilateral; anterior neck midline; anterolateral neck
left
• Fracture, Mandible, Open, Comminuted, Body, Right to Body, Left secondary to Gunshot
Injury
• Avulsed wound, 6x4cm, menton to submental area secondary to Gunshot Injury
• Wound debridement, Partial removal of multiple metallic foreign body, application of
Kirschner Wire, and Repair/GA was done
• Non asthmatic
• No food and drug allergies
 Family History
(-) Hypertension
(-) Diabetes
(-) Malignancy
(-) Asthma
 Personal and Social History
• Birth rank 4/4
• Patient is a grade 3 pupil, but has stopped going to school since the time of injury
• Non smoker
• Non alcoholic beverage drinker
Keloid scar with 4cm extruded Kirschner wire at the menton area
• Patient was admitted and scheduled for Dental Arch Bar placement, Removal
of Multiple Slugs, Kirschner wire removal under GA
• Daily wound dressing
• Labs:
• CBC
• Urinalysis
• Clotting Time
• Bleeding time
• Protime
• Serum electrolytes
• Skull Xray APL
• Facial CT Scan with 3D Recon
Course in the Ward
• Postop Day 1
• Surgical site dry, no bleeding, sutures intact, no dehiscence
• Soft cold diet
• Cold compress
• Strict Oral care
• Ampicillin + Sulbactam 750mg IV
• Tranexamic Acid 500mg IVTT
• Dexamethasone 4mg IVTT
• BNP ointment
• Chlorhexidine oral gargle
Course in the Ward
• Postop Day 2
• Surgical site dry, no bleeding, sutures intact, no dehiscence
• Continue soft cold diet
• Strict Oral care
• Ampicillin + Sulbactam 750mg IV
• Tranexamic Acid 500mg IVTT
• Dexamethasone 4mg IVTT
• BNP ointment
• Chlorhexidine oral gargle
 Physical Examination
• General: awake, coherent, ambulatory, not in cardiorespiratory
distress

• Vital signs: T- 36.7 P- 88 bpm R- 18cpm

• Skin: fair, no jaundice, warm, good mobility and turgor

• Eyes: anicteric sclerae, pink palpebral conjunctivae, (-) discharge

 Ear Examination
• Symmetrical
• No deformities
• (-) tug test
• (-) tragal tenderness
• EAC:
• Patent
• (-) erythema
• (-) swelling
• (-) discharge

A.D A.S.
 Otoscopic Examination
External auditory canal
(-) non erythematous
(-) lesions
(-) cerumen

Tympanic membrane
Intact
(+) cone of light
 Otoscopic Examination
External auditory canal
(-) lesions
(-) cerumen

Tympanic membrane
intact
(+) cone of light
 Anterior Rhinoscopy
Right:
• (+) Vibrissae, pinkish
mucosa, non
erythematous turbinate,
no masses.
Left:
• (+) Vibrissae, pinkish
mucosa, non
erythematous turbinate,
no masses.
Posterior Rhinoscopy
Oral cavity
• Lips moist, no lesions
• Loss of dentition from tooth
number 21 to 28
• Dental arch bar in place
anchored on 2nd premolar
and 1st molar bilaterally
• (+) sialorrhea
Oral cavity
• Sutures in place at left
hemi-mandible, no
dehiscence, no bleeding
• Able to close
mouth fully
• (-)malocclusion
 Indirect laryngoscopy
• No mass
• No lesion
• Fully mobile vocal cords
 Neck Examination

• No tracheal deviation
• 22cm surgical wound extending from right mastoid tip, along the inferior border of the mandible, to
the left mastoid tip
• Sutures intact, no wound dehiscence, no hematoma formation
• Penrose drain, patent at the left aspect of surgical wound
• No palpable lymphadenopathy
• No distended neck veins
 Physical Examination

• Chest and Lungs: equal chest expansion, no retractions, clear breath

sounds
• Cardiovascular: adynamic precordium, distinct heart sounds, no
murmurs
• Abdomen: flat, no visible pulsations, normoactive bowel sounds,
nontender, no rigidity, no organomegaly
• Extremities: no gross deformities, full peripheral pulses, CRT < 2
seconds
Diagnosis
• GSW, POEn, Menton; POEx, Submental area with Multiple Metallic
Foreign body in situ, submental area; submandibular area, bilateral;
anterior neck midline; anterolateral neck left
• Fracture, Mandible, Open, Comminuted, Body, Right to Body, Left
secondary to Gunshot Injury
• Avulsed wound, 6x4cm, menton to submental area secondary to
Gunshot Injury
• S/P Wound debridement, Partial removal of multiple metallic foreign
body, application of Kirschner Wire, and Repair/GA (Sept 2017 –
VSMMC)
• Infected Steinmann Pin with Extrusion and multiple metallic foreign
body in situ, submental area; submandibular area, left, anterior neck
midline; anterolateral neck, left, S/P Debridement, removal of
Kirschner Wire and Partial Removal of multiple metallic foreign
body/GA
Case Discussion
The Mandible
• The mandible is the strongest facial bone
• It is a U-shaped bone with a horizontal portion, called the body, that
carries an alveolar process with teeth and two vertical portions, or
rami, that articulate through the temporomandibular joints (TMJs)
with the skull bilaterally
• Most mandible defects are caused by resection of neoplasms, and
most of these are malignant
• Effective reconstruction of the oral cavity soft tissue components of
the defect is critical for functional restoration, especially to preserve
mobility, position, and shape of the tongue, which is probably the
most critical factor for functional rehabilitation.
Classification of defects
Goals of Mandibular Reconstruction
• restore oral competency
• maintain occlusal relationships with remaining teeth
• allow for prosthetic dental restoration
• restore bone continuity
• restore facial symmetry and contour to the lower third of the face
Background and History
• Prior to the development of advances in surgical techniques and
improvements in hardware, reconstructive options were limited and
had disappointing results
• Vascular pedicled bone grafts
• Avascular bone grafts
• Hardware (trays, prostheses, and Kirschner wires)
Current Methods
• a reconstruction plate alone
• A reconstruction plate combined with an osseous free tissue transfer
• A reconstruction plate combined with a soft tissue flap
end