|Year : 2015 | Volume
| Issue : 1 | Page : 6-10
A 2-year review of maxillofacial accident and emergency cases in a Nigerian tertiary hospital
KU Omeje1, IO Amole1, OD Osunde2, AA Efunkoya1
1 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Bayero University, and Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Dental Surgery, Faculty of Medicine and Dentistry, University of Calabar, and University of Calabar Teaching Hospital, Calabar, Nigeria
|Date of Web Publication||19-Nov-2015|
Dr. O D Osunde
Department of Dental Surgery, University of Calabar Teaching Hospital, Calabar
Source of Support: None, Conflict of Interest: None
Background: The role of oral and maxillofacial surgeons in the management of maxillofacial emergencies has been well recognized. The present study aimed to review the maxillofacial emergency practice in our institution, highlighting the pattern of maxillofacial conditions requiring emergency services, the gaps in our practice and factors that will improve it.
Materials and Methods: The study was a 2-year retrospective review of patients managed at the accident and emergency (A/E) unit of our institution. Sources of clinical information were A/E register, patients' case folders and discharge summaries. These data were analyzed using Statistical Package for Social Sciences (SPSS) version 15.0 (SPSS Inc, Chicago, IL, USA).
Results: Of the 549 patients studied, male accounted for 437 (79.6%), while female accounted for 112 (20.4%) giving a gender (male: female) ratio of 3.9:1. Fifty-five (10%) patients with sole maxillofacial injuries were attended to at the A/E unit and discharged home on the same day, while 494 (90%) patients required admission and further treatment. Ages of the subjects ranged from 2 months to 86 years with a mean age of 36.4 ± 27.1 years. Road traffic accident (RTA) had the highest frequency of A/E attendance (58.3%), with mandibular fracture being the commonest (41.6%). Debridement and suturing were the most performed procedure (44.0%).
Conclusion: RTA related injuries and orofacial infections are common conditions, which frequently present at the A/E unit. Prompt access to quality maxillofacial care may help to reduce the attendant morbidity arising from the conditions.
Keywords: Accident and emergency, maxillofacial, tertiary hospital
|How to cite this article:|
Omeje K U, Amole I O, Osunde O D, Efunkoya A A. A 2-year review of maxillofacial accident and emergency cases in a Nigerian tertiary hospital. Afr J Trauma 2015;4:6-10
|How to cite this URL:|
Omeje K U, Amole I O, Osunde O D, Efunkoya A A. A 2-year review of maxillofacial accident and emergency cases in a Nigerian tertiary hospital. Afr J Trauma [serial online] 2015 [cited 2021 Apr 21];4:6-10. Available from: https://www.afrjtrauma.com/text.asp?2015/4/1/6/169815
| Introduction|| |
The role of oral and maxillofacial surgery in the management of maxillofacial emergencies has been well recognized. The specialty is known to play a leading role in facial trauma care. Maxillofacial injuries constitute an important component of multiple injured patients and often present as most obvious injuries due to prominence of the maxillofacial region. Emergency response is a critical component in the management of trauma patients to stabilize the patient and initiate early treatment, which may improve outcome. It is known that even "minor" facial trauma or its management can impact on the ability of patients to integrate back into the society, affecting both personal relationships and employment opportunities. Also, delayed response may affect the healing pattern of orofacial tissues increasing posttreatment morbidity and poor quality of life outcome.
The proximity of the maxillofacial structures to the airway and the ease with which the airway may be involved in maxillofacial pathologies often necessitates a need for prompt response to save life in maxillofacial conditions in which the airway is at risk. This prompt response is usually provided in accident and emergency (A/E) settings.
Aminu Kano Teaching Hospital (AKTH) Kano is a tertiary health care center in the North-West geopolitical zone of Nigeria. It serves as a major referral center for the seven states within the sub region including Kano, the most populated state in Nigeria. The pattern of emergency response practiced in AKTH involves an initial patient review and stabilization by the triage officer, followed by a review by the maxillofacial team on call, when maxillofacial patients are involved.
Clinical review is a systematic, critical analysis of the quality of surgical care provided with the aim of improving it, providing continuous education for surgeons and guiding appropriate use of health resources. To the authors knowledge, there is no published review of maxillofacial A/E cases in AKTH and the Northern part of Nigeria at large, despite the role clinical review plays in enhancing the quality of care.
The present study aimed to review the emergency maxillofacial practice in AKTH, highlighting the pattern of maxillofacial conditions requiring emergency services. Knowledge gain from this review may help to identify the gaps in maxillofacial emergency practise in our environment and to highlight factors responsible and ways to improve it.
| Materials and Methods|| |
This study was a 2-year retrospective review of patients managed in the A/E unit of AKTH Kano from January 2012 to December 2013. Sources of clinical information were A/E register, patients' case folders and discharge summaries. The information collated included patient demographics, indication for A/E attendance, treatment rendered, and duration of admission in the A/E department.
The indication for the presentation was grouped into road traffic accidents (RTAs), falls, assault, domestic accidents, industrial accidents, and gunshot/bomb blast. Others were orofacial infection, temporomandibular joint (TMJ) dislocation, acute exacerbation of malignant lesions, postextraction bleedings, allergic reactions, and others. Facial fractures seen in the patients within the period under review were classified into upper, middle and lower thirds facial fractures according to Banks and Brown. All the patients that presented to the A/E unit of the hospital with maxillofacial conditions during the period of the review were included in the study; however subjects that were confirmed dead on arrival were excluded, also excluded were patients whose medical records were missing or incomplete.
These data were analyzed using Statistical Package for Social Sciences (SPSS) version 15.0 (SPSS Inc, Chicago, IL, USA). Absolute numbers and simple percentages were used to describe categorical variables.While quantitative variables were presented as mean and standard deviation, qualitative variables were presented as frequencies and percentages. No tests of significance was performed.
| Results|| |
During the period of the review, a total of 571 patients with maxillofacial conditions were seen at the A/E unit of AKTH Kano, 5 patients were certified dead on arrival, 13 patients had incomplete records, while 4 patients had missing case files/data and were excluded from the study thus only 549 patients were studied. Of the studied patients, male subjects accounted for 437 (79.6%) patients, while female subjects accounted for 112 (20.4%) giving a gender (male: female) ratio of 3.9:1. Fifty-five (10%) patients with sole maxillofacial injuries were attended to at the A/E unit and discharged home on the same day (this excludes patients that were inapropriately received in the A/E), while 494 (90%) patients required admission and further treatment. Patients that were attended to and discharged home immediately include 10 patients who were managed conservatively with medication, 12 patients who had reduction of TMJ dislocation, 2 patients managed for postextraction bleeding and 31 patients who had debridement and suturing under local anesthesia. The ages of the patients ranged from 2 months to 86 years with a mean age of 36.4 ± 27.1 years.
The distribution of patient by indication for A/E attendance is presented in [Table 1]. Patients whose injuries were RTA related were observed to have soft tissue injuries alone (34 cases), hard tissue injuries alone (41 cases) or a combination of both (245 cases). Of the patients that had isolated soft tissue injuries, laceration accounted for 23 patients while avulsion accounted for 11 patients. Of patients with isolated hard tissue injuries, bone fracture accounted for 34 patients while teeth fracture/avulsion accounted for 7 patients. Many of the facial fractures occurred as various combinations. Isolated fractures of the upper and lower third accounted for 4 and 100 patients respectively while combinations of the middle and lower thirds and upper, middle, and lower thirds accounted for 62 and 46 patients, respectively.
|Table 1: Distribution of patient by indication for accident and emergency attendance (n=549)|
Click here to view
The pattern of fractures seen during the period of study is shown in [Table 2]. There was a bi-modal age range representation in patients managed for falls (2 months–9 years and 70–86 years). The chin was the commonest point of impact, and the condylar fracture was the commonest fracture observed in patients that presented following a fall. Patients that attended the A/E for other reasons include 9 cases of cancrum oris, 7 cases of TMJ ankylosis, and 6 cases of swallowed dental prosthesis.
|Table 2: Pattern of maxillofacial fractures seen at the accident and emergency unit (n=281)|
Click here to view
The orofacial infective conditions were fascial space cellulitis, Ludwigs angina, mumps, and osteomyelitis of the jaws while the allergic reactions included acute erythema multiforme, and angiooedema. The duration of admission at the A/E ranged from 1 h to 5 days with an average of 2 days. The treatments carried out on the patients during the period under review are presented in [Table 3]. Debridement/suturing (n = 314; 44%) was the most frequent treatment administered. This was followed by reduction and immobilization (n = 281; 39.4%). Incision and drainage was performed in 92 (12.9%) cases.
|Table 3: Types of treatment carried out at the accident and emergency unit|
Click here to view
| Discussion|| |
Chung  observed that publications on clinical review in connection with emergency medicine are scarce in the medical literature; he recommended that clinical audit should be made compulsory for all healthcare professionals providing clinical care. Leicestershire primary audit group defined clinical audit as a structured process that ensures best practice by reviewing what is done, compared with what should be done.
Maxillofacial surgery cases have been documented to present frequently in emergency settings  and the spectrum of cases that have been reported in the A/E units include maxillofacial trauma (which may arise from falls, domestic accidents, industrial, and RTAs), cervicofacial infections, TMJ dislocation, acute complications of malignant lesions (usually presenting as bleeding, malnutrition and its sequale, pain or respiratory obstruction). Others may include reactionary or secondary postextraction bleeding and allergic reactions.
The number of patients seen within this period in our study was larger than 106 documented by Owotade et al. from a maxillofacial surgery unit of a similar tertiary health care center for the same duration of the survey. This difference may be related to the difference in population of the states where the hospitals are domiciled, volume of traffic, commercial activities and the paucity of maxillofacial referral centers in Northern Nigeria despite its large population.
The number of patients admitted in the A/E unit compared to the number that was discharged home within few hours of review may reveal the peculiarity of maxillofacial conditions in terms of injury severity and need for prolonged close monitoring. It may also be deduced that only a small percentage of emergency maxillofacial patients sustain a minimal injury that does not necessitate prolonged observation. The likelihood that maxillofacial injuries may be combined with injuries to the other parts of the body necessitating multidisciplinary care may also result in a prolonged admission. This tendency to often admit maxillofacial patients overnight may serve as a guide to hospital administrators in bed space allocation for maxillofacial patients in the A/E units.
RTA constitutes the commonest reason for patient presentation at the A/E units in developing nations., Reasons adduced for this include the poor condition of the roads, a penchant for used cars/tires and substandard vehicle parts. Others include poor enforcement of highway discipline and use of a motorcycle as commercial means of transportation among untrained individuals. Most of the patients that presented following RTA had initial stabilization, debridement/suturing of open wounds and subsequent transfer to the ward for definitive management of facial fractures. Only patients whose stabilization necessitated treatment of fractures had fracture treatment at the A/E. Debridement and suturing constituted the most performed procedure in our review; this may be largely related to the large number of emergency admission from RTA. These patients often present with open wounds and lacerations, which may require debridement and suturing.
The high prevalence of mandibular fracture in our A/E unit is similar to the finding of Owotade et al. and it indicates a need for triage officers who are usually only medically trained to be well equipped with the resuscitative challenges in mandibular fracture patients especially in cases of bilateral mandibular body fracture (in an unconscious patient) in which the airway may be at risk. In cases in which resources, manpower and protocol permits immediate complete treatment for facial fractures in the A/E could have significantly reduced the duration of hospital stay, hospital visits, and cost and probably improve outcome.
There was a higher population of male patients in our review compared to female patients. This may be related to the cultural and religious beliefs of the people in the region of this study. They are predominantly Muslims and practice Islamic/sharia law that usually restrict the movement of women. Thus, a number of female patients with emergencies may not readily present to the hospital. This difference in gender presentation to the hospital in this region has been previously highlighted in another Nigerian study  Therefore, more provisions should be made in hospitals in this region to accommodate male patients with maxillofacial emergencies.
There was a bi-modal age distribution in patients who presented following a fall. The younger age group sustained falls while playing at home or school while the patients in the older age group sustained falls as a result of limitations in other systemic functions and following convulsions in epileptic patients. The systemic impairment in these patients includes visual, proprioceptive, impairment in blood pressure and glycemic control. The finding of condylar fracture in patients who fell with the chin has been well described in the literature. Failure of clinicians to have this high index of suspicion of condylar fracture following a fall with the chin has been implicated in the pathogenesis of TMJ ankylosis.
Presentation of patients with cancrum oris and TMJ ankylosis to the A/E unit may be inappropriate, as there may be no need for emergency intervention in these patients. Acceptance of these patients by the triage officer may reflect the uncommon nature of these conditions in medical literature and training. This may further justify the need for triage officers to undergo limited maxillofacial surgery training to at least help in patients' referrals.
Patients that swallowed dental prosthesis (usually plastic dentures) often presents initially to the maxillofacial surgeon, however our experience has shown that ultimate management of such patients often reside in the domains of either the ear nose and throat surgeons or general surgeons after the prosthesis have gone beyond the oro-pharynx.
| Conclusion|| |
The result of this review has re-emphasized the role of the oral and maxillofacial surgeons in the emergency setting of health care facilities. Maxillofacial injuries resulting from RTA and orofacial infections constitute the commonest maxillofacial indication for A/E attendance in our environment. There is therefore need for regular training in basic and advanced life support and resuscitative measures for these conditions especially for triage personnel, practicing maxillofacial surgeons and trainees who occasionally may be the first contact at certain emergency situations.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Wood GD, Leeming KA. Oral and maxillofacial surgery in accident and emergency departments. J Accid Emerg Med 1995;12:270-2.
Gassner R, Tuli T, Hächl O, Rudisch A, Ulmer H. Cranio-maxillofacial trauma: A 10 year review of 9,543 cases with 21,067 injuries. J Craniomaxillofac Surg 2003;31:51-61.
Curtin L. Restoring America's wounded: Advanced Surgical Technique Research. Force Health Protection and Readiness 2000;5:4-5.
Royal Australasian College of Surgeons. Surgical audit and peer review. A guide by the Royal Australasian College of Surgeons. 3rd
ed. Melbourne: RACS; 2008. p. 5-6.
Bank P, Brown A. Fractures of the Facial Skeleton. 1st
ed. Oxford: Wright Bristol; 2001. p. 17-34.
Chung C. Clinical audit in emergency medicine. Hong Kong J Emerg Med 2003;10:181-7.
Owotade FJ, Fatusi OA, Ojo MA. Call hour maxillofacial emergencies presenting to a Nigerian teaching hospital. Afr J Oral Health 2004;1:17-24.
Ugboko VI, Odusanya SA, Fagade OO. Maxillofacial fractures in a semi-urban Nigerian teaching hospital. A review of 442 cases. Int J Oral Maxillofac Surg 1998;27:286-9.
Adeyemo WL, Ladeinde AL, Ogunlewe MO, James O. Trends and characteristics of oral and maxillofacial injuries in Nigeria: A review of the literature. Head Face Med 2005;1:7.
Agbara R, Fomete B, Obiadazie AC, Idehen K, Okeke U. Temporomandibular joint dislocation: Experiences from Zaria. J Korean Assoc Oral Maxillofac Surg 2014;40:111-6.
Zimmermann CE, Troulis MJ, Kaban LB. Pediatric facial fractures: Recent advances in prevention, diagnosis and management. Int J Oral Maxillofac Surg 2005;34:823-33.
[Table 1], [Table 2], [Table 3]