Clinician’s Handbook of Oral and Maxillofacial Surgery

Clinician’s Handbook of Oral and Maxillofacial Surgery

Clinician’s Handbook of

Oral and Maxillofacial

Surgery Second Edition

Berlin, Barcelona, Chicago, Istanbul, London, Milan, Moscow, New Delhi, Paris, Prague, São Paulo, Seoul, Singapore, Tokyo, Warsaw

Edited by

Daniel M. Laskin, dds, ms, dscProfessor and Chairman Emeritus Department of Oral and Maxillofacial

SurgerySchool of Dentistry

Division of Oral and Maxillofacial SurgeryDepartment of SurgerySchool of Medicine

Virginia Commonwealth UniversityRichmond, Virginia

Eric R. Carlson, dmd, md, edmProfessor and Kelly L. Krahwinkel ChairmanDirector of Oral and Maxillofacial Surgery

Residency ProgramDepartment of Oral and Maxillofacial

SurgeryGraduate School of Medicine University of Tennessee

Director of Oral/Head and Neck Oncologic Surgery Fellowship Program

University of Tennessee Cancer InstituteKnoxville, Tennessee

© 2019 Quintessence Publishing Co, Inc

Quintessence Publishing Co, Inc411 N Raddant RoadBatavia, IL 60510www.quintpub.com

5 4 3 2 1

All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without prior written permission of the publisher.

Editor: Marieke ZaffronDesign: Erica NeumannProduction: Kaye Clemens

Printed in the USA

Library of Congress Cataloging-in-Publication Data

Names: Laskin, Daniel M., 1924- editor. | Carlson, Eric R., editor.Title: Clinician’s handbook of oral and maxillofacial surgery / edited by Daniel M. Laskin and Eric R. Carlson.Description: Ed 2. | Hanover Park, IL : Quintessence Publishing Co Inc, [2018] | Includes bibliographical references and index.Identifiers: LCCN 2018019085 | ISBN 9780867157307 (hbk.)Subjects: | MESH: Mouth--surgery | Oral Surgical Procedures | HandbooksClassification: LCC RK529 | NLM WU 49 | DDC 617.5/22--dc23LC record available at https://lccn.loc.gov/2018019085

To my wife, Evie, whose memory continues to be my inspiration.DML

To all of my current and former residents and fellows—thank you for teaching me.ERC

ContentsPreface viiiContributors ix

1 Hospital Protocol and Procedures 1Joseph E. Cillo, Jr

2 Patient Evaluation 18Alia Koch

3 Laboratory Tests and Their Interpretation 30Edward Lahey • Jason W. Lee

4 Diagnostic Imaging 73William F. Conway • Seth T. Stalcup • Marques L. Bradshaw

5 Interpretation of the Electrocardiogram 89Robert A. Strauss

6 Management of Fluids and Electrolytes 109Nagi Demian

7 Nutrition for the Surgical Patient 131Mark J. Steinberg • Stephen MacLeod

8 Use of Blood and Blood Products 145Matthew E. Lawler • Mark A. Green • Zachary S. Peacock

9 Basic Patient Management Techniques 161Daniel M. Laskin

10 Management of the Medically Compromised Patient 176Steven M. Roser • Gary F. Bouloux

11 Management of Postoperative Medical Problems 204James Murphy • Brent Ward

12 Management of Medical Emergencies 220Robert A. Strauss

13 Diagnosis and Management of Emergencies Related to Sedation and Anesthesia 246Jeffrey D. Bennett • Kyle J. Kramer

14 Managing Complications of Dentoalveolar Surgery 272Dean M. DeLuke • James A. Giglio

15 Implantology 287Tara Aghaloo • Nadia Hassan

16 Management of Head and Neck Infections 300Thomas R. Flynn

17 Diagnosis and Management of Dentofacial Anomalies 332Stephanie Drew

18 Diagnosis and Management of Cleft Lip and Palate 352Paul S. Tiwana • Matthew Weber

19 Diagnosis and Management of Craniofacial Abnormalities 368Carolyn C. Dicus Brookes • Timothy A. Turvey

20 Differential Diagnosis and Management of TMDs and Orofacial Pain 378Daniel M. Laskin

21 Differential Diagnosis and Management of Cysts and Tumors 393David Webb • Brandon C. Clyburn

22 Diagnosis and Management of MRONJ 404Kenneth E. Fleisher • Robert S. Glickman

23 Differential Diagnosis and Management of Salivary Gland Diseases 419Thomas Schlieve

24 Differential Diagnosis and Management of Oral Mucosal Lesions 442Ellen Eisenberg • Daniel Oreadi

25 Differential Diagnosis of Intraosseous Lesions 472Ellen Eisenberg

26 Differential Diagnosis and Management of Oral Squamous Cell Carcinoma 483Jonathan T. Williams • B. J. Schlott

27 Differential Diagnosis and Management of Neck Masses 495Eric R. Carlson

28 Management of Craniomaxillofacial Trauma 510David B. Powers

29 Head and Neck Reconstruction 544Din Lam

30 Diagnosis and Management of Nerve Injuries 570John M. Gregg

31 Cosmetic Surgery 584Peter D. Waite • Michael Babston

Index 596

viii

Preface

The intent of the previous edition of this book was to provide the oral and maxillofacial sur-geon with a single, readily available, portable source to quickly find important information, especially in clinical situations that required an immediate answer. Although the amount of material included eventually made the book too large for the intended pocket transport, clinicians still found the format and content very useful. Therefore, in this new edition it was decided to disregard portability and again focus on making it a quick, comprehensive reference source.

To accomplish this objective, five new chapters have been added to the book: Implantol-ogy, Diagnosis and Management of Cleft Lip and Palate, Head and Neck Reconstruction, Differential Diagnosis and Management of Oral Squamous Cell Carcinoma, and Cosmetic Surgery. The previous chapter Diagnosis and Treatment of Dentofacial and Craniofacial Abnormalities has also been divided into separate chapters. All of the previously included chapters have been comprehensively updated, and many now have new authors, bring-ing a fresh perspective to the topics. In addition, this expanded version has allowed the inclusion of many tables, imaging examples, and clinical photographs to improve the clarity of the information. Finally, Dr Eric R. Carlson has been added as coeditor of the book, pro-viding additional expertise and another critical eye to oversee the accuracy of the content.

This book has been revised and expanded so it may serve purposes other than as a quick reference source. It can also serve as a handy compilation of relevant information for trainees in oral and maxillofacial surgery as well as a review source for the American Board of Oral and Maxillofacial Surgery examination. Familiarity with the material will not only increase the clinician’s knowledge base but make it easier to find important information in urgent situations.

The success of any multi-authored book depends on the knowledge and expertise of its contributors. We have been fortunate in making the right choices. All authors have our sincere appreciation and thanks for their effort and cooperation in helping make this book a reality.

ix

Heading

Tara Aghaloo, DDS, MD, PhD Professor and Assistant Dean for Clinical

ResearchSection of Oral and Maxillofacial Surgery School of Dentistry University of California, Los Angeles Los Angeles, California

Michael Babston, DMD, MD Private Practice Limited to Oral and

Maxillofacial SurgeryMobile, Alabama

Jeffrey D. Bennett, DMD Former Professor and Chair Department of Oral and Maxillofacial

Surgery School of Dentistry Indiana University Indianapolis, Indiana

Gary F. Bouloux, DDS, MD Professor, Residency Program Director, and

Director of Research Division of Oral and Maxillofacial Surgery Department of Surgery School of Medicine Emory University Atlanta, Georgia

Marques L. Bradshaw, MD Associate Professor of Clinical Radiology

and Radiological SciencesDepartment of RadiologyVanderbilt University Medical CenterNashville, Tennessee

Carolyn C. Dicus Brookes, MD, DMD Assistant Professor and Interim Division

Chief Division of Oral and Maxillofacial Surgery Department of Otolaryngology and

Communication SciencesMedical College of Wisconsin Milwaukee, Wisconsin

Eric R. Carlson, DMD, MD, EdM Professor and Kelly L. Krahwinkel Chairman Director of Oral and Maxillofacial Surgery

Residency Program Department of Oral and Maxillofacial

Surgery Graduate School of Medicine University of Tennessee

Director of Oral/Head and Neck Oncologic Surgery Fellowship Program

University of Tennessee Cancer Institute Knoxville, Tennessee

Joseph E. Cillo, Jr, DMD, PhD, MPH Associate Professor and Program Director Division of Oral and Maxillofacial Surgery Allegheny General Hospital Pittsburgh, Pennsylvania

Brandon C. Clyburn, DDS Oral and Maxillofacial SurgeonDepartment of Oral and Maxillofacial

SurgeryBarksdale Air Force BaseShreveport, Louisiana

William F. Conway, MD, PhDProfessor of RadiologyDepartment of RadiologyMedical University of South CarolinaCharleston, South Carolina

Dean M. DeLuke, DDS, MBA Professor and Director of Predoctoral Oral

and Maxillofacial Surgery Department of Oral and Maxillofacial

Surgery School of Dentistry

Division of Oral and Maxillofacial Surgery Department of Surgery School of Medicine

Virginia Commonwealth University Richmond, Virginia

Contributors

x

Nagi Demian, DDS, MD ProfessorDepartment of Oral and Maxillofacial

SurgeryHealth Science CenterUniversity of Texas Houston, Texas

Stephanie Drew, DMD Associate Professor Division of Oral and Maxillofacial Surgery Department of Surgery School of Medicine Emory University Atlanta, Georgia

Ellen Eisenberg, DMD Professor and Section Chair Oral and Maxillofacial PathologyDepartment of Oral Health and Diagnostic

Sciences School of Dental Medicine University of Connecticut Farmington, Connecticut

Kenneth E. Fleisher, DDS Clinical Associate Professor Department of Oral and Maxillofacial

Surgery College of Dentistry New York University

Department of Plastic SurgeryLangone Medical Center

Department of Oral and Maxillofacial Surgery

Bellevue Hospital Center New York City, New York

Thomas R. Flynn, DMD Retired Oral and Maxillofacial Surgeon Reno, Nevada

James A. Giglio, DDS, M,EdRetired Professor of Oral and Maxillofacial

Surgery Richmond, Virginia

Robert S. Glickman, DMD Professor and Chair Department of Oral and Maxillofacial

SurgeryCollege of Dentistry New York University

Department of Plastic SurgeryLangone Medical Center

Department of Oral and Maxillofacial Surgery

Bellevue Hospital Center New York City, New York

Mark A. Green, DDS, MD Resident Department of Oral and Maxillofacial

Surgery Massachusetts General Hospital Boston, Massachusetts

John M. Gregg, DDS, MS, PhD Adjunct ProfessorDepartment of Oral and Maxillofacial

Surgery School of Dentistry Virginia Commonwealth University Richmond, Virginia

Adjunct ProfessorDepartment of SurgeryVirginia Tech Carilion School of MedicineRoanoke, Virginia

Nadia Hassan, DDS, MD Private Practice Limited to Oral Surgery Laguna Niguel, California

Alia Koch, DDS, MDAssistant Professor and Program DirectorDepartment of Oral and Maxillofacial

SurgeryCollege of Dental MedicineColumbia University

Attending SurgeonDepartment of Oral and Maxillofacial

Surgery New York Presbyterian Hospital Columbia University Medical Center New York City, New York

xi

Kyle J. Kramer, DDS, MS Assistant Clinic Professor Department of Oral Surgery and Hospital

Dentistry School of Dentistry Indiana University Indianapolis, Indiana

Edward Lahey, DMD, MD Assistant Professor, Medical Director, and

Quality and Safety ChairDepartment of Oral and Maxillofacial


Din Lam, DMD, MD Private Practice Limited to Oral and

Maxillofacial Surgery Indian Trail, North Carolina

Daniel M. Laskin, DDS, MS, DSc Professor and Chairman Emeritus Department of Oral and Maxillofacial


Division of Oral and Maxillofacial Surgery Department of Surgery School of Medicine


Matthew E. Lawler, MD, DMD Resident Department of Oral and Maxillofacial


Jason W. Lee, MD, DMD Resident Department of Oral and Maxillofacial

SurgeryMassachusetts General Hospital Boston, Massachusetts

Stephen MacLeod, BDS, MB ChB Joseph R. and Louise Ada Jarabak Professor

of SurgeryDivision Director Division of Oral and Maxillofacial Surgery Loyola University Medical Center Maywood, Illinois

James Murphy, DDS, MD Attending Physician Department of Oral and Maxillofacial

SurgeryJohn H. Stroger, Jr. Hospital of Cook County Chicago, Illinois

Daniel Oreadi, DMD Assistant Professor Department of Oral and Maxillofacial

Surgery School of Dental Medicine Tufts University Boston, Massachusetts

Zachary S. Peacock, DMD, MD Assistant Professor Department of Oral and Maxillofacial


David B. Powers, DMD, MD Associate Professor Division of Plastic, Maxillofacial, and Oral

Surgery Director of Duke Craniomaxillofacial Trauma

ProgramSchool of Medicine Duke University Durham, North Carolina

Steven M. Roser, DMD, MD Professor and Chief Division of Oral and Maxillofacial Surgery Department of Surgery School of Medicine Emory University Atlanta, Georgia

xii

Thomas Schlieve, DDS, MD Graduate Program Director and Assistant

Professor Department of Oral and Maxillofacial

Surgery Parkland Memorial HospitalSouthwestern Medical Center University of Texas Dallas, Texas

B. J. Schlott, DMD, MD Clinical Assistant Professor Department of Oral and Maxillofacial

Surgery School of Dental MedicineSouthern Illinois University Alton, Illinois

Seth T. Stalcup, MD Assistant Professor of RadiologyDepartment of RadiologyMedical University of South CarolinaCharleston, South Carolina

Mark J. Steinberg, DDS, MD Clinical Professor of SurgeryDivision of Oral and Maxillofacial SurgeryStritch School of MedicineLoyola UniversityMaywood, Illinois

Robert A. Strauss, DDS, MD Professor and Residency Program Director Department of Oral and Maxillofacial


Division of Oral and Maxillofacial Surgery Department of SurgerySchool of Medicine


Paul S. Tiwana, DDS, MD, MS Reichmann Professor and Chair Department of Oral and Maxillofacial

Surgery Health Sciences CenterThe University of Oklahoma Oklahoma City, Oklahoma

Timothy A. Turvey, DDS Professor Department of Oral and Maxillofacial

Surgery School of Dentistry University of North Carolina Chapel Hill, North Carolina

Peter D. Waite, MPH, DDS, MD Endowed Charles McCallum ChairProfessor and Chairman Department of Oral and Maxillofacial

Surgery School of Dentistry University of Alabama at Birmingham Birmingham, Alabama

Brent Ward, DDS, MD Associate Professor Department of Oral and Maxillofacial

SurgerySchool of Medicine and DentistryUniversity of Michigan Ann Arbor, Michigan

David Webb, DDS Private Practice Limited to Facial and Oral

Surgery Vacaville, California

Matthew Weber, DDS, MDResidentDepartment of Oral and Maxillofacial

SurgeryParkland Memorial HospitalSouthwestern Medical CenterUniversity of TexasDallas, Texas

Jonathan T. Williams, DMD, MD Private Practice Limited to Oral and

Maxillofacial Surgery North Conway, New Hampshire

1

1

Hospital Protocol and Procedures

Joseph E. Cillo, Jr, dmd, phd, mph

The hospital is an institution that provides medical and surgical treatment and nursing care for sick or injured individuals. Hospitals have existed since the Middle Ages in Europe and the Middle East. Since that time, there has emerged a set of policies and procedures directed toward a safe and efficient environment that benefits the healing process of the individual while standardizing care. The protocol standards-setting and accrediting body in health care in the United States is the Joint Commission, an independent, not-for-profit organization that evaluates and accredits nearly 21,000 health care organizations and programs. The mission of the Joint Commission is to continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations. This chapter highlights contemporary hospital protocols and procedures gen-erally found in modern hospitals in the United States.

2

Hospital Protocol and Procedures1

Admission NotePurposeAn admission note (Fig 1-1) is that part of a medical record that documents the patient’s status, reason for admission for inpatient care to the hospital or other facility, and the initial patient care instructions. Its purpose is to provide a concise and accurate assessment of requirements of the patient to other health care providers who will be attending to the pa-tient. According to the Joint Commission, this must be completed and documented within 24 hours following admission of the patient, but prior to surgery or a procedure requiring anesthesia services (including moderate sedation).

ContentThe components of an admission note include the following:

• Chief complaint (CC)• History of present illness (HPI)• Review of systems (ROS)• Past medical history (PMH)• Past surgical history (PSH)• Allergies• Medications• Physical examination (PE)• Assessment and plan

The CC generally consists of one to two sentences in a concise statement that de-scribes the symptoms, problems, condition, diagnosis, or other factors that are the reason for the encounter, usually stated in the patient’s own words (eg, “My bite is off after I got punched.”). The HPI is a chronologic description of the development of the patient’s com-plaints that contains the patient’s age, race, gender, and a detailed presenting complaint. The ROS is an inventory of all the organ systems, with a focus on the subjective symptoms perceived by the patient, which seeks to identify signs and/or symptoms that the patient may be experiencing or has experienced. There are 14 systems recognized by the Centers for Medicare and Medicaid Services, as follows:

• General• Head, eyes, ears, nose, and throat (HEENT) as well as sinuses, mouth, and neck• Cardiovascular system• Respiratory system• Gastrointestinal system• Urinary system• Genital system• Vascular system• Musculoskeletal system• Nervous system• Psychiatric• Hematologic/lymphatic system• Endocrine system• Allergic/immunologic system

3

Admission Note

CC: “I was in a car accident and now I can’t bite right.”

HPI: 52-year-old white man, status post motor vehicle collision this morning sustaining multiple facial traumas. No reported loss of consciousness. Brought to emergency department by ambulance and admitted to the Oral and Maxillofacial Surgery Service for consultation and repair. Admitting diagnoses include open grossly displaced right mandibular body fracture, closed moderately displaced and minimally dislocated left mandibular subcondylar process fracture, and comminuted left zygomaticomaxillary complex fracture.

PMH: HTN.

PSH: Cholecystectomy.

Medications: Lisinopril 40 mg PO BID.

Allergy: Sulfa drugs (rash).

Family medical history: Father alive, mother deceased (stroke).

Social history:Lives independent w/ spouse Alcohol: Occasionally Smoker: NoIllicit drugs: No cocaine, heroin, marijuanaOccupational history: Truck driver, 27 years

ROS: Unremarkable apart from the symptoms above.

PE:Vitals: Vital signs stable, afebrile.General appearance: WN/WD/WM in NAD. HEENT: Extraocular muscle movement intact bilateral, PERRL, no epistaxis, no CSF rhinorrhea/otorrhea, MIO approx 30 mm with deviation to right, (+) malocclusion.Neck: Supple, no JVD, no palpable nodes, trachea midline.Lungs: Clear to auscultation bilaterally, no crackles/rhonchi/wheezes. Heart: Clear S1-S2, RRR, no apparent click/gallops/rubs. Abdomen: S/NT/ND +BS.Extremities: No clubbing, cyanosis, edema, 2+ pulses.Neuro: AAO × 3, CN II to XII grossly intact except right V3 paresthesia.

Labs: CBC w/diff, urinalysis, CT of mandible and facial bones.

Assessment: 52 y/o WM with multiple facial fractures.

Plan:1. Take patient to operating room tomorrow morning for open reduction and internal

fixation of facial and mandibular fractures via multiple surgical approaches.

2. Continue home meds.

3. Unasyn (Pfizer) 3 gm IV q 8 h

Signature

Fig 1-1 Admission note example.

AAO × 3, awake, alert, and oriented to date, place, and person; BID, twice per day; CBC, complete blood count; CC, chief complaint; CN, cranial nerves; CSF, cerebrospinal fluid; CT, computed tomography; HEENT, head, eyes, ears, nose, and throat; HPI, history of present illness; HTN, hypertension; IV, intravenous; JVD, jugular venous distention; MIO, maximum interincisal opening; NAD, no acute distress; PE, physical examination; PERRL, pupils equal, round, and reactive to light; PMH, past medical history; PO, by mouth; PSH, past surgical history; q, every; ROS, review of symptoms; RRR, regular rate and rhythm; S/NT/ND+BS, soft, nontender, nondistended, bowel sounds present; WN/WD/WM, well-nourished, well-developed white male.

4


Admission OrdersPurposeThe purpose of the admission orders (Fig 1-2) is to establish a set of clear and concise instructions that will allow the nursing and auxiliary staff to manage the admitted patient according to the requests of the admitting doctor. These are completed prior to admission to the hospital through a standard set of instructions (ie, orders) that are to be carried out by the nursing staff to ensure optimal care for the admitted patient.

ContentThe admission orders are usually represented by a mnemonic that reflects the functional types of orders, such as ADCVAANDIML (admit, diagnosis, condition, vital signs, activity, allergies, nursing, diet, IV fluids, medications, labs/procedures).

• Admitting doctor or service: Name of the doctor or service under which the patient is being admitted to the hospital (eg, admit to Dr X or Oral and Maxillofacial Surgery Service).

• Diagnosis: The admission diagnosis according to the information that is available at the time (eg, maxillofacial trauma).

• Condition of patient: Condition of the patient at the time of admission (eg, stable condition).

• Vital signs: The interval at which the requisite vital signs, such as heart rate and blood pressure, are to be taken and recorded by the nursing staff (eg, record vital signs every [q] shift).

• Activity: List the level of activity that you would like the patient to tolerate. Usually related to the type of injury, illness, or procedure that the patient has sustained or undergone (eg, as tolerated, out of bed to chair, encourage ambulation).

• Allergies: List any pertinent known allergies and, if available, the reaction that the patient has to that allergy (eg, penicillin w/ rash or no known drug allergies [NKDA]).

• Nursing care: List the specific orders that you require the nursing staff to perform, any consults requested, and when the admitting surgeon or service should be con-tacted in the care of the admitted patient (eg, nothing by mouth after midnight [NPO MN], void bladder on call to operating room [OR]).

• Diet: The type and route of nourishment of the admitted patient (eg, liquid PO diet).• Intravenous (IV) fluids: The specific type and amount of IV fluid that the patient is to

receive while in the hospital (eg, run dextrose 5% in half normal saline [D5 1/2 NS] with potassium chloride [KCl] 20 mEq/L at 125 mL/h after MN).

• Medications: Specific name, route, dosage and interval of both hospital medications and home medications that patient may be taking (eg, 2 mg morphine IV q 4 hours as needed [PRN] for pain).

• Laboratory tests: List the specific type of laboratory tests to be done on the patient (eg, hemoglobin and hematocrit [H&H], pregnancy test).

5

Admission Orders

Admit to: Oral and Maxillofacial Surgery Service.

Attending: Dr Tucker.

Diagnoses: Facial and mandibular fractures.

Condition: Stable.

Vital signs: Routine q shift.

Activity: As tolerated.

Allergies: NKDA.

Nursing care:1. NPO after MN2. Void bladder on call to OR3. Start peripheral IV with 18 g catheter4. Run D5 1/2 NS with KCl 20 mEq/L at 125 mL/h after MN5. Ice packs to face 20 minutes on/off6. Operative permit for open reduction and internal fixation of mandible and facial bone

fractures on chart7. Contact OMFS on call for: T > 101.5° F, HR < 60 or > 120, RR > 25, BP < 90/60

or > 180/110, decline in neurostatus, UOP < 30 mL/hr, O2 sat < 92%

Diet: Full liquid, as tolerated, NPO after midnight.

IV fluids: Maintenance 30 mL/kg/24h, emphasize oral route when possible.

Meds: 1. Oxycodone elixir 5 to 10 mg PO 6 hours PRN for pain2. Unasyn (Pfizer) 3 gm IVPB q 8 h3. Lisonopril 40 mg PO BID

Labs: 1. CBC w/diff3. UA4. PT, PTT5. ECG6. PA & Lat CXR7. CT mandible, facial bones

Special: DVT prophylaxis, respiratory therapy, sitting up & deep breathing, supplemental O2.

Page OMFS on call with questions.

Signature

BID, twice per day; BP, blood pressure; CBC, complete blood count; CT, computed tomography; CXR, chest radiograph; D5, dextrose 5%; DVT, deep venous thrombosis; ECG, electrocardiogram; HR, heart rate; IV, intravenous; IVPB, IV piggyback; KCl, potassium chloride; Lat, lateral; MN, midnight; NKDA, no known drug allergies; NPO, nothing by mouth; NS, normal saline; OMFS, oral and maxillofacial surgeon; OR, operating room; PA, posterior-anterior; PO, by mouth; PRN, as needed; PT, prothrombin time; PTT, partial thromboplastin time; q, every; RR, respiratory rate; T, temperature; UA, urinalysis; UOP, urinary output.

Fig 1-2 Admission orders example.

6


Preoperative NotePurposeThe purpose of preoperative orders (Fig 1-3) is to confirm that the patient is ready for sur-gery. This includes confirmation that the necessary laboratory tests, radiographs, consul-tations, and informed consents will be or are completed and assurance of their availability before surgery.

ContentIn general, the preoperative note should include at least the following information:

• Proposed surgical procedure• NPO status• Operative informed consent signed by the patient, surgeon, and witness, and present

in chart• Laboratory test results

BUN, blood urea nitrogen; Cl, chloride; Cr, creatinine; CT, computed tomography; CXR, chest radiograph; ECG, electrocardiogram; Gluc, glucose; Hb, hemoglobin; HCO3, bicarbonate; Hct, hematocrit; IV, intravenous; K, potassium; MN, midnight; Na, sodium; NPO, nothing by mouth; OR, operating room; Plt, platelets; WBC, white blood cells.

Fig 1-3 Preoperative note example.

Preoperative diagnosis1. Right mandibular body fracture2. Left mandibular subcondylar process fracture3. Comminuted left zygomaticomaxillary complex fracture

Planned procedure and scheduled time: Open reduction and internal fixation of fractures in operating room at 7 am tomorrow.

Indication: Facial bone and mandible fractures and malocclusion.

Labs/studies:

GlucHb

Hct

Na

K

Cl BUN

CrWBC

HCO3

Plt

Official CXR and CT readings: Completed, reviewed, and on chart.

Official ECG reading: Completed, reviewed, and on chart.Type and cross-screen for 2 units in blood bankNPO after MNIV fluids ordered after MN

Antibiotics ordered on call to OR: 3 g Unasyn (Pfizer) IV.

Anesthesia evaluation: Completed and on chart.

Operative consent: Signed, witnessed, and on chart.

7

Surgical Site Marking (Universal Protocol)

Preoperative ProtocolInformed consentAccording to the World Health Organization, the American College of Surgeons, and the Joint Commission, it is critically important that the surgeon receive informed consent from the patient, parent, or legal guardian before performing any procedure. Informed consent pertains to providing a full explanation in clearly understandable language of what you are proposing, your reasons for wishing to undertake the procedure, and what you hope to find or accomplish. Avoid the use of medical jargon. Be attentive to legal, religious, cultural, linguistic, and family norms and differences.

The informed consent process is completed in the following way:

• Describe the planned procedure to the patient in understandable lay terms. Draw pictures and use an interpreter, if necessary.

• Describe the risks associated with the procedure as well as those with any anesthesia.• Discuss any alternative methods of treatment.• Allow the patient and any family members to think about what you have said.• Ask the patient if they have any questions or concerns and address them.• Confirm that the patient has understood the plan.• Obtain written and verbal permission to proceed.

It may be necessary to consult with a family member or legal guardian/power of attorney who may not be present; allow for this if the patient’s condition permits. If a person is too ill to give consent (eg, unconscious) and his or her condition will not allow further delay (eg, life-threatening airway obstruction from Ludwig angina), you should proceed without formal consent, acting in the best interest of the patient. Record your reasoning and plan.

Surgical Site Marking (Universal Protocol)PurposeThe purpose of the Universal Protocol is to prevent the occurrence of wrong person, wrong procedure, and/or wrong site surgery (Fig 1-4) in either hospital or outpatient settings.

Fig 1-4 Surgical site marking to avoid surgery at the wrong site.

8


The Universal Protocol consists of three stages:

1. Preoperative verification of the correct patient. Verification with at least two iden-tifiers (patient name, medical record number, and/or date of birth) ensures correct patient identification. Missing information and/or discrepancies must be addressed before the start of the procedure, such as the history and physical examination find-ings and signed consent with the correct procedure verified in the medical record.

2. Marking the correct operative site. The Joint Commission as a part of its Universal Protocol mandates that the correct surgical site must be marked when there is more than one possible location for the procedure and when performing the procedure in a different location could harm the patient (eg, right temporomandibular joint versus left temporomandibular joint). This is generally completed by the attending surgeon with the surgical site marked with his or her initials and “YES,” personally confirm-ing the surgical site is correct. The mark must be visible after the patient has been prepped and draped (see Fig 1-4). Further, the Joint Commission guidelines purport:nn The site does not need to be marked for bilateral structures (eg, bilateral temporo-mandibular joints).nn The site is marked before the procedure is performed, ideally in the preoperative suite.nn If possible, involve the patient in the site-marking process.nn The site should be marked by a licensed independent practitioner who is ultimately accountable for the procedure and will be present when the procedure is performed.nn In limited circumstances, site marking may be delegated to a resident, physician assistant (PA), or advanced practice registered nurse (APRN). However, the li-censed independent practitioner is ultimately accountable for the procedure even when delegating site marking.nn The mark should be unambiguous and used consistently throughout the organization.nn The mark must be made at or near the procedure site.nn Adhesive markers are not the sole means of marking the site.nn For patients who refuse site marking, or when it is technically or anatomically impos-sible or impractical to mark the site, it is recommended to use your organization’s written, alternative process to ensure that the correct site is operated on. However, some anatomical structures such as teeth do not generally have to be marked.

3. Final verification/“Time out.” A deliberate pause in all activity is performed by a dedi-cated individual immediately before starting the procedure. Complete attention is giv-en to the individual conducting the time out, and the following details are confirmed:nn Patient namenn Date of birthnn Correct procedure site verified by the consent formnn The correct site and side have been markednn Surgeon’s namenn Procedure to be performednn All perioperative medications (antibiotics, etc) have been givennn Patient is properly positionednn Correct devices and any special equipment are available

Verbal confirmation of the previous details among all members of the surgical/proce-dural team is required, and the procedure is not started until any questions or concerns are resolved. The Universal Protocol/time out is usually required by hospital policy in all patients who undergo an invasive procedure requiring consent and any form of anesthesia.

9

Brief Operative Note

Brief Operative NotePurposeThe brief operative note (Fig 1-5) is created immediately after the surgery or procedure is complete and usually before the patient leaves the operating room. This note highlights the important details of the completed procedure so the nursing staff at the patient’s next level of care may be informed of what has occurred. The Joint Commission requires that the brief operative note include the exact time it is written because it is very important to confirm that the note was recorded prior to moving the patient to the next level of care.

EBL, estimated blood loss; GNETA, general nasoendotracheal anesthesia; ORIF, open reduction internal fixation; PACU, postanesthesia care unit.

Date/time: 09/08/2017, 10:02

Preoperative diagnosis: Mandible and facial bone fractures.

Postoperative diagnosis: Same.

Procedure: ORIF mandible and facial bone fractures.

Anesthesia type: GNETA.

Surgeon: Dr Tucker.

Assistant(s): Dr Williams.

EBL: 20 mL.

IV fluids: 1200 mL lactated Ringer (B Braun).

Urine output: Approx 40 mL.

Findings: Displaced mandibular and facial bone fractures.

Pathology: None.

Disposition: Patient tolerated the procedure well and was taken to PACU without complications.

Fig 1-5 Brief operative note example.

ContentThe brief operative note is a condensed and concise version of the more detailed operative note. It should contain the following information:

• Date/time: MM/DD/YYYY: 00:00• Preoperative diagnosis: Reason for surgery• Postoperative diagnosis: Diagnosis based on findings at surgery• Procedure: What procedure(s) were performed• Anesthesia (type): General, spinal, epidural, etc• Surgeon: Name of attending physician• Assistant(s): Resident, medical student, dental student, PA, etc

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• Estimated blood loss (EBL): Estimated amount of blood lost during the procedure• IV fluids: Type and amount of IV fluid administered• Urine output: Amount of urine produced through the catheter during the operation• Findings: Detailed description of what was found at surgery; describe sizes, location,

etc• Pathology: Specimens that were sent to pathology for evaluation• Disposition: Where patient is going from the operating room

Operative ReportPurposeThe operative note or report (Fig 1-6) details the procedure completed on the patient as dictated by the operating surgeon of record or designated associates (ie, resident or PA). If the individual dictating is different from the surgeon of record, the report will include his or her name as well. Operative reports are created after every surgical procedure for the purposes of both documentation and billing. The Centers for Medicare and Medicaid Services require that the operative report be completed immediately after surgery, while the Joint Commission will allow a hospital to define what this time period would be if there has been a brief operative note already dictated.

ContentThe operative report will include the patient’s name, date of birth, medical record number (or other identification number), as well as the following:

• Preoperative diagnosis: Working diagnosis of perceived problem• Postoperative diagnosis: Final diagnosis after the surgery is completed, adding any

additional information that was not available prior to surgery• Procedure(s): Detailed list of surgical procedures performed by the operating team• Statement of medical necessity: Medical reason for the patient to have the procedure

performed• Surgical service: Service performing the surgery• Attending surgeon: Name of the surgeon of record• Assistant surgeon(s): Those who were scrubbed and participated in the surgery• Anesthetic administered: The type of anesthetic used and method of administration

(eg, general nasoendotracheal anesthesia, monitored anesthesia care)• Operative report: Detailed description of the operative procedure as told by the indi-

vidual who performed the procedure or a designated associate• Specimen(s): Any tissue, fluid, or material removed from the patient during surgery

intended for examination• Drains: Type and location of any device intended for fluid drainage• IV fluids administered: Amount and type• EBL: Estimation of blood lost during the surgery usually based on conference be-

tween members of the operating room team• Urine output: Obtainable when a Foley catheter has been placed• Complications: Detailed description of any perceived intraoperative complications• Disposition: The condition of the patient at the end of the surgery and where patient

is being sent

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Operative Report

Preoperative diagnosis: 1. Right mandibular body fracture2. Left mandibular subcondylar process fracture3. Comminuted left zygomaticomaxillary complex fracture

Postoperative diagnosis: Same

Procedures:1. Intraoral open reduction and internal fixation of right mandibular body fracture. 2. Extraoral open reduction and internal fixation of left mandibular subcondylar process fracture. 3. Open reduction and internal fixation of comminuted left zygomaticomaxillary complex fracture via multiple surgical approaches.

Surgeon: OMFS attending.

Assistants: OMFS chief resident.

Anesthesia: OMFS junior resident.

EBL: Approximately 20 mL.

UOP: 55 mL.

IVF: 1100 mL lactated Ringer.

Findings: Displaced mandibular and facial bone fractures.

Specimens: None.

Drains: None.

Complications: None.

Disposition: Patient tolerated the procedure well.

Statement of medical necessity: This is a 52-year-old male, status post motor vehicle collision, who sustained multiple facial trauma including open grossly displaced right mandibular body fracture, closed moderately displaced and minimally dislocated left mandibular subcondylar process fracture, and comminuted left zygomaticomaxillary complex fracture. All risks, benefits, complications, and alternatives to treatment were discussed with the patient. The patient agreed to the above procedures, and written and verbal consent was obtained.

Operative report: Patient was taken to the operating room and placed on the operating room table. Monitors were attached, and the patient was secured. Following induction of general anesthesia and nasoendotracheal intubation by the anesthesia service, the tube was secured, the eyes protected, a throat pack placed, and the surgical site was prepped and draped in the usual sterile fashion while the surgeons scrubbed and gowned in the usual sterile fashion. Following Universal Protocol time out, 6 mL of 2% lidocaine with 1:100,000 epinephrine was injected into the surgical sites. Following placement of maxillary and mandibular Erich arch bars, a Bovie electrocautery was used to make a right mandibular vestibular incision that was taken down to bone. Subperiosteal dissection with a no. 9 periosteal elevator was completed until the right mandibular body fracture was visualized. The patient was placed into maxillomandibular fixation according to occlusal wear facets with 24-gauge wire. The right mandibular body fracture was reduced and an inferior border 2.0-mm mandibular fracture plate was adapted to the bone and secured with bicortical locking screws. Once the fracture was fixed, the patient was cut out of maxillomandibular fixation and the occlusion was checked. The occlusion was found to be unstable and fell back to the right. The surgeons then regloved and gowned and, using new sterile instruments, an incision was made with a no. 15 blade 2 centimeters

Fig 1-6 Operative report example.Continued on next page

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Immediate Postoperative NotePurposeThe purpose of the immediate postoperative note (Fig 1-7) is to assess the recovery status of the patient in the immediate postoperative period (ie, the first few hours following the procedure) and once out of the postoperative care unit or postanesthesia care unit (PACU) and on the nursing floor. This will include the findings from a physical examination to en-sure early detection of any potential postanesthesia or postoperative complications such as pulmonary embolism, deep vein thrombosis, atelectasis, and so forth.

ContentThe postoperative note should be more detailed than a regular progress note and should provide information about the patient’s immediate postoperative recovery. This should in-clude the findings on an examination of the patient’s lungs, heart, abdomen, extremities, and neurologic status. The note should list both the hospital day (HD) number and the postoperative day (POD) number.

Continued from previous page

inferior to the right retromandibular area. The incision was taken down to bone, and blunt dissection with nerve monitoring was completed until the posterior mandibular ramus was palpated. Sharp incision through the periosteum was completed, and subperiosteal dissection was done with a no. 9 periosteal elevator. The proximal and distal edges of the mandibular subcondylar process fracture were visualized. The patient was placed back into maxillomandibular fixation with 24-gauge wire. The mandibular subcondylar process fracture was reduced and fixed with a 2.0-mm fracture plate with nonlocking screws. The patient was cut out of maxillomandibular fixation and the occlusion checked. The occlusion was found to be stable and reproducible, with free range of mandibular motion, and the fractures were found to be well reduced with good bone approximation and plate adaptation. Attention was then given to the ZMC fracture, where combined subconjunctival and maxillary vestibular incisions were used to access the fracture. Using an elevator, the ZMC fracture was reduced and then plated with 1.7-mm miniplates with 4-mm screws. Good osseous reduction and good plate adaptation were noted. A forced duction test on the right eye revealed free and full range of motion without restriction. The surgical sites were copiously irrigated and found to be clean. The surgical incisions were sutured in layers. Good hemostasis was achieved, and no complications were noted. The patient was turned over to the anesthesia service for awakening and extubation.

Fig 1-6 (cont) Operative report example.

EBL, estimated blood loss; IVF, intravenous fluids; OMFS, oral and maxillofacial surgeon; UOP, urine output; ZMC, zygomaticomaxillary complex

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Progress Note (SOAP Note)

HD: 2

POD: 1 52-year-old white male, status post open reduction and internal fixation of mandible and facial bone fractures, doing well postop.

Physical examination:General appearance: WN/WD/WM in NAD. Incisions clean, dry, and intact and tissues well approximated. No s/s infection.Chest/CV: No murmurs/clicks/gallops/rubs, RRR.Lungs: Clear to auscultation bilaterally.Abdomen: S/NT/ND+BS.Extremities: No clubbing/cyanosis/edema. 2+ pulses.Neuro: CN II to XII grossly intact except right cranial nerve V2 and V3 paresthesia.

Assessment and plan:52-year-old WM, POD 1 s/p ORIF mandible and facial fractures doing well. Pain well controlled, consider d/c home today.

Fig 1-7 Postoperative note example.

Progress Note (SOAP Note)PurposeThis note indicates the patient’s current status and further plans. The SOAP note (Fig 1-8) easily lends itself to an organized and recognizable standard format that allows for a suc-cinct and informative narrative of the patient’s daily hospital course.

ContentThe postoperative note organized in the SOAP format includes the following:

• Subjective: Describe how the patient feels (eg, current symptoms).• Objective: This includes findings on physical examination, vital signs, laboratory re-

sults, etc.• Assessment: Based on the above information, the practitioner’s opinion about the

patient’s current status is presented.• Plan: What is planned for the patient, such as change in medication, additional tests,

discharge, etc. It may also include directives, which are written in a specific location as orders.

CN, cranial nerve; CV, cardiovascular; d/c, discharge; HD, hospital day; NAD, no acute distress; ORIF, open reduction internal fixation; POD, postoperative day; RRR, regular rate and rhythm; S/NT/ND+BS, soft, nontender, nondistended, bowel sounds present; s/p, status post; s/s, signs or symptoms; WN/WD/WM, well-nourished, well-developed white male.

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Postoperative OrdersPurposeThe purpose of postoperative orders is to confirm that the findings and effects of surgery are properly considered. As all previous standing orders are automatically canceled when the patient goes to the operating room, these orders must be recreated, if indicated, and also include any new orders that need to be added.

ContentPostoperative orders are written similar to the admission orders using the same mnemonic ADCVAANDIML, but they are updated based on the procedure that was completed on the patient.

Discharge SummaryPurposeThe purpose of a discharge summary (Fig 1-9) is to succinctly summarize the events of the hospitalization for the patient’s primary care physician and other subspecialists. It is not a day-to-day documentation of the patient’s hospital course.

Fig 1-8 SOAP note example.

S: “Feeling better today.” Patient reports headache and moderate facial pain.

O: Afebrile, P 84, R 16, BP 130/82. No acute distress. Occlusion stable and reproducible. No TMJ c/p/c/t. MIO ~35 mm. No deviations or deflections. Incisions c/d/i. Facial nerve intact bilateral, right V3 paresthesia. PERRL, EOMI without diplopia. Lungs: CTA BilateralHeart: RRR Abd bowel sounds present. Ext without edema

A: Patient is a 52-year-old male on postoperative day 2 for ORIF facial fractures. Recovering well.

P: Advance diet. Nutrition consult. Prepare for discharge home today.

Abd, abdominal; BP, blood pressure; c/d/i, clean/dry/intact; c/p/c/t, clicking/popping/crepitus/tenderness; CTA, clear to auscultation; EOMI, extra-ocular muscles intact; MIO, maximum incisal opening; ORIF, open reduction and internal fixation; P, pulse; PERRL, pupils equal, round, and reactive to light; R, respirations; RRR, regular rate and rhythm; TMJ, temporomandibular joint; V3, third branch of the trigeminal nerve.

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Discharge Summary

Date of admission: 09/07/2017

Date of discharge: 09/09/2017

Discharge primary diagnosis: s/p ORIF maxillofacial fractures.

Secondary diagnosis: HTN.

Consultations: Nutrition consult for nonchew diet.

Procedures: ORIF mandible and facial bone fractures.

Brief history: The patient is a 52-year-old male with history of hypertension who was involved in a motor vehicle collision on 09/07/2017 in which he sustained maxillofacial fractures. He was transferred from an outside hospital for definitive maxillofacial treatment. The patient was admitted to the OMFS service for open reduction and internal fixation of mandibular and facial bone fractures.

Diagnostic studies: CT of the maxillofacial area showed bilateral fractures of the mandible and fracture of the zygoma. Chest radiographs were normal, and ECG showed normal left ventricular function, ejection fraction estimated greater than 65%.

Hospital course: Following admission to the OMFS service, the patient was taken to the operating room the following morning where he received open reduction and internal fixation of his mandibular and facial bone fractures without complications. He tolerated the procedure well and was discharged home on the first postoperative day.

Discharge disposition: Discharged home.

Activity: As tolerated.

Diet: Soft nonchew diet for 6 weeks.

Medications:Chlorhexidine oral rinses 15 mL PO (swish and spit) BIDOxycodone/APAP 5/325 20 tablets, one tab PO q 6 h PRN for pain Ibuprofen 600 mg 40 tablets, one tab PO q 6 hLisonopril 40 mg PO BID

Discharge instructions: Follow nonchew diet as directed by nutritionist and take medications as prescribed.

Pending studies: Panoramic radiograph and maxillofacial CT scan.

Recommendations: Call OMFS on call with any issues.

Follow-up:1. Follow up with OMFS in 1 week.2. Follow up with primary care provider within 2 to 3 weeks of arriving home.

APAP, acetaminophen; BID; twice per day; CT, computed tomography; ECG, electrocardiogram; HTN, hypertension; OMFS; oral and maxillofacial surgery; ORIF, open reduction internal fixation; PO, by mouth; PRN, as needed; q, every; s/p, status post.

Fig 1-9 Discharge summary example.

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ContentThe Joint Commission mandates that discharge summaries contain certain components such as the reason for hospitalization, significant findings, procedures and treatment pro-vided, patient’s discharge condition, patient and family instructions, and attending physi-cian’s signature. Additionally, the National Quality Forum recommends that a discharge summary also include a comprehensive and reconciled medication list and a list of acute medical issues, tests, and studies for which confirmed results were unavailable at the time of discharge and that require follow-up. The order of a discharge summary should be:

• Date of admission/transfer: MM/DD/YYYY• Date of discharge/transfer: MM/DD/YYYY• Admitting diagnosis: Working diagnosis at the time of admission. This can be a pre-

senting symptom (eg, oral bleeding).• Discharge diagnosis: The diagnosis at time of discharge cannot be a symptom or sign.• Secondary diagnoses: Include all active medical problems regardless of whether they

were diagnosed during this admission.• Procedures: List all procedures with the date of occurrence and key findings, when

applicable.• Consultations: List names and specialties of all consultants who saw the patient

while an inpatient (eg Dr Smith, infectious disease).• History of present illness: A brief summary (one to two sentences) of how the patient

initially presented. May be followed by the phrase “see full H&P (history and physical) for details.”

• Hospital course: Detailed account of the hospital stay, highlighting significant inter-ventions and/or episodes such as any complications or improvements based on spe-cific treatments. This information should be thorough but not exhaustive in detail, such as day-by-day specifics of activity and medication regimens.

• Condition of patient: Provide a brief functional and cognitive assessment.• Disposition: Where the patient is going following discharge from the hospital (eg,

skilled nursing center, home with daughter).• Discharge medications: List all the patient home medications prescribed, including

doses, route of administration, frequency, and date of last dose, when applicable.• Discharge instructions: Specific details of activity level, diet, wound care, or other

issues the patient’s doctor needs to know. This is different from the discharge in-structions you give to patients, which include symptoms and signs to report or seek care for (eg, “call Dr X if temperature greater than 100” or “go to ER if chest pain returns”) and must be in language they understand. They also should include a 24/7 callback number.

• Pending studies: List all studies that are outstanding and to whom the results will be sent.

• Recommendations: Include any necessary consults or studies that should be done.• Follow-up: Name of doctor, specialty, and appointment location and time. If the pa-

tient is to schedule the appointment, make sure you include the time frame in which the patient should schedule the appointment (eg, patient to arrange appointment to be seen within 2 weeks).

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Recommended Reading

Recommended ReadingBraithwaite J, Wears RL, Hollnagel E. Resilient health care: Turning patient safety on its

head. Int J Qual Health Care 2015;27:418–420.Creager RT. The “peer review privilege” should not shelter hospital policies and proce-

dures from discovery. Litigation News, Virginia State Bar 2008;8(9):1–7. http://www.vsb.org/docs/sections/litigation/LitNews_Spring081.pdf. Accessed 5 July 2018.

Destache DM. Hospital policies: Will they be a burden or a benefit to you in litigation? Midwest Legal Advisor: Lamson, Dugan and Murray, LLP, 2013. http://ldmmedlaw.com/hospital-policies-will-they-be-a-burden-or-a-benefit-to-you-in-litigation/. Accessed 5 July 2018.

Perioperative Standards and Recommended Practices for Inpatient and Ambulatory Set-tings. Denver: Association of periOperative Registered Nurses, 2014.

Schyve PM. Leadership in healthcare organizations: A guide to Joint Commission leader-ship standards. San Diego: The Governance Institute, 2009. http://www.jointcommis-sion.org/assets/1/18/wp_leadership_standards.pdf. Accessed 5 July 2018.

Some red rules shouldn’t rule in hospitals. Institute for Safe Medication Practices, Med-ication Safety Alert, 2008. https://www.ismp.org/resources/some-red-rules-shouldnt-rule-hospitals. Accessed 5 July 2018.

Documents

Clinician’s Handbook of Oral and Maxillofacial Surgery