AAO-HNSF Primary Care Otolaryngology Handbook

CHAPTER 12

associated injuries, and administration of antibiotics and a tetanus shot (as indicated). Do not forget to check to be sure that the cervical spine has been cleared. Smaller lacerations can often be repaired satisfactorily in the emergency room. Larger, more complex lacerations may be better repaired in the oper- ating room, where the patient can be made more comfortable and the wound thoroughly cleaned. Pay particular attention to deep wounds that traverse the course of the facial nerve or parotid duct, as these structures may be injured as well. Lacerations that involve the eyelid may have injured the globe, and ophthalmic consultation should be considered. Once these other considerations have been satisfied and the wounds are ready to be repaired, several principles may be helpful. First is careful reapproximation of all remaining tissue. After the wound has been anes- thetized and cleansed, it becomes more obvious where the tissue needs to go. It is important to be meticulous when you are repairing these wounds, somewhat like putting together a jigsaw puzzle. Line up known lines first: the vermilion border of the lips, free margins of the nose and eyelids, edges of eyebrows, and parts of the pinna must be perfectly aligned. Second, careful handling of soft tissue is important to avoid crushing the delicate tissue edges further. It may take more than one effort to repair some of these wounds properly; removing any misplaced sutures and starting over is not uncommon. Buried resorbable sutures of material, such as polyglactan or monocaproic acid, help to reduce the tension placed on the wound (which is an important determinant of reducing scar formation). Last, when closing the final layer, it is important to be sure that the skin edges are everted and not inverted, as this will lead to a depressed scar that is more visible. On the face, 5-0 or 6-0 sutures are usually adequate, and resorbable mild suture, such as fast-absorbing gut, or a permanent suture, such as nylon or polypropylene, is best. Immediately after a wound is closed, it fills with serum, which clots. This serum prevents water from entering the wound. Wounds may be allowed to get wet within a few minutes of closure as long as the microscopic clot is not disrupted. Thus, you may tell patients they can get their wound wet, as long as they do not scrub it and the water is reasonably clean. Showering is fine; swimming in a lake probably is not. Instruct them to keep antibiotic ointment or petrolatum jelly on the wound. This will help it retain moisture and reduce crusting until the skin has healed (usually about a week on the face). Sutures on the face should be removed at three to five days, while those on the ear and scalp should be allowed to remain somewhat longer,

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Primary Care Otolaryngology