Year : 2008 | Volume
: 52 | Issue : 3 | Page : 311--316
Airway Management in Maxillofacial Trauma: A Retrospective Review of 127 Cases
Prof. and Head, Senior Advisor, Anaesthesiology, Command Hospital (Air Force), Bangalore - 560007, India
Command Hospital Air Force, Airport Road, Agram Post, Bangalore - 560007
Maxillofacial injuries are the result of high velocity trauma arising from road traffic accidents, gunshots and missile injuries. These injuries require emergency airway management in prehospital and hospital settings and as well as for reconstruction of fractures subsequently. Anaesthesiologist must be conversant with the alternative techniques and appliances.
One hundred twenty seven cases of maxillofacial injuries, treated over a period of three years in a service hospital were reviewed. Fracture mandible was most common injury (51%) followed by fractures of maxilla and zygoma (35%). Nasal intubation with direct visualization of vocal cords was most common (56%) and this was followed by oral intubation (17%). Blind awake nasal intubation was carried out in 20%. Fibreoptic bronchoscope and preoperative tracheostomy were other methods of airway management.
Maxillofacial injuries need special attention since it involves difficult airway due to fracture to facial bones, Further the airway is shared with surgeon and restrictions are imposed during surgery. Issues involved are time of surgery, preoperative airway assessment, type of intubation and way to achieve it, alternative methods available and their complications.
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Saraswat V. Airway Management in Maxillofacial Trauma: A Retrospective Review of 127 Cases.Indian J Anaesth 2008;52:311-316
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Saraswat V. Airway Management in Maxillofacial Trauma: A Retrospective Review of 127 Cases. Indian J Anaesth [serial online] 2008 [cited 2020 Sep 21 ];52:311-316
Available from: http://www.ijaweb.org/text.asp?2008/52/3/311/60640
Trauma has been dubbed "the forgotten epidemic" and "neglected disease of modern society". Road traffic accidents are responsible for majority of maxillofacial injuries. In addition gunshot wound, missile and blast injuries account for rest in armed forces. Maxillofacial trauma assumes importance as it involves vital organs, look ghastly, may lead to massive haemorrhage and are potentially life threatening. Associated head trauma and injuries to other vital and non-vital organs may contribute to significant morbidity and mortality. Most of the injuries belong to first and second peak of trimodal mortality curves  and required to be dealt early for management of airway. Subsequent fixation of fractures and reconstruction demands efficient airway management. Single universal technique of intubation may not find favour in all circumstances and anaesthesiologist must be conversant with the alternative techniques as well as appliances.
In a retrospective review, one hundred twenty seven patients of maxillofacial trauma were studied. All patients were administered general anaesthesia for various surgical procedures.
Patients were subjected to pre-anaesthetic assessment and informed consent was obtained from all the patients. Airway assessment by Mallmpatti classification, Thyromental distance and atlanto-axial mobility was the basis of decision-making for selection of intubation technique. Patients who did not meet at least two criteria were labeled as difficult intubation and airway was secured either by blind, blind retrograde, preoperative tracheostomy or fibreoptic technique of intubation. Surgeons' preference was the only guiding factor for the choice of nasal or oral intubation.
Routine monitoring, in the form of NIBP, pulse oximetry and ECG was instituted on arrival in operation theatre. All patients were premedicated with atropine 0.6 mg and pethedine/morphine IV on the operating table. Patients, in whom, airway was considered adequate, anaesthesia was induced with sleep dose of thiopentone, intubation accomplished with succinylcholine2 mg.kg -1 and maintained with nondepolarizing muscle relaxants (pancuronium or vecuronium), N2O: O2 and halothane/ isoflurane. Residual effects of nondepolarizing muscle relaxant were antagonized by mixture of neostigmine 80 mcg.kg -1 and atropine 20mcg.kg1 administered intravenously. Extubation was carried out with the patients fully awake, breathing spontaneously, obeying command and satisfactory muscle power.
Patients, in whom, airway was considered inadequate, administration of intravenous or inhaled anaesthetics were withheld till it was established with one of the alternative technique. Procedure for alternative techniques was explained to the patients. Analgesia was provided by instillation of 2% lidocaine in nasal cavity and allowed to stay in oropharynx for surface analgesia. Bilateral superior laryngeal nerve block was established with lidocaine injected lateral to greater horn of thyroid cartilage. Tracheal mucosa was anaesthetized with 2-3 ml of 2% lidocaine injected through cricoid membrane and needle withdrawn immediately before patient started coughing, which lead to spread of analgesic over tracheal mucosa and vocal cords.
Blind nasal intubation was established with a welllubricated endotracheal tube introduced through the nostril into the pharynx. Thereafter breath sound guided the insertion of endotracheal tube into the glottis. Manipulation was needed in most cases by way of flexion of neck, extension at atlantoaxial joint, and stabilization of larynx by cricoid pressure and correcting direction of endotracheal tube.
One hundred twenty seven patients of maxillofacial injuries reported to tertiary care hospital over a period of three years. The mean age of patients was 34 years with range of 15 to 58 years. Majority of patients were in the age group of 20-40 years [(96 patients, 75.6%)]. Also, 104 patients were male whereas only 23 were female.
The time of reporting to tertiary care hospital varied from four hour to six days. Some of the patients also reported after a period of one to three months for definitive or repeat surgery.
Fracture mandible was found to be most common injury (65 patients, 51%). Fracture maxilla (19 patients, 15%) and zygoma (25 patients, 20%) combined contributed to another 35% of the injuries. Panfacial trauma and blast injuries of face contributed to only 7% each (9 patients each) [Table 1].
Nasal intubation with direct visualization of vocal cords was achieved in 71 patients (56%). Oral intubation, whenever permitted by maxillofacial surgeon, was carried out in 22(17%) patients. These constituted mix of injuries to maxilla, mandible and isolated fractures of Zygoma. Patients considered to have difficult airway, were secured airway by blind awake nasal intubation (25 patients, 20%). This group constituted multiple fractures of maxilla and mandible. Two patients (1.5%) needed assistance with fibreoptic bronchoscope subsequent to failed blind nasal intubation attempt. In seven patients (5.5%) preoperative tracheostomy, done at earlier occasion, was utilized [Table 2]. Preoperative tracheostomy was carried out to secure airway immediately after injury in panfacial fractures and were subjected to surgery after three to five days post injury.
Head injury and other injuries, where associated, had already been addressed before taking up for surgery for maxillofacial trauma.
Trauma is considered the 'Epidemic of twenty first century' and accounts for thousands of deaths every year. It is of even more importance to society as young productive lives are involved. Trauma carries a universal young and male predominance. Our figures are a reflection of the same although some bias is inevitable; armed forces being mostly male society.
Patients having maxillofacial injuries with or without cervical spine fractures and head injury need securing of airway by the anaesthesiologist or trauma surgeon. ATLS protocol must be followed in all cases of maxillofacial trauma and associated injuries addressed according to the priority. Maxillofacial trauma leads to varying degree of compromised airway and presents major challenge to anaesthesiologist, who needs to use all his skills and expertise to eliminate morbidity and mortality. Emergency trauma care was not the part of this review since other teams managed it separately.
The time lag between the injury and surgery is variable depending on the institutional protocols and may range from few hours to few days as seen in this review. Emergency stabilization of fractures is often performed under local analgesia avoiding repeated anaesthesia and allowing time for preoperative optimization by correction of blood volume and electrolyte. The resolution in facial edema during this time allows for more accurate clinical evaluation of airway and ease of intubation. The delay in final reconstruction of facial fractures in the critically ill patient has an acceptably low complication rate and may be advantageous in decreasing operative risk  . A carefully planned reconstruction schedule is required to achieve satisfactory function and appearance as unnecessary delay in surgery may predispose to complications like malunion and serious infections in the presence of CSF leak.
Preoperative assessment of airway is the key to a successful anaesthetic management. Mallampatti classification provides good assessment of airway but may not be accurate in presence of disrupted anatomy, muscle spasm, tissue edema and presence of arch bars placed by maxillo-facial surgeon. We used three criteria to improve assessment of airway. Thyromental distance and atlantoaxial mobility correlated well with ease of intubation in all cases.
Awake intubation in compromised airways may be an excellent alternative. This needs patience on the part of anaesthesiologist and high degree of co-operation from the patients. Weitzel et al reported the success rate of 90% for prehospital intubation using the blind nasotracheal method in penetrating neck trauma  . In our experience, if procedure is well explained, as safe and life saving, motivated patients pose no problems. However, back up plans for failed conventional techniques of intubation is mandatory. We failed in two cases where fibreoptic bronchoscope assisted intubation was carried out. Fibreoptic bronchoscope assisted intubation is safest and most certain method of ensuring nasal or oral intubation, as it confirms the placement of endotracheal tube in the trachea.
Orotracheal intubation with planned neuromuscular blockade and in-line cervical traction is a safe, effective method for airway control in patients who are severely injured  . This technique is also indicated to expedite therapy in combative, uncooperative patients because of the high incidence of significant life-threatening injuries to the brain and other organs.
Inadvertent placement of intracranial nasogastric, ,, nasopharyngeal  and naso-tracheal  tubes are hazardous in blind instrumentation of the nasal passages in the presence of frontobasal fractures. Although most anaesthesia texts include basilar and facial fractures in the list of contraindications to nasotracheal intubation, the evidence to support this recommendation is sparse and mainly based on anecdotal reports ,,,, . The reports suggest that, in this clinical situation, the nasogastric tube is far more dangerous than the endotracheal tube.
In a study of 160 patients with base of skull fractures and CSF fistula, Bahr and Stoll reported that the route of trachea! intubation had no influence on the postoperative complication rate  . There was no case of direct cerebral injury associated with nasotracheal intubation and the incidence of meningitis was the same, 2.5%, after oral and nasal intubation. The authors concluded that nasal intubation was not contraindicated in the presence of frontobasal fractures.
In a study of 86 patients with clinical and/or radiological evidence of base of skull fractures, Rhee et al, concluded that attempts at blind nasotracheal intubation in the field did not markedly increase the complications associated with base of skull fractures .
Maxillo-facial surgeons prefer to have nasal intubation as it gives them freedom to operate. This requirement guided us to carry out nasal intubations in majority of cases, however patients with CSF rhinorhea were excluded. Nasal or oral intubation, with direct visualization of vocal cords, does not present much problem if there is no gross disruption of anatomy. Smoot EC  in a survey reported that more than 50% of the respondents chose some form of nasotracheal intubation (blind or fibreoptic) for fracture patterns involving the midface.
Surgical airway should be reserved for the patients with severe injuries or failed intubations  . Tracheostomy was a first choice for patients with panfacial fractures or those with loss of consciousness and midface fractures. Cricothyrodotomy provides efficient airway in emergency situations, and is quick to perform with minimal early postoperative complications . Tracheostomy is preferable for long-term management as surgical airway. In the present series five out of nine patients of panfacial fractures were subjected to tracheostomy during emergency management.
Lord  et al in a retrospective study concluded that choice of airway control in the trauma patient with cervical spine fractures differs between anaesthesiologists and surgeons. However, the method selected does not have an adverse affect on neurological status as long as in-line stabilization is maintained. The methods available are safe, effective, and acceptable. The technique utilized is dependent upon the judgment and experience of the intubator.
In an attempt to avoid both tracheostomy and naso-tracheal intubation in patients with basilar skull fracture (BSF), the passage of an armoured endotracheal tube through the floor of the mouth has been advocated. Submental , and both anterior and lateral submandibular routes ,, have been described in the surgical management of severe panfacial fractures. The technique, in its various forms, is said to be relatively simple and safe to perform and produces a cosmetically acceptable scar. It is further claimed that it may be safely used for elective ventilation for periods of up to ten days  . In a recent review submental intubation has been found to be safe but observed increased tracheal pressure as a result of deviation and compression of tube  . Since we did not have any experience in these techniques it was not considered.
Retrograde oral or nasal intubation, utilizing epidural catheter may be other good alternative in difficult or failed intubations. However, availability of fibreoptic bronchoscope prohibited us to use this technique, which is much more safe and definitive. Recently various intubation aids like Airtraq and Macintosh laryngoscopes, Frova single-use tracheal tube introducer and PAXpress have been tried with variable results ,, .
Mid face fractures of Le Fort Type II and III may be displaced postero-inferior by along the inclined plane of the base of the skull, blocking the nasal airway. Nasal intubations may be difficult and require disimpacting by pulling the maxilla forward in the mouth. This fact should also be kept in mind while surgeon does so during surgery. Nasal tube may be pulled out leading to inadvertent extubation.
In conclusion, maxillofacial trauma invariably presents with difficult airway and demands special attention. Time of surgery should be carefully planned allowing reduction of tissue edema and avoiding development of malunion. Nasal intubation is the choice of intubation by surgeon, providing them with free access to operating field. Blind awake nasal intubation is safe and simple with some experience in difficult airway, where as fibreoptic bronchoscope provides most definite placement of endotracheal tube. Alternative techniques like submental, submandibular and retrograde intubations need more expertise, but can provide efficient airway control. Intraoperative manipulations may cause significant displacement of endotracheal tube and should be addressed.
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