• Users Online: 903
  • Print this page
  • Email this page

Year : 2008  |  Volume : 52  |  Issue : 3  |  Page : 311-316 Table of Contents     

Airway Management in Maxillofacial Trauma: A Retrospective Review of 127 Cases

Prof. and Head, Senior Advisor, Anaesthesiology, Command Hospital (Air Force), Bangalore - 560007, India

Date of Acceptance04-Mar-2008
Date of Web Publication19-Mar-2010

Correspondence Address:
V Saraswat
Command Hospital Air Force, Airport Road, Agram Post, Bangalore - 560007
Login to access the Email id

Source of Support: None, Conflict of Interest: None

Rights and PermissionsRights and Permissions

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.

Keywords: Maxillofacial injuries, Blind awake nasal intubation, Tracheostomy, Fibreoptic bronchoscopic intubation

How to cite this article:
Saraswat V. Airway Management in Maxillofacial Trauma: A Retrospective Review of 127 Cases. Indian J Anaesth 2008;52:311-6

How to cite this URL:
Saraswat V. Airway Management in Maxillofacial Trauma: A Retrospective Review of 127 Cases. Indian J Anaesth [serial online] 2008 [cited 2020 Oct 20];52:311-6. Available from: https://www.ijaweb.org/text.asp?2008/52/3/311/60640

   Introduction Top

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 [1] 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.

   Methods Top

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.

   Results Top

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.

   Discussion Top

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 [2] . 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 [3] . 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 [4] . 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, [5],[6],[7] nasopharyngeal [8] and naso-tracheal [9] 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 [10],[11],[12],[13],[14] . 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 [15] . 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 [16].

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 [17] 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 [18] . 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 [19]. 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 [20] 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 [21],[22] and both anterior and lateral submandibular routes [23],[24],[25] 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 [24] . 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 [26] . 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 [27],[28],[29] .

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.

   References Top

1.Trunkey DD. Trimodal distribution of death. Trauma SCI Am 1983; 249: 20-27  Back to cited text no. 1      
2.Casapi N, Zeltser R, Regev E, Shteyer A maxillofacial gun­shot injuries in hostility activities in 2000-2003 Refuat Hapeh Vehashinayim 2004; 21:47-53.  Back to cited text no. 2      
3.Weitzel N, Kendall J, Pons P. Blind nasotracheal intuba­tion for patients with penetrating neck trauma. J Trauma 2004; 56:1097-101.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]  
4.Norwood S, Myers MB, Butler TJ. The safety of emer­gency neuromuscular blockade and orotracheal intuba­tion in the acutely injured trauma patient. J Am Coll Surg 1994;179:646-52.  Back to cited text no. 4  [PUBMED]    
5.SeebacherJ, Nozik D, Mathieu A. Inadvertent intracranial introduction of a nasogastric tube, a complication of se­vere maxillofacial trauma. Anesthesiology 1975; 42: 100-2.  Back to cited text no. 5      
6.Bouzarth WF. Intracranial nasogastric tube insertion (Edi­torial). J Trauma 1978; 18: 818-9.  Back to cited text no. 6  [PUBMED]    
7.FremstadJD, Martin SH. Lethal complication from inser­tion of nasogastric tube after severe basilar skull frac­ture. J Trauma 1978; 18: 820-1.  Back to cited text no. 7      
8.Muzzi DA, Losasso TJ, Cucchiara RF. Complication from a nasopharyngeal airway in a patient with a basilar skull fracture. Anesthesiology 1991; 74: 366-8.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]  
9.Horellou MF, Mathe D, Feiss P. A hazard of naso-tra­cheal intubation (Letter). Anaesthesia 1978; 33:73-4.  Back to cited text no. 9  [PUBMED]    
10.Stehling LC. Management of the airway. In: Barash PG, Cullen BF, Stoelting RK (Eds.). Clinical Anesthesia, 2nd ed. Philadelphia: JB Lippincott Co 1992; 685-708.  Back to cited text no. 10      
11.Stone DJ, Gal TJ. Airway management. In: Miller RD (Ed.). Anesthesia, 4th ed. New York: Churchill Livingstone 1994;1403-35.  Back to cited text no. 11      
12.Florete OGJr. Airway management. In: Civetta JM, Taylor RW, Kirby RR (Eds.). Critical Care, 2nd ed. Philadelphia: JB Lippincott 1992; 1419-36.  Back to cited text no. 12      
13.Connell F. Management of the airway and endotracheal intubation. In: Murray MJ, Coursin DB, Pearl RG, Prough DS (Eds.). Critical Care Medicine. Perioperative Manage­ment. Philadelphia: Lippincott -Raven 1996; 57-70.  Back to cited text no. 13      
14.Gotta AW. Management of the traumatized airway. In: American Society of Anesthesiologists. Annual Re­fresher Course Lectures. Philadelphia: Lippincott, 1994: 226, 1-7.  Back to cited text no. 14      
15.Ba'hr W, Stoll P. Nasal intubation in the presence of frontobasal fractures: a retrospective study. J Oral Maxillofac Surg 1992; 50: 445-7.  Back to cited text no. 15      
16.Rhee KJ, Muntz CB, Donald PJ, TamadaJM. Does nasotracheal intubation increase complications in pa­tients with skull base fractures? Ann Emerg Med 1993; 22: 1145-7.  Back to cited text no. 16      
17.Smoot EC 3rd, Jernigan JR, Kinsley E, Rey RM Jr. A sur­vey of operative airway management practices for midface fractures. J Craniofac Surg 1997;8:201-207.  Back to cited text no. 17  [PUBMED]    
18.Walls RM. Airway management. Emerg Med Clin North Am 1993; 11:53-60  Back to cited text no. 18      
19.American college of surgeons committee on trauma. Air­way and ventilatory management In: Advance trauma life support for doctors. 6th Ed , Chicago: American col­lege of surgeons 1997; 59-72  Back to cited text no. 19      
20.Lord SA, Boswell WC, Williams JS, Odom JW, Boyd CR. Airway control in trauma patients with cervical spine frac­tures. Prehospital Disaster Med. 1994; 9:44-9.  Back to cited text no. 20      
21.Taher AAY. Nasotracheal intubation in patients with fa­cial fractures (Letter). Plastic Reconstr Surg 1992; 90: 1119­20.  Back to cited text no. 21      
22.Altemir FH. The submental route for endotracheal intu­bation. A new technique. Journal of Maxillofacial Sur­gery 1986; 14: 64-5.  Back to cited text no. 22      
23.Honig JF, Braun U. Laterosubmental tracheal intubation. An alternative method to nasal-oral intubation or tra­cheostomy in single-step treatment of pan facial multiple fractures or osteotomies. (German) Anaesthetist 1993; 42: 256-8.  Back to cited text no. 23      
24.Stoll P, Galli C, Wdchter R, Bdhr W. Submandibular en­dotracheal intubation in pan facial fractures (Letter). J Clin Anesth 1994; 6: 83-6.  Back to cited text no. 24      
25.Katsnelson T, Farcon E, Adamo AR. More on sub-man­dibular endotracheal intubation for panfacial frac-tures (Letter). J Clin Anesth 1994; 6: 527-8.  Back to cited text no. 25  [PUBMED]    
26.Caubi AF, , Vasconcellos RJ, Morais HH, Rocha NS. Sub­mental intubation in oral maxillofacial surgery: Review of the literature and analysis of 13 cases.Med Oral Patol Oral Cir Bucal 2008;13:E197-200.  Back to cited text no. 26  [PUBMED]  [FULLTEXT]  
27.Maharaj CH, Costello JF, Harte BH, Laffey JG. Evaluation of the Airtraq and Macintosh laryngoscopes in patients at increased risk for difficult tracheal intubation. Anaes­thesia 2008;63:182-8.  Back to cited text no. 27      
28.Hodzovic I, Wilkes AR, Stacey M, Latto IP. Evaluation of clinical effectiveness of the Frova single-use tracheal tube introducer. Anaesthesia 2008;63:189-94.  Back to cited text no. 28      
29.Ahmed SM, Khan RM, Maroof M, Ahmed M. Assess­ment of manoeuvres required for successful blind tra­cheal intubation through the PAXpress. Anaesthesia 2008;63:32-5.  Back to cited text no. 29  [PUBMED]  [FULLTEXT]  


  [Table 1], [Table 2]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article
    Article Tables

 Article Access Statistics
    PDF Downloaded799    
    Comments [Add]    

Recommend this journal