airway management of maxillofacial trauma

1. Maxillofacial trauma
GUIDE:
Dr Dilip Singh Chouhan Sir
By: Dr Jayesh Shakeet

2. RELEVANT ANATOMY
• Each individual maxilla can be conceptualized as a 5-
sided structure, the base of which makes up the lateral
nasal wall.
• The remaining 4 sides of the pyramid are composed of
• the orbital floor superiorly,
• the alveolar ridge inferiorly,
• the front wall of the maxillary sinus anteriorly, and
• the anterior face of the pterygopalatine fossa
posterolaterally.

3. • Important structures may be damaged during injury or
repair.
• The infraorbital nerve
• Branches of the internal maxillary artery provide much of
the vascular supply to the mid face
• In patients with extensive epistaxis or bleeding, ligation of
this artery may be necessary

4. PATHOPHYSIOLOGY
• Le Fort said that predictable patterns of fractures follow
certain types of injuries.
Three predominant types
were described.
• Le Fort I
• Le Fort I I
• Le Fort I I I

5. Le Fort I
• Fractures (horizontal) may result from a force of injury
directed blow on the maxillary alveolar rim in a downward
direction.The fracture extends from the nasal septum to the
lateral pyriform rims

6. Le Fort II
• Fractures (pyramidal) may result from a blow to the lower or
mid maxilla.
• Such a fracture has a pyramidal shape and extends from the
nasal bridge at or below the nasofrontal suture
• Free floating midface

7. Le Fort III
• Fractures (transverse): also termed craniofacial
dysjunctions, may follow impact to the nasal bridge or
upper maxilla

8. • In reality, the classification is an oversimplification
Maxillary fractures are a combination of the various Le
Fort types. Fracture lines often diverge from the described
pathways and may result in mixed-type fractures, unilateral
fractures, or other atypical fractures.
• In addition, in very high-energy blows, maxillary fractures
may be associated with fractures to the mandible, cranium
or both (ie, panfacial).

9. CLINICAL FEATURES
• Mechanism of the injury may assist in determining a
diagnosis.
• Mental status changes or loss of consciousness
• The presence of any functional deficiencies, such as
those related to airway, vision, cranial nerves, occlusion,
or hearing, may provide clues to fracture location and
resultant adjacent nonosseous injury

10. Physical examination
• Evaluation of the maxilla and facial bones should be
undertaken only after the patient has been fully
stabilized and life-threatening injuries have been addressed.
• In particular, airway considerations and intracranial
injuries must take immediate priority

11. • Periorbital swelling may indicate Le Fort II or III fractures.
• A global posterior retrusion of the mid face creates a
flattened appearance of the face.
The so-called dish-face or pan-face deformity may occur
after an extensive Le Fort II or Le Fort III fracture.

12. Imaging Studies
• Plain radiographs
• Historically, plain radiographs with Waters and
submental-vertical views of the paranasal sinuses,
lateral skull, and lateral cervical spine are used as
screening examinations.
• Lateral skull – films provide information about the global
anteroposterior position of the mid face and the integrity of
the inner and outer tables of the frontal sinus.
• Cervical spine films are important to exclude injury to
the vertebral column.

13. • CT scans
• Generally, CT scan images are taken of all patients
with possible facial fractures.
• Recently, CT scanning has become the modern standard of
care for diagnostic imaging (ie, criterion standard).

14. ANAESTHETIC MANAGEMENT
• Special Consideration
• Preoperative Management
• Intraoperative Management
• Post operative Management

15. • Problems:
• Major problem: Airway Management
• Extensive, long operation
• Significant blood loss
• Micro-vascular surgery
Caution with Vasoconstrictors
Caution with Transfusion
Caution with Diurresis
Blood Rheology (Hct:25-27)

16. Routine Monitoring
• NIBP / IBP
• ECG
• SPO2
• ETCO2
• TEMPERATURE

17. SPECIAL CONSIDERATIONS FOR
INTRA-OPERATIVE MANAGEMENT
• Two large bore canulae
• Invasive blood pressure monitoring
• Central venous pressure monitoring
• Use of muscle relaxants
• Induced hypotension
• Blood loss & transfusion
• Haemodynamic changes
• Venous air embolism

18. FACTORS WHICH DETERMINE
THE POSSIBLE
TECHNIQUE OF SECURING
THE AIRWAY
1.Anticipated difficult airway
2.Patient’s ability to open the mouth
3.Possibility of cervical spine fracture
4.Possibility of concurrent base skull fracture

19. VARIOUS METHODS AVAILABLE :
• Awake vs anaesthetized patient.
• Orotracheal vs nasotracheal intubation.
• Direct /blind nasal intubation/ fiberoptic.
• laryngoscopy
• Anterograde vs retrograde.
• Surgical Airway. Cricothyroidotomy.

20. AWAKE INTUBATION
• If the patient has an anticipated difficult
airway.
• Local anaesthesia of the upper airway is
essential
• for an awake oral / nasal intubation.

21. • BLIND NASOTRACHEAL INTUBATION:
• If the patient has an anticipated difficult airway which requires
an awake intubation and is also unable to open the mouth
(mechanical obstruction); blind nasotracheal intubation may be
done.
• This technique requires expertise; and monitors like
pulse oximeter and EtCO2 are helpful in guiding the
tracheal tube into the Larynx.

22. FIBEROPTIC INTUBATION
• Fiberoptic intubation may be the safest way to secure the
airway in a suspected cervical spine injury patient.
• Useful in cases of reduced mouth opening
• It can be almost impossible to see the larynx through a pool of
blood.
• Requires expertise

23. BULLARD LARYNGOSCOPE
• In patients with severe maxillofacial injuries , awake
intubation with conventional direct laryngoscopy may be
unsuccessful because of distorted airway anatomy, a cervical
collar, presence of excessive blood in the oropharynx and lack
of patient cooperation.
• Flexible fiberoptic laryngoscopy may not be possible because
of blood and secretions may be too numerous to allow
adequate visualization.

24. • The use of the Bullard laryngoscope, has a rigid fibreoptic system,
with a specialized blade, in conjunction with forceful oxygen flow
through its insufflation port, may allow the practitioner to
effectively clear blood and secretions in patients with maxillofacial
injuries.
• The oxygen insufflation port of the Bullard blade is much larger in
diameter than that of a conventional fiberoptic bronchoscope. This
allows for more forceful delivery of oxygen through the instrument.
• In addition, the Bullard laryngoscope is particularly
effective in trauma situations because the patient's head may be
maintained in a neutral position (eg without removing the cervical
collar, if present).

25. SUBMENTAL INTUBATION
• When both nasal and oral intubation are deemed
unsuitable, control of the airway can be achieved with
submental intubation .
• After induction of general anaesthesia orotracheal
intubation is achieved with an armoured tracheal tube
(with a detachable connector).
• Under all sterile conditions, a 1.5cm skin incision is made
in the submental region just medial to the lower border of
mandible.

26. An artery forcep is introduced through the submental
incision towards the floor of the mouth. An incision is
given in the floor of the mouth, and the deflated pilot
tube cuff along with the tube is pulled out through the
submental incision. The connector is reattached and
ventilation achieved.
• At the end of the surgery, the tube is pulled back into the oral cavity
and trachea extubated when the patient is awake.
• Since submental intubation requires adequate mouth opening for
the initial orotracheal intubation, this technique may not be
possible in maxillofacial trauma with restricted mouth opening.
Retrograde submental intubation with the help of a pharyngeal loop
assembly has been performed successfully in such situations.

27. RETROMOLAR INTUBATION
• Retromolar positioning of the tracheal tube in the retromolar trigone
during intermaxillary fixation provides an optimal intraoperative
control of dental occlusion.
• The tube is fixed at the angle of the mouth.
• At the end of the procedure, extubation can be achieved from the
retromolar space, when the patient is awake.
• A wire cutter should always be kept beside the patient in case of
emergency.

28. RETROGRADE INTUBATION
• In certain cases flexible fiberoptic bronchoscopy
is not possible either because of distorted anatomy or blood.
• Retrograde wire passed through the suction port of the
fiberoptic bronchoscope may guide the scope into the trachea.
• Requires considerable experience and expertise

29. ROLE OF SURGICAL
AIRWAY TECHNIQUES
• Maxillofacial injuries esp. in high velocity impacts, bullet
associated and blast victims, can be severe enough to make both
oral and nasal routes of intubation impossible.
• If repeated attempts at endotracheal intubation fail, emergency
cricothyroidotomy should be done.
• Cricothyroidotomy is a temporary measure, it should be
converted to a tracheostomy once acute hypoxia is relieved.
• For less emergent situations, tracheostomy under local
anaesthesia is recommended.

30. INTRA-OPERATIVE MANAGEMENT
• Two Large Bore Canulae
Two large bore canulae can be put in large veins so that rapid
fluid replacement can be carried out in case need arises.
• Invasive Blood Pressure Monitoring is indicated due to following
reasons :
• Blood loss may be rapid secondary to
Neck dissection
Pre operative radiotherapy
Surgery close to big vessels of neck
• Frequent fluctuations in the blood pressure due to manipulation
in the area of carotid body and sinus.

31. Central Venous Pressure
Monitoring
• Risk of venous air embolism during neck dissection
• As a guide to the management of fluid therapy
• The site of insertion is either:
 Antecubital vein
 Femoral vein

32. Use of Muscle Relaxants
• During surgery IPPV is carried out without
muscle relaxant as surgeons need to identify
the nerves during surgery

33. Induced Hypotension
Mild degree of hypotension is required during surgery to
reduce the blood loss. This can be achieved by following:
• 15-30 degree head up tilt
• Increasing the conc. of volatile anesthetics
• Use of peripheral vasodilators
• Use of beta blockers

34. Blood Transfusion
Before the decision of blood transfusion the following
points should be considered
• Patient’s underlying medical condition
• Possibility of risks of transfusion hazards
• Increased risk of post-transfusion cancer recurrence as a
result of immune suppression

35. Haemodynamic Changes
During radical neck dissection, the traction or pressure on
the carotid sinus and / or stellate ganglion can cause
following:-
• Brady-dysrhythmias
• Sinus arrest leading to asystole
• Wide swings in blood pressure
• Prolonged QT Interval

36. Haemodynamic Changes
Treatment
• Immediate cessation of the stimulus
• Blockage of the sinus with local anesthetic
by the surgeon
• Vagolysis by atropine

37. Venous Air Embolism
• When the venous pressure in neck veins is
low and these veins are open to atmosphere,
air is sucked in causing air embolism.
• Diagnosis
• Early Detection
• Hypoxia
• Hypotension
• Hypocarbia

38. Venous Air Embolism Treatment
• Compression of neck veins
• Positive pressure ventilation
• Place the patient in the left lateral position
• Aspiration of air through the central venous catheter
• Ionotropes

39. EXTUBATION
• Antiemetics are recommended to prevent vomiting after
intermaxillary fixation.
• Patients with maxillofacial injuries require a smooth emergence and
the ability to maintain their open airways at extubation.
• A unique means of avoiding difficult postoperative reintubations is
via placement of a pediatric airway exchange catheter.
• The decision to extubate the trachea is always a clinical judgment;
“when in doubt, don’t take it out.”

40. POST-OPERATIVE CARE
I. ROUTINE CARE
II. SPECIAL CONSIDRATIONS
• ICU care & Possible mechanical Ventilation
• Hemodynamic Instability
• Analgesia
• Tracheostomy

41. ICU Care & Possible Mechanical
Ventilation
Patient should be kept in the intensive care unit
for 24-48 hours in case of
• Prolonged Surgery
• Airway Oedema
• Co-existing diseases
• Risk of bleeding and or Neck hematoma

42. Haemodynamic Instability
• As bilateral neck dissection may result in
post-operative hypertension and hypoxic
drive because of the denervation of the
carotid sinus and carotid body

43. Analgesia
• Non Steroidal Anti-inflammatory Agents should be used as
opioids cause respiratory depression in spontaneously
breathing patients
• When patient is on ventilator opioid analgesia can be given

44. Tracheostomy Care
• Humidified Oxygen
• Intermittent Suction
• Sterile Precautions
• Adjustment of cuff pressure to15-20 mmHg