Trends in Anaesthesia and Critical Care xxx (2013) 1e7

Contents lists available at ScienceDirect

Trends in Anaesthesia and Critical Care

journal homepage: www.elsevier.com/locate/tacc

REVIEW

Anaesthetic management of maxillofacial trauma

Bikash R. Ray a, Dalim Kumar Baidya b, *, Devalina Goswami b, Anjan Trikha b, Ajoy Roychoudhury c, Ongkila Bhutia c
a

Fortis Medical Research Institute, Gurgaon, India Dept of Anaesthesia, All India Institute of Medical Sciences, New Delhi, India c Dept of Oral & Maxillo-facial Surgery, All India Institute of Medical Sciences, New Delhi, India
b

s u m m a r y
Keywords: Maxillofacial trauma Emergency management Airway Anaesthesia

Maxillofacial trauma, alone or as part of polytrauma, can pose a signicant challenge to the anaesthesiologist in the emergency department, in the operating room and in the intensive care unit as it may hamper effective airway management in these patients. Detailed knowledge of maxillofacial and airway anatomy can help in understanding the mechanism, diagnosing the extent and severity of injury and formulating a proper airway management plan. Basic principles of trauma care should be followed at every step. Moreover, the presence of experienced personnel with adequate airway expertise is essential. Anaesthetic drugs and techniques should be optimally tailored to ensure maximal patient safety. Crown Copyright 2013 Published by Elsevier Ltd. All rights reserved.

1. Introduction The incidence and aetiology of maxillofacial trauma have been found to be variable with socioeconomic status, religion, culture, geographical region and era.1 Major causes of maxillofacial trauma are road trafc accidents, falls from height, sports injuries, injuries due to assault and civilian warfare.2 Associated injuries to vital organs, soft tissues and skeletal framework make the management of these patients challenging. Anaesthesiologists may be needed early on in the management of these patients in the emergency department especially for securing the airway and later on in the operating room for denitive surgical procedure. The emergency department management of unstable patients requires an emphasis on initial resuscitation and stabilization of the patient together with judicious use of anaesthetic drugs and airway devices for securing the airway. In the elective scenario proper planning of the anaesthetic and airway management is essential. In the current review, both the early emergency department management and the late operating room management of maxillofacial trauma have been discussed on the background of relevant anatomy and the mechanism of injury.

2. Relevant anatomy An understanding of the maxillofacial anatomy is essential for the proper management of maxillofacial trauma. The human skull is divided into two major parts: the calvaria, which encloses and protects the brain, and the facial skeleton with mandible. The facial skeleton is further subdivided into the following three parts: The upper face: frontal bone and the fronto-zygomatic processes. Midface: orbits, nasal bones, ethmoid bone, zygomatic bones and maxilla. Lower face: mandible. The zygomatic bones together with temporal and frontal bones form a series of arches and buttresses to protect the intracranial contents. The muscles involved in mastication (masseter, temporalis and pterygoids) are attached to the mandible and produce a hinge-like and gliding movement at the temporomandibular joint (TMJ) to fully open the mouth.3

3. Aetiology and incidence of maxillofacial trauma Assaults followed by motor vehicle accidents are the most frequent cause of facial trauma in developed countries.4 Sports injuries, falls and industrial accidents are other common causes. In developing countries motor vehicle accidents still remain the most common cause.1,5 Eighty to ninety percent of maxillofacial traumas

* Corresponding author. Dept of Anaesthesia, All India Institute of Medical Sciences, Room No 507, 5th Floor, CDER, New Delhi 110029, India. Tel.: 91 9868398013. E-mail address: dalimkumarb001@yahoo.co.in (D.K. Baidya).

2210-8440/$ e see front matter Crown Copyright 2013 Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.tacc.2013.07.001

Please cite this article in press as: Ray BR, et al., Anaesthetic management of maxillofacial trauma, Trends in Anaesthesia and Critical Care (2013), http://dx.doi.org/10.1016/j.tacc.2013.07.001

Review / Trends in Anaesthesia and Critical Care xxx (2013) 1e7

are found in men and it may be associated with drug or alcohol intoxication.1,4e6 Motor vehicle accidents more commonly produce fractures of the midface whereas trauma due to assault commonly leads to a fracture of the nasal bones, mandible and zygoma.7 Mandibular fractures following assault commonly involve the body, whereas injury due to falls especially in children involve the condyles of the mandible.1,6 Other causes of facial trauma may be penetrating injuries (knife and gunshot wounds) and domestic violence. Trauma due to penetrating injuries and industrial accidents are usually extensive and involve complex fractures with comminution and loss of soft tissue.4 4. Pathophysiology When a moving object is suddenly subjected to a deceleration force, rapid dispersion of the kinetic energy leads to injuries and trauma. The force generated is classied into high-impact or lowimpact force depending on whether the force is more than or less than 50 times the force of gravity. The resultant injury after an impact depends on the strength of the bone as well. High impact force is required for producing trauma to the supraorbital rim, frontal bones, maxilla, mandibular symphysis and angles. The zygoma and nasal bones may get damaged by even low-impact force.7 5. Classication and presentation Maxillofacial trauma involves both injuries of the soft tissues and bony skeleton. Bony injuries are classied according to the part of the face involved: 5.1. Upper face fractures Fractures involving the frontal bone and sinuses. Usual presentation includes disruption of the supraorbital rims and paraesthesia of the supraorbital and supratrochlear nerves. 5.2. Mid-face fractures

LeFort I: This is a dento-alveolar horizontal fracture that separates the maxillary alveolus from the mid-face. It presents as facial oedema and mobility of the hard palate, maxillary alveolus and teeth. LeFort II: This is a pyramidal or triangular fracture that separates maxilla from the zygoma. Clinical presentation includes facial oedema, subconjunctival haemorrhage, tele-canthus, mobility of the maxilla at the naso-frontal suture, epistaxis and possible cerebrospinal uid (CSF) rhinorrhoea. LeFort III: This is a complete dislocation of the facial skeleton from the cranial skeleton running parallel to the skull base. Characteristic ndings of LeFort III include massive oedema with facial rounding or elongation and attening and movement of all facial bones in relation to the cranial base with manipulation of the teeth and hard palate. Epistaxis and CSF rhinorrhoea may also be present.

5.3. Lower face fractures Involve fractures of the mandible. Condylar fracture presents as tenderness anterior to the external auditory meatus. Fractures of the mandibular body present as painful jaw movement and malocclusion of the teeth. Bilateral mandibular fracture can present as an anterior open bite or an open hanging mouth. The loss of normal contour of the face following fracture of the mandible was classically described as Andy Gump after a famous cartoon character of 1930s.3,8 At times posterioreinferior displacement of the fractured mandibular segment can cause airway obstruction. Mandibular fracture involving the angle, body or parasymphysis may cause disruption of the inferior alveolar nerve leading to paraesthesia or anaesthesia of half of the lower lip, chin, teeth and gingiva.7 5.4. Pan-facial fractures This includes fractures involving the upper, mid and lower face. Physical ndings depend on the combination of fractures sustained. 6. Emergency management

Fractures involving nasal bones, orbital oor, naso-ethmoid, zygomatic arch and maxilla. The mid facial fractures are named after Rene LeFort, who in 1902 tried to nd out the correlation between external evidence of facial trauma with the severity of the underlying facial fractures. Although no such correlation was found in his study, three patterns of mid-face fractures were identied (Fig. 1).3,7

6.1. Initial assessment and management A rapid and thorough evaluation of the patient should be performed according to the Advanced Trauma Life Support (ATLS) protocol i.e., ABCDE. (A airway management with cervical spine control, B assessment of breathing and ensuring ventilation,

Fig. 1. Le Fort fractures Type IeIII.

Please cite this article in press as: Ray BR, et al., Anaesthetic management of maxillofacial trauma, Trends in Anaesthesia and Critical Care (2013), http://dx.doi.org/10.1016/j.tacc.2013.07.001

Review / Trends in Anaesthesia and Critical Care xxx (2013) 1e7

C checking circulation with haemorrhage control, D delineating disability or assessing the neurological status, E exposure and removing the patient from harmful environment or chemicals).9,10 Immediate management of maxillofacial injuries is required when impending or existing airway compromise and/or profuse haemorrhage is present. After securing the airway, the patient should be stabilized rst before performing any emergency surgery. Among soft tissue injuries ophthalmic injury should be treated on a priority basis. Surgeries for facial skeleton reconstruction can be done later as semi-elective procedures.4 6.1.1. Airway management 6.1.1.1. Airway injuries in maxillofacial trauma. Upper airway obstruction (complete, partial or impending) requires emergent airway management. Hutchinson et al.11 described six specic patterns of injury which may adversely affect the airway: 1. Postero-inferior displacement of a fractured maxilla may obstruct the nasopharyngeal airway. 2. Bilateral anterior mandibular or para-symphysial fracture may cause the tongue to fall back in supine patients due to loss of its anterior insertion leading to oropharyngeal obstruction. 3. Teeth, vomitus, blood, bone-fragments and other foreign bodies may obstruct the airway. 4. Haemorrhage may contribute to airway obstruction. 5. Soft tissue swelling, oedema and haematoma resulting from trauma to the head and neck may result in delayed airway compromise. 6. Laryngotracheal trauma may cause swelling and displacement of anatomic structures like the epiglottis, arytenoid cartilages and vocal cords leading to airway obstruction. A high index of suspicion along with a meticulous physical examination and close observation is required for early detection and timely management. A universal technique for airway management is not applicable in all circumstances. Hence a timely, decisive and skilful management of the airway can often make the difference. 6.1.1.2. Airway management: initial consideration. Urgent airway management in maxillofacial trauma requires a trained anaesthesiologist. Initial steps in the assessment involve seeking a verbal response followed by direct inspection of the mouth and pharynx for any signicant bleed, foreign body and obstruction.12 All patients with maxillofacial trauma should be considered to have cervical spine (C-spine) injury unless proven otherwise10 and mandate C-spine protection by application of a hard collar/ spine board from the early stages of assessment.12 The airway should be periodically reassessed as delayed airway compromise may occur due to displacement of tissue, haematoma and oedema.13 As per ATLS protocol, all trauma patients should receive high ow oxygen along with pulse oximetry monitoring.12 The mouth, nose and pharynx should be cleared of all the secretions using wide bore suction. Lack of protective gag reex during suctioning requires tracheal intubation. Jaw thrust and chin lift manoeuvre commonly used to maintain the airway, may not be possible in a comminuted mandibular fracture. Care should be taken to prevent C-spine movement during these manoeuvres.14 Head tilt and snifng the morning air positions are contraindicated in case of suspected C-spine injury.12 An oropharyngeal airway may induce vomiting and laryngospasm; nasopharyngeal airway is better tolerated but may be associated with bleeding and is not advisable in suspected skull base fractures.12 In a patient with patent airway and absent spontaneous breathing, bag and mask ventilation should be initiated and continued till a denitive airway is

established. Preferably, a two person technique should be used for bag and mask ventilation in trauma victim cases. In an emergency situation a simple and straightforward approach is needed for airway management. The available options are orotracheal intubation, nasotracheal intubation or a surgical airway (cricothyroidotomy or tracheostomy). Direct laryngoscopy and orotracheal intubation is the most commonly preferred method. It is essential to perform manual in-line cervical immobilization during orotracheal intubation if C-spine is not cleared. In the absence of craniofacial and mid-face injury, nasotracheal intubation can be performed. If the mouth opening is adequate, direct laryngoscopy guided intubation is suitable. However, in the absence of an adequate mouth opening, either blind or breoptic bronchoscope guided nasotracheal intubation can be tried. Presence of blood and secretions in the airway and the unavailability of trained personnel may limit the usefulness of the breoptic bronchoscope in an emergency situation.12 When both mask ventilation and intubation are difcult, laryngeal mask airway (LMA) and combitube may be helpful.12,15 These devices are easy to insert and require minimal expertise. Although LMA does not provide a denitive airway it is a bridging airway device to ventilate the patient until a denitive airway is achieved. The combitube is inserted blindly, mainly in the pre-hospital setting. It is difcult to insert in patients with distorted anatomy and insertion may at times result in serious complications such as the formation of a false track, tongue oedema, vocal cord injury, tracheal injury and esophageal injury.16 Surgical airway under local anaesthesia may be the only available option in some cases where it is not possible to secure the airway with the help of a direct/breoptic laryngoscope within a safe period of time. In an emergency, available options are: cricothyroidotomy (needle or surgical) and tracheostomy (surgical or percutaneous). The cricothyroid membrane is the preferred site for emergency surgical access as it is supercial, less vascular, easily identiable and associated with a low rate of complications.17 ATLS protocol advocates needle cricothyroidotomy, but its routine use remains controversial.10 However, it provides limited oxygenation while waiting for surgical cricothyroidotomy. Surgical cricothyroidotomy is now considered the most appropriate choice for emergency airway control.18 In contrast to needle cricothyroidotomy, a larger airway can be introduced and effective positive pressure ventilation can be achieved. In an emergency setting, tracheostomy is inappropriate as it is time consuming and difcult to perform.12 However, McClure et al. advocated percutaneous tracheostomy using dilating forceps as an emergency salvage airway procedure in the hands of experienced practitioners.19 6.1.1.3. Factors affecting emergency airway management in maxillofacial trauma. Apart from the problem of an anticipated difcult airway, several other factors may worsen the scenario: 6.1.1.3.1. Distorted anatomy. The maxillofacial trauma is associated with both difcult mask ventilation and difcult intubation. Mechanical trauma, bleeding and oedema usually disrupt the normal anatomy which makes mask ventilation and intubation difcult.12,15 6.1.1.3.2. C-spine injury. Cervical spine injury in patients with maxillofacial trauma has been reported to be associated in up to 6% of cases.20e22 However, any patient with maxillofacial trauma should be considered to have associated C-spine injury until proven otherwise. C-spine must be immobilized until it is cleared for injury, which may take hours to days. Accepted immobilisation techniques are a rigid collar, blocks and straps.12 Clinical examination alone or in combination with radiological investigations in doubtful cases have been recommended for C-spine clearance.23,24 Clinically, C-spine clearance is acceptable if the patient meets the

Please cite this article in press as: Ray BR, et al., Anaesthetic management of maxillofacial trauma, Trends in Anaesthesia and Critical Care (2013), http://dx.doi.org/10.1016/j.tacc.2013.07.001

Review / Trends in Anaesthesia and Critical Care xxx (2013) 1e7

following criteria12: 1) Glasgow Coma Scale (GCS) score of 14e15 (fully awake), 2) not intoxicated, 3) absence of distracting injuries, 4) absence of pain and tenderness on deep palpation of the spine and 5) active movement without pain and neurological changes. Most of the patients can be cleared on clinical grounds and imaging may be required in doubtful cases. Available imaging options are plane radiograph, CT, MRI and dynamic uoroscopy.12,25 In-line stabilization by an assistant at the time of intubation prevents neck movement.26 Recent data suggests that direct laryngoscopy and intubation is unlikely to cause clinically signicant neck movement. Similarly, in-line stabilization may not always immobilize injured segments effectively27 and degrade the laryngoscopic view, which may cause hypoxia and worsen the outcome in traumatic brain injury.28,29 Use of the McCoy laryngoscope and bougie has been found to cause less C-spine movement.12,30,31 Robitaille and coworkers advocated using the GlideScope (videolaryngoscope) for minimizing neck movements in these situations.32 6.1.1.3.3. Full stomach. Like any trauma patient, these patients should always be considered to have a full stomach. In addition, pain due to trauma, alcohol and swallowed blood increases the gastric emptying time and the use of opioids for pain relief may result in nausea, vomiting and increase the risk of regurgitation and aspiration. Although the insertion of a nasogastric tube for evacuation of gastric content is often practised, it may not always be possible and may trigger vomiting. Rapid sequence induction and Sellicks manoeuvre have traditionally been recommended to prevent aspiration.33 Although widely used, the effectiveness and safety of the technique have been questioned.34 Moreover, several studies have shown that cricoid pressure may signicantly worsen the laryngeal view, making endotracheal intubation more difcult.35e37 H2 blockers, gastrokinetics, and nonparticulate antacids have a limited role in an emergency setting. 6.1.1.3.4. Laryngotracheal injury. Laryngeal injuries are rare but when present may lead to life threatening airway obstruction.38 Nearly 96% of patients with laryngotracheal trauma have associated maxillofacial injuries.39 The most common mechanism is blunt trauma. Common signs and symptoms of laryngeal injury are subcutaneous emphysema, haemoptysis, ecchymosis, laryngeal tenderness, crepitus and widening of thyroid membrane and even stridor. Management options may be conservative or surgical correction depending on airway obstruction, CT scan ndings and the amount of cartilage displacement. Evaluation of the laryngeal injury starts with ensuring a patent airway. Orotracheal intubation may cause iatrogenic damage and is hazardous. The preferred articial airway in these patients is a tracheostomy and it should be performed whilst awake under local anaesthesia.39 6.1.1.3.5. Emergency situations. Emergency airway management poses an additional difculty as both decision making and the time to accomplish the task are short and the patients condition may deteriorate quickly. The performance of urgent or emergent intubation is associated with high complication rates, which may exceed 20%. Several factors, including repeated attempts, direct laryngoscopy without muscle relaxation and lack of operator experience have been implicated behind this high failure rate.40e43 6.1.1.3.6. Availability of experienced personnel. Several studies have shown that proper assessment, timely decision making and execution of treatment priorities reduce the complication rate particularly when skilled and experienced personnel are available. However, in most of the emergency situations, the inverse care law is applied i.e. the care of these critical patients are in the hands of caregivers who are not so expert in managing these cases.44,45 Schmidt and coworkers46 found that the complication rate in emergency tracheal intubation was signicantly lower when supervised by an attending anaesthesiologist.

6.1.2. Haemorrhage control Circulatory shock from haemorrhage in maxillofacial trauma is uncommon47; therefore if shock is present other bleeding sources should be looked for. In maxillofacial trauma, supercial bleeding from the soft tissue of the face can be easily managed. Bleeding from the middle third of the face or base of the skull may be profuse and should be evaluated by a maxillofacial surgeon. Bleeding from the mid-face generally presents with bleeding from the mouth, nose and cheek swelling. Bleeding from skull base fractures should be excluded by palpating the pharyngeal wall for the presence of tears and fractures. A tear of the maxillary artery can result in signicant haemorrhage which requires packing of the anterior and posterior nasal spaces. Careful application is essential to prevent partial airway obstruction by packing.48 A rupture of the inferior alveolar artery may be due to a fracture of the mandible body, requiring emergent reduction and stabilization of the fracture. Tongue lacerations may at times cause signicant haemorrhage that is hard to control. When common modalities of treatment such as pressure, packing, and correction of coagulopathy fail to control the haemorrhage, trans catheter arterial embolization is a safe alternative to surgical control.49 6.1.3. Soft tissue injuries Soft tissue injuries especially lacerations should be thoroughly cleaned and sutured under local anaesthesia. Swelling due to these injuries can have an insidious onset and may maximize 10e12 h after the injury. These patients should be closely monitored for the development of any airway obstruction. 6.1.4. Pain management Mobile facial fractures may be very painful and should be managed with analgesics like paracetamol and non-steroidal antiinammatory drugs (NSAID). Opioids and sedative drugs should be avoided particularly in cases of partial and impending airway obstruction and in patients with associated traumatic brain injury, where neurological monitoring is required. 6.1.5. Infection prevention Broad-spectrum antibiotics may be used prophylactically in cases of associated dural tear and CSF leak. However, retrospective studies indicate that prophylactic antibiotics do not signicantly affect the incidence of meningitis in patients with a CSF leak.50 Prophylactic antibiotics may however be recommended if there is evidence that infected material was introduced into the wound during injury or if there are deep wounds with a chance of developing anaerobic infections. 7. Late management Denite surgery for fractures and soft tissue injuries should be done electively after the initial stabilization. Surgery should be deferred till the oedema subsides.5 However, an excessive delay may interfere with the nal outcome of the surgery. 7.1. Preoperative evaluation and preparation The mechanism of injury, extent of injury and other associated injuries should be considered during the preoperative evaluation. A review of the preoperative radiological imaging (CTscan) helps in assessing the extent of maxillofacial injury and formulating an appropriate airway management plan. It also helps in diagnosing or excluding associated head and cervical spine injury. A limited mouth opening may be due to pain or TMJ injuries. Sedation and analgesia during induction will improve mouth

Please cite this article in press as: Ray BR, et al., Anaesthetic management of maxillofacial trauma, Trends in Anaesthesia and Critical Care (2013), http://dx.doi.org/10.1016/j.tacc.2013.07.001

Review / Trends in Anaesthesia and Critical Care xxx (2013) 1e7 Table 1 Advantages and disadvantages of different airway management techniques. Technique Oral endotracheal intubation Retromolar endotracheal intubation Advantage Fastest method of airway control Nonsurgical Both maxillo-mandibular and nasal surgery are possible Easy, time efcient Maxillo-mandibular xation possible Direct visualization of airway Both maxillo-mandibular and nasal surgery are possible Acceptable scar Disadvantage

Fibreoptic nasotracheal intubation

Submental intubation

Tracheostomy

Comfortable for patient Airway security Long term Ventilatory support possible Better pulmonary toileting

Maxillo-mandibular xation not possible Tube in operating eld Mucosal trauma Long buccal nerve palsy Risk of inadequate occlusion Contraindicated in skull base fracture Nasal surgery not possible Risk of epistaxis Surgically invasive procedure Can be kept for 24e48 h Not suitable for long period of ventilation Risk of infection Risk of salivary stula Not suitable for repeated surgery Invasive, Time consuming procedure, Risk of bleeding and pneumothorax, Need for post-tracheostomy care Risk of tracheal stenosis

opening if it is due to pain. Care should be taken to ascertain any loose teeth so as to prevent aspiration during airway management. 7.2. Anaesthesia and airway management In contrast to an emergency situation, the anaesthesiologist has a wider variety of airway management options for elective procedures. An evaluation for cervical spine injury should be done before the surgery. Peterson and coworkers51 reported that the risk of airway-related complications associated with difcult airway management exists throughout the peri-operative period (67% at induction, 15% in the intraoperative period, 12% at extubation and 5% during recovery) in patients with maxillofacial trauma. A proper airway management plan should be formulated and discussed with all the team members. A difcult airway cart including emergency cricothyroidotomy and tracheostomy sets should be available. The technique should be chosen based on a patients injuries, status of the airway and the anaesthesiologists experience. In this review, we have focused on only a few of the basic airway management techniques and devices which can be used for managing maxillofacial trauma (Table 1). Direct laryngoscopy and orotracheal intubation is the preferred technique with due care to minimize manipulation of the fractures and to maintain in-line stabilization of the neck in case of C-spinal injury. The GlideScope (video laryngoscope) is designed for the visualization of vocal cords with minimal manipulation and may be helpful during a difcult intubation.32 However, as the presence of an oral endotracheal tube may interfere with maxillofacial xation, nasal intubation is an option, but care should be taken to avoid complications like epistaxis, avulsion of the adenoids or tonsils, retropharyngeal dissection, turbinectomy and even inadvertent intracranial placement of the nasotracheal tube.52e54 However, contrary to the popular belief, nasal intubation has been found to be safe in cases of skull base fractures.55e57 Flexible breoptic bronchoscope guided intubation under local anaesthesia in an awake patient, using either the oral or nasal route, is preferred in cases of difcult intubation, difcult mask ventilation and cervical spine injury58 but this is not free of risk. The inability to accomplish effective local anaesthesia and the requirement for patient cooperation are other limitations of this technique. When nasal intubation is not advisable, retromolar intubation may be helpful in avoiding invasive procedures (tracheostomy, submental intubation) for securing the airway.59 After routine

orotracheal intubation has been performed with a slightly smaller endotracheal tube, the tube is pushed into the retromolar space or missing tooth space and secured with stitches. The main advantage of this technique is minimal interference in the surgical eld and achievement of proper intraoperative dental occlusion. It can also be used if prolonged ventilatory support is required in the postoperative period. However, intraoperative peak airway pressures should be closely monitored.60e62 The retrograde intubation technique has been described in the difcult intubation scenario. It is associated with minimal neck movement but its experience in a trauma setting is limited. In a case of maxillofacial trauma, passing the guide wire cephaloid and bringing it out through the oral cavity may be difcult. Impaction of the endotracheal tubes on the anterior commissure of the larynx is another common difculty which limits its usefulness.12,63,64 Submental and submandibular approach for intubation are the other two methods of securing the airway in case of mid-facial and pan-facial trauma. These techniques may be useful where orotracheal or nasotracheal intubations are not feasible or contraindicated. This technique avoids interference of the orotracheal tube in the surgical eld or the need for surgical tracheostomy. In the classic submental technique, after standard orotracheal intubation with an armoured tube, a small incision is made in the submental region adjacent to the mandible. This is followed by creating a tunnel through the muscular layers up to the oral mucosa using a blunt dissection technique. After the access is made the tube is taken out through the tunnel and secured with sutures. The submental intubation should be converted to an orotracheal intubation before extubation. It is contraindicated when long term airway support is required.65 Schutzet et al.66 compared submental intubation and tracheostomy for airway management in maxillofacial trauma patients. They suggested that the submental approach is associated with low morbidity and can be a replacement for a tracheostomy in selected patients where prolonged ventilation is not required. This approach has been used successfully with few minor complications in maxillofacial trauma. Infection of the wound, salivary stula, mucocele and hypertrophic scar are some of the relatively rare complications of the submental approach which can be avoided by using a meticulous technique.65 Submandibular intubation is a modication of submental intubation where the incision is made posteriorly in the submandibular area, avoiding injury to the important salivary structures (sublingual and submandibular ducts and lingual nerve). Anwer and

Please cite this article in press as: Ray BR, et al., Anaesthetic management of maxillofacial trauma, Trends in Anaesthesia and Critical Care (2013), http://dx.doi.org/10.1016/j.tacc.2013.07.001

Review / Trends in Anaesthesia and Critical Care xxx (2013) 1e7

coworkers have described the successful use of this approach in maxillofacial surgical patients.67 Surgical airway (cricothyroidotomy and tracheostomy) is required, when it is not possible to secure the airway by other means within a safe period of time, in an emergency situation. It is also a relatively safe option in the elective situation.68 However, it may be painful and is associated with a 5% risk of complications such as bleeding and pneumothorax.15 Nevertheless it is probably the best option when the trauma is extensive, when prolonged jaw wiring i.e. maxillo-mandibular xation is needed or when a patient is expected to require long term ventilation. The use of total intravenous anaesthesia in these groups of surgical patients has many advantages. Short acting drugs enable rapid awakening and the return of airway reexes, which helps in immediate neurological monitoring in cases of associated head injury and cooperation in eye testing after zygomatic and orbital oor surgeries.4 Simple measures like maintaining adequate hydration, normocapnia and head up tilt can decrease intraoperative blood loss. Controlled hypotension has a limited role in these cases. 8. Post-operative management and recovery Postoperative considerations include planning extubation strategy, pain management, prevention and treatment of nausea and vomiting (PONV), anti-oedema measures and monitoring for secondary haemorrhage. Extubation strategy depends on the preoperative airway compromise, medical comorbidities, duration of the surgery, anticipated postoperative airway oedema, use of maxillo-mandibular xation devices, haemodynamic stability, level of consciousness and airway reexes.3 Throat packs are commonly placed in the pharynx during surgery in order to prevent the aspiration of blood and surgical debris. Care should be taken to ensure removal at the end of surgery prior to tracheal extubation as undetected retained oropharyngeal packs can lead to airway obstruction.69 Tracheal extubation in these patients should be considered as at e risk extubation as per the extubation guidelines.70 Preoxygenation, head up positioning, oropharyngeal suction and alveolar recruitment should be performed prior to extubation. Awake extubation, extubation with remifentanil infusion and airway exchange catheter guided extubation are the techniques available for extubation in maxillofacial surgical patients.70 If uncertainty remains regarding the safety of extubation, it may be prudent to keep the patient intubated until further assessment yields reassuring evidence or a decision can be taken to proceed with a tracheostomy to protect the airway. Direct visualization with a exible breoptic endoscope and a cuff-leak test prior to extubation, may be helpful in evaluating the patency of the upper airway. The cuff-leak test (CLT) helps to identify patients at risk of developing post-extubation stridor due to laryngeal oedema. However the discrimination power of CLT is highly variable. While the presence of cuff-leak predicts successful extubation, a failed cuff-leak test is not an accurate predictor of post-extubation stridor and if used as a criterion for extubation may lead to unnecessarily prolonged intubation or to unnecessary tracheostomy.71,72 In cases where a delayed extubation is planned, the patients should be monitored either in the post-anaesthesia care unit or in the intensive care unit. In patients in whom maxillo-mandibular xation is done, wire-cutters should be available at the bedside at all times for emergency airway intervention. Patient-controlled analgesia appears to be a useful approach to managing pain in this patient population.73 Alternately, a multimodal analgesia strategy using combinations of opioids and nonsteroidal analgesics may be helpful.

These patients may have increased PONV due to the presence of swallowed blood, secretions and the use of opioids for pain control. Successful treatment may require multiple agents, including gastrokinetics, butyrophenones, steroids, and 5HT3 receptor antagonists. The patient should be closely monitored in the postoperative period for evidence of bleeding. Early bleeding frequently presents as slow oozing, leading to haematoma formation which may obstruct the airway, requiring emergency airway management and surgical exploration. Secondary bleeding may occur approximately 10 days after surgery, usually attributable to wound infection and may be severe enough to warrant surgical intervention.3 9. Conclusion Basic principles of trauma care should be followed in the management of maxillofacial trauma patients. Prompt and thorough evaluation of the severity of injury and successful airway management determines emergency department survival. Direct laryngoscopy and orotracheal intubation is still considered the technique of choice for securing an airway in the emergency department unless contraindicated. Denitive surgical management should be scheduled later as an elective manner. Difcult airway equipment including a breoptic bronchoscope with the availability to alternate airway management techniques including surgical airway and a clear back up plan are essential. The presence of an experienced anaesthesiologist with expertise in various types of airway equipment and experience in managing maxillofacial trauma may improve patient care. Conict of interest The authors do not have any conict of interest related to the preparation of this manuscript. References
1. Motamedi MH. An assessment of maxillofacial fractures: a 5 year study of 237 patients. J Oral Maxillofac Surg 2003;61(1):61e4. 2. Telfer MR, Jones GM, Shepherd JP. Trends in the aetiology of maxillofacial fractures in the United Kingdom (1977e1987). Br J Oral Maxillofac Surg 1991;29(4):250e5. 3. Krohner RG. Anesthetic considerations and techniques for oral and maxillofacial surgery. Int Anesthesiol Clin 2003;41(3):67e89. 4. Curran JE. Anesthesia for facial trauma. Anesth Intensive Care Med 2005;6: 258e62. 5. Raval CB, Rashiduddin M. Airway management in patients with maxillofacial trauma e a retrospective study of 177 cases. Saudi J Anaesth 2011;5(1):9e14. 6. Chidzonga MM. Mandibular fractures, analysis of 541 cases. Cent Afr J Med 1990;36(4):97e103. 7. Adamo AK. Initial evaluation and management of maxillofacial injuries. Emedicine.medscope.com [accessed 20.02.13]. 8. Seshul MB, Sinn DP, Gerlock Jr AJ. The Andy Gump fracture of the mandible: a cause of respiratory obstruction or distress. J Trauma 1978;18(8):611e2. 9. Mohan R, Iyer R, Thaller S. Airway management in patients with facial trauma. J Carniofac Surg 2009;20(1):21e3. 10. American College of Surgeons Committee on Trauma. Advanced trauma life support for doctors ATLS. 7th ed. Chicago: American College of Surgeons; 2004. p. 1e391. 11. Hutchison I, Lawlor M, Skinner D. ABC of major trauma. Major maxillofacial injuries. BMJ 1990;301(6752):595e9. Erratum in: BMJ 1990;301(6755):804. 12. Perry M, Morris C. Advanced trauma life support (ATLS) and facial trauma: can one size t all? Part 2: ATLS, maxillofacial injuries and airway management dilemmas. Int J Oral Maxillofac Surg 2008;37(4):309e20. 13. Ardekian L, Rosen D, Klein Y, Peled M, Michaelson M, Laufer D. Life-threatening complications and irreversible damage following maxillofacial trauma. Injury 1998;29(4):253e6. 14. Donaldson 3rd WF, Heil BV, Donaldson VP, Silvaggio VJ. The effect of airway maneuvers on the unstable C1-C2 segment. A cadaver study. Spine (Phila Pa 1976) 1997;22(11):1215e8. 15. Krausz AA, El-Naaj IA, Barak M. Maxillofacial trauma patient: coping with the difcult airway. World J Emerg Surg 2009;4:21.

Please cite this article in press as: Ray BR, et al., Anaesthetic management of maxillofacial trauma, Trends in Anaesthesia and Critical Care (2013), http://dx.doi.org/10.1016/j.tacc.2013.07.001

Review / Trends in Anaesthesia and Critical Care xxx (2013) 1e7 16. Vzina MC, Trpanier CA, Nicole PC, Lessard MR. Complications associated with the Esophageal-Tracheal Combitube in the pre-hospital setting. Can J Anaesth 2007;54(2):124e8. 17. Wright MJ, Greenberg DE, Hunt JP, Madan AK, McSwain Jr NE. Surgical cricothyroidotomy in trauma patients. South Med J 2003;96(5):465e7. 18. Salvino CK, Dries D, Gamelli R, Murphy-Macabobby M, Marshall W. Emergency cricothyroidotomy in trauma victims. J Trauma 1993;34(4):503e5. 19. McLure HA, Dob DP, Mannan MM, Soni N. A laboratory comparison of two techniques of emergency percutaneous tracheostomy. Anaesthesia 1997;52(12):1199e201. 20. Beirne JC, Butler PE, Brady FA. Cervical spine injuries in patients with facial fractures: a 1-year prospective study. Int J Oral Maxillofac Surg 1995;24(1 Pt 1): 26e9. 21. Haug RH, Wible RT, Likavec MJ, Conforti PJ. Cervical spine fractures and maxillofacial trauma. J Oral Maxillofac Surg 1991;49(7):725e9. 22. Hackl W, Hausberger K, Sailer R, Ulmer H, Gassner R. Prevalence of cervical spine injuries in patients with facial trauma. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;92(4):370e6. 23. Jones PS, Wadley J, Healy M. Clearing the cervical spine in unconscious adult trauma patients: a survey of practice in specialist centres in the UK. Anaesthesia 2004;59(11):1095e9. 24. Grossman MD, Reilly PM, Gillett T, Gillett D. National survey of the incidence of cervical spine injury and approach to cervical spine clearance in U.S. trauma centers. J Trauma 1999;47(4):684e90. 25. Griffen MM, Frykberg ER, Kerwin AJ, Schinco MA, Tepas JJ, Rowe K, et al. Radiographic clearance of blunt cervical spine injury: plain radiograph or computed tomography scan? J Trauma 2003;55(2):222e7. 26. Crosby ET. Airway management in adults after cervical spine trauma. Anesthesiology 2006;104(6):1293e318. 27. Lennarson PJ, Smith D, Todd MM, Carras D, Sawin PD, Brayton J, et al. Segmental cervical spine motion during orotracheal intubation of the intact and injured spine with and without external stabilization. J Neurosurg 2000;92(2 Suppl.):201e6. 28. Manoach S, Paladino L. Manual in-line stabilization for acute airway management of suspected cervical spine injury: historical review and current questions. Ann Emerg Med 2007;50(3):236e45. 29. Santoni BG, Hindman BJ, Puttlitz CM, Weeks JB, Johnson N, Maktabi MA, et al. Manual in-line stabilization increases pressures applied by the laryngoscope blade during direct laryngoscopy and orotracheal intubation. Anesthesiology 2009;110(1):24e31. 30. Gabbott DA. Laryngoscopy using the McCoy laryngoscope after application of a cervical collar. Anaesthesia 1996;51(9):812e4. 31. Laurent SC, de Melo AE, Alexander-Williams JM. The use of the McCoy laryngoscope in patients with simulated cervical spine injuries. Anaesthesia 1996;51(1):74e5. 32. Robitaille A, Williams SR, Tremblay MH, Guilbert F, Thriault M, Drolet P. Cervical spine motion during tracheal intubation with manual in-line stabilization: direct laryngoscopy versus GlideScope videolaryngoscopy. Anesth Analg 2008;106(3):935e41. 33. Sellick BA. Cricoid pressure to control regurgitation of stomach contents during induction of anaesthesia. Lancet 1961;2(7199):404e6. 34. Ellis DY, Harris T, Zideman D. Cricoid pressure in emergency department rapid sequence tracheal intubations: a risk-benet analysis. Ann Emerg Med 2007;50(6):653e65. 35. Levitan RM, Kinkle WC, Levin WJ, Everett WW. Laryngeal view during laryngoscopy: a randomized trial comparing cricoid pressure, backward-upwardrightward pressure, and bimanual laryngoscopy. Ann Emerg Med 2006;47(6): 548e55. 36. Noguchi T, Koga K, Shiga Y, Shigematsu A. The gum elastic bougie eases tracheal intubation while applying cricoid pressure compared to a stylet. Can J Anaesth 2003;50(7):712e7. 37. Haslam N, Parker L, Duggan JE. Effect of cricoid pressure on the view at laryngoscopy. Anaesthesia 2005;60(1):41e7. 38. Schaefer SD. The acute management of external laryngeal trauma. A 27-year experience. Arch Otolaryngol Head Neck Surg 1992;118(6):598e604. 39. Verschueren DS, Bell RB, Bagheri SC, Dierks EJ, Potter BE. Management of laryngo-tracheal injuries associated with craniomaxillofacial trauma. J Oral Maxillofac Surg 2006;64(2):203e14. 40. Mort TC. Complications of emergency tracheal intubation: immediate airwayrelated consequences: part II. J Intensive Care Med 2007;22(4):208e15. 41. Li J, Murphy-Lavoie H, Bugas C, Martinez J, Preston C. Complications of emergency intubation with and without paralysis. Am J Emerg Med 1999;17(2): 141e3. 42. Benedetto WJ, Hess DR, Gettings E, Bigatello LM, Toon H, Hurford WE, et al. Urgent tracheal intubation in general hospital units: an observational study. J Clin Anesth 2007;19(1):20e4.

43. Mort TC. Emergency tracheal intubation: complications associated with repeated laryngoscopic attempts. Anesth Analg 2004;99(2):607e13. 44. Boylan JF, Kavanagh BP. Emergency airway management: competence versus expertise? Anesthesiology 2008;109(6):945e7. 45. Kovacs G, Law JA, Ross J, Tallon J, MacQuarrie K, Petrie D, et al. Acute airway management in the emergency department by non-anesthesiologists. Can J Anaesth 2004;51(2):174e80. 46. Schmidt UH, Kumwilaisak K, Bittner E, George E, Hess D. Effects of supervision by attending anesthesiologists on complications of emergency tracheal intubation. Anesthesiology 2008;109(6):973e7. 47. Ardekian L, Samet N, Shoshani Y, Taicher S. Life-threatening bleeding following maxillofacial trauma. J Craniomaxillofac Surg 1993;21(8):336e8. 48. Helwani M, Saied NN, Foroughi V. Management of airway obstruction caused by nasal packing material in a trauma patient. J Clin Anesth 2006;18(1):50e1. 49. Bynoe RP, Kerwin AJ, Parker 3rd HH, Nottingham JM, Bell RM, Yost MJ, et al. Maxillofacial injuries and life-threatening hemorrhage: treatment with transcatheter arterial embolization. J Trauma 2003;55(1):74e9. 50. Brodie HA. Prophylactic antibiotics for posttraumatic cerebrospinal uid stulae. A meta-analysis. Arch Otolaryngol Head Neck Surg 1997;123(7): 749e52. 51. Peterson GN, Domino KB, Caplan RA, Posner KL, Lee LA, Cheney FW. Management of the difcult airway: a closed claims analysis. Anesthesiology 2005;103(1):33e9. 52. Hall CE, Shutt LE. Nasotracheal intubation for head and neck surgery. Anaesthesia 2003;58(3):249e56. 53. Marlow TJ, Goltra Jr DD, Schabel SI. Intracranial placement of a nasotracheal tube after facial fracture: a rare complication. J Emerg Med 1997;15(2):187e91. 54. Horellou MF, Mathe D, Feiss P. A hazard of naso-tracheal intubation. Anaesthesia 1978;33(1):73e4. 55. Bhr W, Stoll P. Nasal intubation in the presence of frontobasal fractures: a retrospective study. J Oral Maxillofac Surg 1992;50(5):445e7. 56. Rosen CL, Wolfe RE, Chew SE, Branney SW, Roe EJ. Blind nasotracheal intubation in the presence of facial trauma. J Emerg Med 1997;15(2):141e5. 57. Bracken CA. Base of skull fractures and intubation: archaic medicine or sound rationale? J Trauma 2001;50:365e6. 58. Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, et al. Practice guidelines for management of the difcult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difcult Airway. Anesthesiology 2013;118(2):251e70. 59. Malhotra N. Retromolar intubation-a simple alternative to submental intubation. Anaesthesia 2006;61(5):515e6. 60. Dutta A, Kumar V, Saha SS, Sood J, Khazanchi RK. Retromolar tracheal tube positioning for patients undergoing faciomaxillary surgery. Can J Anaesth 2005;52(3):341. 61. Hernndez Altemir F. Sub-mental vs. retromolar intubation. Anaesthesia 2006;61(11):1123e4. 62. Lee SS, Huang SH, Wu SH, Sun IF, Chu KS, Lai CS, et al. A review of intraoperative airway management for midface facial bone fracture patients. Ann Plast Surg 2009 Aug;63(2):162e6. 63. Barriot P, Riou B. Retrograde technique for tracheal intubation in trauma patients. Crit Care Med 1988 Jul;16(7):712e3. 64. Weksler N, Klein M, Weksler D, Sidelnick C, Chorni I, Rozentsveig V, et al. Retrograde tracheal intubation: beyond breoptic endotracheal intubation. Acta Anaesthesiol Scand 2004;48(4):412e6. 65. Lima Jr SM, Asprino L, Moreira RW, de Moraes M. A retrospective analysis of submental intubation in maxillofacial trauma patients. J Oral Maxillofac Surg 2011;69(7):2001e5. 66. Schtz P, Hamed HH. Submental intubation versus tracheostomy in maxillofacial trauma patients. J Oral Maxillofac Surg 2008;66(7):1404e9. 67. Anwer HM, Zeitoun IM, Shehata EA. Submandibular approach for tracheal intubation in patients with panfacial fractures. Br J Anaesth 2007;98(6): 835e40. 68. Helm M, Gries A, Mutzbauer T. Surgical approach in difcult airway management. Best Pract Res Clin Anaesthesiol 2005;19(4):623e40. 69. Knepil GJ, Blackburn CW. Retained throat packs: results of a national survey and the application of an organisational accident model. Br J Oral Maxillofac Surg 2008;46(6):473e6. 70. Difcult Airway Society Extubation Guidelines Group, Popat M, Mitchell V, Dravid R, Patel A, Swampillai C, Higgs A. Difcult Airway Society Guidelines for the management of tracheal extubation. Anaesthesia 2012;67(3):318e40. 71. Fisher MM, Raper RF. The cuff-leak test for extubation. Anaesthesia 1992;47(1):10e2. 72. Kriner EJ, Shafazand S, Colice GL. The endotracheal tube cuff-leak test as a predictor for postextubation stridor. Respir Care 2005;50(12):1632e8. 73. Zuniga JR. Guidelines for anxiety control and pain management in oral and maxillofacial surgery. J Oral Maxillofac Surg 2000;58(10 Suppl. 2):4e7.

Please cite this article in press as: Ray BR, et al., Anaesthetic management of maxillofacial trauma, Trends in Anaesthesia and Critical Care (2013), http://dx.doi.org/10.1016/j.tacc.2013.07.001