Airway in Maxillofacial Trauma

Reviewed and revised 29 June 2014

OVERVIEW

  • Maxillofacial trauma directly impacts on the airway resulting in compromise and hindering attempts to secure the airway
  • delays in securing the airway may lead to morbidity and mortality
  • multiple approaches to securing the airway are possible, each with pros and cons
  • once airway is secured and hemorrhage is control, definitive surgical management of bone and soft tissue injuries can be deferred until other life-threatening injuries are dealt with

AIRWAY COMPROMISE FROM MAXILLOFACIAL INJURY

Mechanisms of airway obstruction include:

  • Posteroinferior displacement of a fractured maxilla parallel to the inclined plane of the skull base may block the nasopharyngeal airway
  • A bilateral fracture of the anterior mandible may cause the fractured symphysis to slide posteriorly along with the tongue attached to it via its anterior insertion causing oropharyngeal obstruction in the supine patient
  • Fractured or exfoliated teeth, bone fragments, vomitus and blood as well as foreign bodies may cause airway obstruction
  • Hemorrhage ( distinct vessels in open wounds or severe nasal bleeding) may cause airway obstruction
  • Soft tissue swelling and edema may cause delayed airway compromise
  • Trauma to the larynx and trachea may cause swelling and displacement of structures, such as the epiglottis, arytenoid cartilages and vocal cords, causing cervical airway obstruction

Other issues:

  • poor visualisation of the airway due to deformity and debris
  • difficult ventilation e.g. poorly fitting mask, traumatic airway leak
  • requirement for cervical spine immobilisation
  • full stomach and aspiration risk
  • need for emergent intubation due to airway obstruction or hypoxia

Have a high index of suspicion for airway compromise in patient’s with maxillofacial trauma

  • airway compromise may occur with any sedation or analgesia administration
  • if there is time allow the patient to breathe spontaneously until optimal conditions for intubation are available (e.g. experienced anaesthetist and ENT surgeon in an operating theatre)

SPECIFIC QUESTIONS ON AIRWAY ASSESSMENT

  • Is the patient conscious? (maintain!)
  • Is the patient breathing spontaneously? (maintain!)
  • What is the extent, the composition and the anatomy of the injury? (implies difficult airway and BVM)
  • How extensive is the damage to the bony structures of the face? (if extensive BVM likely to be ineffective)
  • Is there a limitation in mouth opening? (suspect TMJ injury and difficult airway)
  • Is there soft tissue oedema and pressure on the airway?

RAPID SEQUENCE INDUCTION WITH DIRECT LARYNGOSCOPY

Advantages

  • Rapid technique
  • Familiar
  • may be only option if patient peri arrest
  • No special expertise required
  • best technique with ENT/Surgical backup at bedside to perform immediate tracheostomy if intubation fails (preferably in patients with normal neck surface anatomy)

Disadvantages

  • Obscured / absent landmarks (potential to lose airway with RSI)
  • Airway swelling
  • Haematomata and ongoing haemorrhage
  • Bony and soft tissue trauma
  • Co-existing upper airway / tracheal injuries
  • Patient unable to lie flat
  • Left lateral position may be preferred but increases degree of difficulty
  • Limited respiratory reserve
  • Pre-oxygenation, bag-mask ventilation problematic — risk of pneumocephalus versus hypoxia
  • Likely to become haemodynamically unstable with induction

Video laryngoscopy has similar disadvantages to fiberoptic approaches, and blood and vomitus may prevent adequate visualisation

CRICOTHYROTOTOMY OR AWAKE TRACHEOSTOMY

Advantages

  • Safe – no risk of losing airway
  • Patient breathing throughout
  • Useful rescue technique of other approaches fail

Disadvantages

  • May be difficult without sedation (pain and discomfort)
  • Positioning may be problematic
  • May be technically challenging in the setting of local tissue damage and haemorrhage
  • complications of surgical airway e.g. pneumothorax, haemorrhage

AWAKE FIBEROPTIC INTUBATION

Advantages

  • No risk of losing airway
  • Patient breathing throughout

Disadvantages

  • Visualisation is extremely challenging in the setting of ongoing haemorrhage
  • Requires a cooperative patient (less likely in the trauma setting)
  • Topicalisation with local anaesthetic is difficult due to trauma and haemorrhage
  • Attempted nasotracheal intubation could result in nasocranial passage of tube and/or severe nasal haemorrhage
  • Need expert/experienced airway assistance

AWAKE LARYNGOSCOPY AND INTUBATION

Advantages

  • Quick – no time wastage
  • Reduced risk of losing airway
  • Patient breathing throughout
  • Uses standard intubating equipment
  • May be method of choice with senior operator
  • Allows easy transition to a back-up technique
  • Can perform with C-MAC and use video

Disadvantages

  • Technically challenging
  • Needs adequate local anaesthesia
  • Positioning patient problematic
  • Video may be obscured by haemorrhage

SUPRAGLOTTIC AIRWAYS

Advantages

  • can be inserted blindly
  • requires little experience
  • may be a useful temporising measure until a definitive airway is achieved

Disadvantages

  • not a definitive airway – risk of aspiration and gastric insufflation
  • requires sedation

SUBMENTAL OROTRACHEAL INTUBATION

Advantages

  • allows an unhindered reduction and fixation of the complex maxillofacial fractures and simultaneous access to nasal pyramid fractures
  • avoids need for tracheostomy

Disadvantages

  • requires general anaesthesia
  • performed by a trained surgeon
  • usually preced by orotracheal intubation, which is then replaced
  • local surgical complication
  • usually performed with a reinforced tube
  • not suitable for patients requiring prolonged mechanical ventilation

POST-OPERATIVE AIRWAY ISSUES

  • Frequency of maxillofacial injury airway complications: 12% at extubation and 5% during recovery
  • defer extubation until normal anatomy is restored and/or until oedema subsides
  • consider early tracheostomy to allow early desedation

AN APPROACH TO SECURING THE AIRWAY IN MAXILLOFACIAL TRAUMA

  • If peri-arrest: RSI with C-MAC (DL or VL); LMA back up; surgical airway if CICV
  • If stable: either in resus room or transfer to OT with anaesthetist and ENT support for awake technique with surgical back up

References and Links

Journal articles

  • Dupanovic M, Fox H, Kovac A. Management of the airway in multitrauma. Curr Opin Anaesthesiol. 2010 Apr;23(2):276-82. doi: 10.1097/ACO.0b013e3283360b4f. PMID: 20042974.
  • Krausz AA, El-Naaj IA, Barak M. Maxillofacial trauma patient: coping with the difficult airway. World J Emerg Surg. 2009 May 27;4:21. doi: 10.1186/1749-7922-4-21. PMC2693512.
  • Langeron O, Birenbaum A, Amour J. Airway management in trauma. Minerva Anestesiol. 2009 May;75(5):307-11. PMID: 19412149. [Free Full Text]
  • Shenoi RS, Badjate SJ, Budhraja NJ. Submental orotracheal intubation: Our experience and review. Ann Maxillofac Surg. 2011 Jan;1(1):37-41 PMC3591038.
  • Walls RM. Management of the difficult airway in the trauma patient. Emerg Med Clin North Am. 1998 Feb;16(1):45-61 PMID: 9496314.

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Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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