Airway Management of the Patient with Maxillofacial Trauma: Review of the Literature and Suggested Clinical Approach

Factors influencing the ability of health professionals to manage of tracheal intubation and tracheal extubation in oral and maxillofacial malignancies patients following surgery: a qualitative study

PURPOSE

This study aimed to explore factors that hinder the effective management of tracheal intubation and tracheal extubation by healthcare professionals (HCPs) in patients with oral and maxillofacial malignancies (OMMs) following surgery in the intensive care unit (ICU).

METHODS

A phenomenological approach was used in this qualitative study. Data were collected using semi-structured, face to face, in-depth interviews with 12 experienced HCPs in three clinical units at a tertiary hospital in Shanghai, China, from February to May 2024. Purposive sampling was used. The data were organized and analyzed using NVivo 12.0 software and Braun and Clarke's reflective thematic analysis.

RESULTS

Twelve HCPs had a mean age of 39.92 years (SD 6.76); n = 7 (58.33%) were nurses. Two themes and seven sub-themes emerged: (1) institutional factors: lack of a risk assessment system for airway obstruction, lack of a tracheal intubation emergency team, inconsistent preparations for delayed extubation, and inadequate reintubation training for airway obstruction, and (2) individual factors: normativity of airway humidification, knowledge of the risk of airway obstruction, and attitude related to learning about airway obstruction.

CONCLUSION

The inadequate management of tracheal intubation and tracheal extubation by HCPs in OMMs patient after surgery is influenced by multiple factors. Designing targeted interventions utilizing these influencing factors will improve the ability of HCPs to manage tracheal intubation and tracheal extubation and ensure the life safety and effective treatment of OMMs patients following surgery.

Videolaryngoscopy As the Primary Approach to Emergency Airway Management in Facial Trauma: A Case Report

Managing the airway in maxillofacial trauma poses significant challenges. The distorted anatomy often complicates face mask ventilation and intubation, necessitating specialized skills in emergency settings. Successful management hinges on prompt planning and patient cooperation. Here, we describe the airway management of a bullhorn fascial injury patient requiring wound exploration and repair under general anesthesia. Timed clinical judgment and an adaptable approach ensured effective airway management using videolaryngoscopy as the primary approach in this case. In addition, we have described the probable difficulties that may be faced while managing the airway of such patients and how to deal with these challenges.

Magnitude, associated factors of difficult airway, and predictive value of airway examinations among maxillofacial surgery patients at public hospitals in Southern Ethiopia: a multicentre cross-sectional study

Background

"Difficult airway" is the clinical situation in which a conventionally trained anesthesiologist experiences difficulty with mask ventilation, laryngoscopy, and difficulty with tracheal intubation, or both. Associated factors and predictive value difficult airways, maxillofacial surgery study setup is under studied.

Objective

To determine the magnitude and associated factors of difficult airways and predictive value of airway examinations among adult patients who underwent maxillofacial surgery at public hospitals in Southern Ethiopia 2022.

Methods and materials

An institutional-based multicenter cross-sectional study was conducted among 250 maxillofacial patients from March to 30 June 2022 at selected hospitals. The data were entered into Epi_Data software version 4.3 and analyzed by STATA software version 14. All variables that were statistically significant in bivariate analysis, at the P less than 0.25, were included in the multivariate logistic regression analysis. The predictive value or the effectiveness of airway examinations in predicting difficult airways was analyzed by receiver operating curve.

Results

In the current study, the magnitude of difficult airways was 21.2% (95% CI = 16.3-26.1%) and the magnitude of difficult intubation, difficult laryngoscopy, and difficult mask ventilation was 6.4% (95% CI 3.3-9.4%), 9.6% (95% CI 6.1-13%), and 13.6% (95% CI (9.1-16.8%), respectively. History of head and neck surgery adjusted odds ratio (AOR)=6.3, 95% CI (2.85-14.34), cervical collar AOR=4.9, 95% CI (1.96-12.49), and cervical spine injury AOR=2.4, 95% CI (1.07-5.38) were independently and significantly associated with difficulty of airway. Modified Mallampati class and sternomental distance were identified as good preoperative tests to predict difficult laryngoscopy, intubation, and mask ventilation.

Conclusion and recommendation

The magnitude of difficult airways was maxillofacial surgery. Among various airway assessment tests, no single test was perfectly accurate. Anaesthesia professionals are recommended to use a combination of preoperative airway assessments.

Airway management in patients undergoing maxillofacial surgery: State of art review

Airway management in maxillofacial surgery is a critical aspect of anesthesia and perioperative care, demanding a broad array of techniques to ensure effective ventilation and oxygenation. The anatomical and physiological complexities of maxillofacial procedures necessitate a deep understanding of airway management strategies. Patients undergoing maxillofacial surgery often face heightened risks of airway compromise due to trauma, congenital abnormalities, or the surgical interventions themselves, requiring clinicians to be proficient in both routine and advanced techniques. This narrative review synthesizes current evidence and clinical practices in airway management for maxillofacial surgery. It examines the anatomical and physiological considerations, preoperative assessment protocols, intraoperative management, and postoperative care strategies. Preoperative assessments are crucial for identifying potential airway management difficulties, utilizing risk assessments, physical examinations, and imaging. Intraoperative strategies include endotracheal intubation while surgical techniques such as tracheostomy, cricothyroidotomy, submental, and retromolar intubation offer alternatives for securing the airway. Postoperative care focuses on meticulous planning and coordination to prevent complications such as airway obstruction and hypoxemia. Extubation is identified as a particularly high-risk phase, necessitating advanced techniques and multidisciplinary collaboration to ensure patient safety. The review underscores the importance of a comprehensive, multidisciplinary approach to airway management in maxillofacial surgery, highlighting the need for ongoing advancements in techniques and technologies to enhance patient outcomes.

Epiglottic injury and airway management - a challenging and unexpected diagnosis

Patients with facial trauma are complex; difficult airway management is often anticipated and challenging for the anaesthetist. Awake tracheal intubation is the gold standard in the management of predicted difficult airway because of its high success rate and safety profile. We present the case of a patient with facial trauma who underwent orotracheal intubation with combined videolaryngoscopy and flexible bronchoscopy, under conscious sedation with intermittent boluses of ketamine and dexmedetomidine. Videolaryngoscopy showed significant oedema and epiglottic laceration, not diagnosed by the computed tomography scan, with visualisation of a false passage that could have led to a failed intubation and further trauma. Airway management in patients with facial trauma is challenging and should be planned and discussed by a multidisciplinary team. A technique combining videolaryngoscopy and flexible bronchoscopy during awake intubation has previously been described and, when used in this case, was successful.

Management of mandibular angle and body fractures using miniplates and 3D plates

Mandibular angle fractures have the greatest recorded rate of postoperative complications of any mandibular location and hence they present an especially difficult task for surgeons. Therefore, it is of interest to compare the conventional miniplates and three dimensional (3D) plates in management of mandibular angle fracture and body fractures.60 patients with isolated non-comminuted mandibular angle fractures and body fractures were randomly assigned into two groups by lottery. Utilizing Champy's osteosynthesis standards, group one (n = 30) received treatment with 2-mm standard miniplate and group two (n = 30) had treatment with open reduction and internal fixation utilizing 2-mm 3D locking stainless steel plates. The mean operative time was greater in conventional miniplate category as compared to three dimensional plates. Need for postoperative occlusion correction was lesser n 3 dimensional plate category. The incidence of postoperative infection was comparable in both categories. Incidental tooth damage was lesser in three-dimensional plate's category three-dimensional locking plates are an alternate strategy that has a comparable result profile to miniplates.

A Surgical Audit of Tracheostomy

To study the magnitude of tracheostomy, its various indications and complications. Prospective Observational Study. A Prospective Observational study was carried out on 640 patients with various indications of tracheostomy admitted in ENT or referred from other departments for tracheostomy from July 2015 to March 2022. The epidemiological data regarding their age, sex, symptoms, indication and complications of tracheostomy were recorded. Necessary interventions were done as and when required. Patients ranged from 6 months to 86 yrs. Assisted ventilation was the most common indications for tracheostomy (68.125%, n = 436). The most common complication was subcutaneous emphysema (10.625%, n = 68) followed by tube displacement (5.625%, n = 36. The complication rate was 21.25% and the mortality rate 4.375% (n = 28) with specific mortality rate 0.625% (n = 4). Tracheostomy is one of the commonest surgeries. Data was collected from this study on the various indications of tracheostomy, the epidemiological factors and various complications associated with tracheostomy. Such a data is useful to learn from the mistakes and carry forward the virtouosity.

Management of Laryngoscope-Induced Iatrogenic Dental Injury: A Case Series

Dental injury is a common anesthesia-related adverse event, with a high incidence of damage to teeth and surrounding tissues during oro-endotracheal intubation. Poor oral hygiene, compromised periodontium, faulty or loose prosthesis, proclined maxillary incisors along with increased difficulty level of airway management, improper use of laryngoscope, and use of maxillary anterior teeth as a fulcrum for achieving accessibility to the airway are all risk factors for iatrogenic dental injury. This type of injury provides additional physical and psychological trauma to patients who have already undergone medical surgical procedures. The consequences of such mishaps might potentially result in medico-legal suits and financial claims. The present case series described three cases of managing iatrogenic dental lesions during oro-endotracheal intubation, after obtaining written informed consent, as well as methods for preventing such accidental injuries. This study emphasized the importance of collaboration between medical and dental professionals in preventing and successfully managing accidental dental injuries.

Morpho-Volumetric Changes of the Pharyngeal Airway With Traumatic Maxillofacial Injuries: A Retrospective Radiographic Study

BACKGROUND

When dealing with traumatized patients, it is crucial to prioritize securing their airway. However, intubating someone who has sustained significant facial injuries can pose difficulties, as the narrow and altered shape of their upper airway may impede their ability to open their mouth. In light of this, the purpose of this study is to evaluate the volumetric and morphological alterations to the upper airway resulting from facial trauma by utilizing computed tomography (CT) scans.

METHOD

This is a single-centered retrospective analytical study. This study included CT scans of patients with traumatic facial injuries admitted to King Fahad Hospital in Madinah, Saudi Arabia. Study variables included age, gender, body mass index (BMI), fractured bones, airway symmetry, and airway volume. Using the 3D Slicer software (Slicer Community, USA), a three-dimensional model of the pharyngeal airway was constructed from the CT scan to evaluate symmetry and volume. IBM SPSS Statistics for Windows, version 23 (released 2013; IBM Corp., Armonk, New York, United States) was used to analyze data.

RESULTS

Among the screened scans, 136 cases with traumatic facial injuries were included in the study. Age ranged from four to 91 years, with a mean of 28.26 (±14.9). Mandibular and zygomatic fractures were the most common, with 71 (52.2%) and 69 (50.7%) cases, respectively. The pharyngeal airway was symmetric in 111 (81.6%) cases and not symmetric in the other 25 (18.4%) cases. A significant association was found between the side of the fracture and airway asymmetry in mandibular fractures (p-value = 0.03). The total airway volume in the displaced mandibular fractures showed a statistically significant decrease (p-value = 0.019). The fracture sites were not statistically linked to airway asymmetry except for parasymphyseal and symphyseal fractures, with a p-value of 0.038 and 0.041, respectively.

CONCLUSION

The study findings suggest that the pharyngeal airway is not usually compromised in most facial bone fractures; however, bilateral displaced mandibular fractures have the potential to diminish the pharyngeal airway volume, especially in fractures involving the symphysis and parasymphysis area.

Airway Management of a Patient With Penetrating Maxillofacial Trauma Caused by Chainsaw Kickback: A Case Report

Anesthesiologists rarely experience airway management in patients with maxillofacial injuries caused by a chainsaw. A 36-year-old male was referred to our hospital because of maxillofacial injuries caused by chainsaw kickback. There were deep lacerations of the right eyelid, medial canthus, cheek, and jaw with venous bleeding. The laceration of the cheek reached the oral cavity and looked like a "second mouth." The patient was taken to the operating room for urgent laceration repair under general anesthesia. Despite a poor laryngeal view, awake orotracheal intubation with a videolaryngoscope was successful on the second attempt without complications. Oxygenation was optimized by supplemental oxygen administration via a suction catheter inserted from the "second mouth" throughout the airway management. The present case highlights the importance of airway management strategies according to the nature of the trauma in patients with penetrating maxillofacial trauma caused by a chainsaw.

Lunch Box Penetrating Injury in the Craniofacial Region Impedes the Primary Airway Management and Surgical Intervention

Penetrating Cranio-Maxillofacial trauma obscuring the clear view of the face in addition to an impediment to emergency airway management has been a rare occurrence in the archives of emergency trauma. A four-year-old girl reported to the emergency following a lunch box sharp rim penetrating wound to her left supraorbital region, limiting the access and clear view of her face. CT scan ruled out the serious orbital injury, but clearly revealed the piercing of the brain matter in the frontal region. The toddler's golden hour of primary management was spent in the darkness with the lunch box covering her entire face, obstructing the basic intubation methods required for primary airway management. Interpretation of the radiological investigations necessitated the multiple collaboration of the neurosurgery and maxillofacial surgeons, planning a systematic recovery of the foreign body without any major complications. Follow-up period was uneventful with no neurological and major cosmetic deficits.

Anesthetic and Airway Management in a Case of Surgical Excision of Recurrent Buccal Hemangioma

Difficult airway is one of the challenges trained anesthesiologists face in their life. Induction of general anesthesia in a patient with a compromised airway has always caused a dilemma for anesthesiologists. Challenges were more in this case of buccal hemangioma as its bleeding tendency makes it a challenging job. Hemangioma is a benign vascular anomaly characterized by rapid endothelial cell proliferation. It appears within the first eight weeks of life, rapidly proliferates between the ages of six and 12 months, and progressively involutes between the ages of nine and 12 years. Hemangiomas are more common in women, with a male-to-female ratio of 1:3 to 1:5. By the age of nine years, over 80%-90% of hemangiomas have completely involuted. The remaining 10%-20% involute incompletely, necessitating post-adolescent ablative treatment or alternative management options. Hemangiomas in the head and neck region account for 50%-60% of all hemangiomas. Intra-orally, the lips, buccal mucosa, and tongue are the most prevalent sites of involvement. Here, we report a case of recurrent left-sided buccal hemangioma in a 20-year-old female patient. Treatment options available to manage hemangioma include cryotherapy, laser ablation therapy, radiotherapy, sclerotherapy, and selective embolization. After prophylactic embolization of feeder vessels, surgically excising the lesion is the modality of choice. So from a general anesthesia management point of view, buccal hemangioma poses multiple challenges including difficulty in mask ventilation, difficulty in intubation, bleeding, and pulmonary aspiration.

Airway Management of Suspected Traumatic Brain Injury Patients in the Emergency Room

The patients of trauma offers a special challenge because of the associated head injury, maxillofacial, neck and spine injuries, which puts the airway at imminent risk. The response time for the emergency team to initiate the airway management determines the outcome of the individual undergoing treatment. A judious implementatin of triage and ATLS guidelines are helpful in the allocation of resources in airway management of trauma patients. One must not get distracted with the severity of other organ systems because cerebral tissue permits a low threshold to the hypoxic insults. Adequate preparedness and a team effort result in better airway management and improved outcomes in trauma patients with variable hemodynamic response to resuscitation. All possible efforts must be made to secure a definitive airway (if required) and should be verified clinically as well as with the available adjuncts. The success of a trauma team depends on the familiarity to the airways devices and their discrete application in various situations.

Surviving a 400 m Fall on Mount Everest

Mountaineering is a dangerous recreational activity with falls causing severe injuries and deaths. Survival from falls longer than 100 m is uncommon. We present a case of a high-altitude porter on Mount Everest who fell 400 m and survived. He slipped from a ridge at 7000 m (22,900 ft). A rescue party found him above Camp 2 (6600 m, 21,600 ft) and arranged a helicopter rescue. The Everest ER medical team at Everest Base Camp (5400 m, 17,700 ft) received the climber. They identified a head injury without signs of other serious trauma. A doctor provided manual inline stabilization of the cervical spine, airway support, and ventilation for the patient during the helicopter and ground transport to a tertiary hospital in Kathmandu. The time from the fall to definitive hospital care was 2.5 h. The hospital emergency team diagnosed an epidural hematoma and subarachnoid hemorrhage without midline shift and right parietal, orbital, and maxillary fractures. The neurosurgical team evacuated the intracranial bleed. The patient spent 6 d in the hospital. He had a positive neurological outcome. He had mild cognitive impairment and vision loss in his left eye but could perform activities of daily living. He returned to physical work, but not to climbing. This case report provides evidence that survival is possible after falls from extreme heights and sheds light on the challenges of an evacuation from austere environments.

A Comparative Study on Sedation Efficacy Between General and Regional Anesthesia with Dexmedetomidine in Patients Under Maxillofacial Surgery

BACKGROUND AND OBJECTIVE

Securing the airway in the surgery of maxillofacial disorders and traumas is fundamental during the operation. The present study aims to investigate the beneficial sedative effects of dexmedetomidine (DEX) in patients who underwent maxillofacial surgery with regional anesthesia compared to general anesthesia.

METHODS

Fifty patients, aged 20-45 years old were randomly divided into two groups of regional anesthesia (RA) and general anesthesia (GA) (each n=25). The group RA received regional block with sedation (DEX: 1 μg/kg infused over 10 min followed by the maintenance dose of 0.5 μg/kg/h) and the group GA underwent general anesthesia (DEX: 0.1 μg/kg/min over 10 min followed by 0.4-0.7 μg/kg/h). Postoperative pain scores, anesthesia outcomes, hemodynamic parameters, the time of the post-anesthesia care unit (PACU) discharge and intra and postoperative complications were comparatively assessed in both groups.

RESULTS

The baseline characteristics of the patients (age, gender, BMI, and ASA physical status) showed no differences between the two groups (P>0.05). Although the duration of surgery and recovery time showed no differences between the groups, the duration of anesthesia and extubation time was remarkably lower in the RA group than in the GA group (P<0.01). Administration of nerve blocks demonstrated less pain and longer sleep time in the postoperative phase as compared to the GA group. Heart rate and mean arterial blood pressure were significantly less in the RA group at the end of the loading dose of DEX and incision time (P<0.05). SpO2, respiration rate and Ramsay sedation scale did not exhibit any significant differences between the two groups at all-time points (P>0.05). No significant differences were observed with regard to the adverse events between the two groups (P>0.05).

CONCLUSIONS

Although our findings revealed that both methods are suitable and safe methods for maxillofacial surgery, the outcomes of anesthesia with regional block and sedation include less pain in the postoperative phase, shorter extubation time and earlier discharge from the PACU demonstrated that this method is more reliable for maxillofacial surgery. Further controlled studies are needed to compare the effectiveness and safety profiles of two RA and GA techniques and also to compare DEX with other anesthetic agents to achieve optimum outcomes in maxillofacial surgeries.

Airway management in self-inflicted gunshot wounds to the face

Background

This study characterizes the prehospital and trauma bay airway management of self-inflicted gunshot wounds (SI-GSWs) to the face.

Methods

We reviewed SI-GSWs to the face from 2017 to 2021. Patients with isolated temporal GSWs were excluded. Emergency Medical Services (EMS) and trauma bay information on airway management were collected.

Results

38 patients presented with a SI-GSW to the face. 20 of the 29 transported by EMS were managed without advanced airways. There were four endotracheal intubations, three supraglottic airways, and two failed intubations. Those with advanced airways had lower GCS (3 vs. 15, p<0.01) and systolic blood pressure (94 vs. 144, p<0.01). After hospital arrival, 22 SI-GSWs were endotracheally intubated in the trauma bay and two in the OR. No cricothyroidotomies were performed.

Conclusions

A majority of SI-GSWs to the face can be managed by EMS using noninvasive support. Supraglottic airways may be an option for those requiring invasive support.

"A" stands for airway - Which factors guide the need for on-scene airway management in facial fracture patients?

Background

Numerous guidelines highlight the need for early airway management in facial trauma patients since specific fracture patterns may induce airway obstruction. However, the incidence of these hallmark injuries, including flail mandibles and posterior displacement of the maxilla, is contentious. We aim to evaluate specific trauma-related variables in facial fracture patients, which affect the need for on-scene versus in-hospital airway management.

Methods

This retrospective cohort study included all patients with any type of facial fracture, who required early airway management on-scene or in-hospital. The primary outcome variable was the site of airway management (on-scene versus hospital) and the main predictor variable was the presence of a traumatic brain injury (TBI). The association of fracture type, mechanism, and method for early airway management are also reported. Altogether 171 patients fulfilled the inclusion criteria.

Results

Of the 171 patients included in the analysis, 100 (58.5) had combined midfacial fractures or combination fractures of facial thirds. Altogether 118 patients (69.0%) required airway management on-scene and for the remaining 53 patients (31.0%) airway was secured in-hospital. A total of 168 (98.2%) underwent endotracheal intubation, whereas three patients (1.8%) received surgical airway management. TBIs occurred in 138 patients (80.7%), but presence of TBI did not affect the site of airway management. Younger age, Glasgow Coma Scale-score of eight or less, and oro-naso-pharyngeal haemorrhage predicted airway management on-scene, whereas patients who had fallen at ground level and in patients with facial fractures but no associated injuries, the airway was significantly more often managed in-hospital.

Conclusions

Proper preparedness for airway management in facial fracture patients is crucial both on-scene and in-hospital. Facial fracture patients need proper evaluation of airway management even when TBI is not present.

Emergent use of a King laryngeal tube for traumatic intraoral bleeding: case reports

Maxillofacial trauma occasionally presents a serious challenge for physicians, and an orofacial injury can be considered life-threatening. It is difficult to control the bleeding and prevent airway obstruction simultaneously with conventional treatment. Herein, we share two cases in which we managed massive orofacial bleeding using a King laryngeal tube, a supraglottic airway device equipped with an inflatable balloon. Both patients had uncontrolled orofacial bleeding. In one of the patients, endotracheal intubation was possible; however, bleeding continued, and vital signs became unstable. The second patient had failed endotracheal intubation due to uncontrolled bleeding. We deployed the King laryngeal tube in both patients and achieved bleeding control and airway maintenance. Both patients were discharged without complications after 3 to 4 weeks. The King laryngeal tube method can be considered a useful management option for addressing massive orofacial bleeding that is uncontrollable with conventional treatment.

Predicting Difficult Airway Intubation Based on Maxillofacial Trauma: A Retrospective Study

Purpose

The purpose of this study was to determine which types of facial injuries in traumatic patients' wounds cause difficult intubation for anesthesiology team. By anticipating potential complications with airway management, the surgeons can be better prepared for emergent cricothyrotomy if needed. This could include prior to the planned procedure in the operating room (OR) as well as in emergent conditions in trauma bay.

Methods

Trauma patients with facial injuries in a level II trauma center from January 2007 to September 2017 that required intubation were evaluated for types of facial injury. Anesthesiology intubation documents were reviewed to determine which types of facial injuries were associated with difficult intubation per anesthesiology documentation.

Results

A total of 232 subjects were selected and it was found that patients with LeFort II facial fracture, bilateral mandibular fracture, and facial fracture associated with basilar skull fracture were noted to have difficult intubation by the anesthesiology team.

Conclusion

On the basis of CT imaging findings, our study demonstrates that certain types of facial fractures could pose difficult intubation. Surgeons should be aware of these injuries and be ready to intervene with emergent cricothyrotomy if necessary.

Difficult Mask Ventilation in Penetrating Facial Trauma Due to Animal Attack: A Unique Challenge in the Emergency Department

Penetrating facial trauma can be a life-threatening condition, especially due to its impact on the airway. In a facial trauma, there is a distortion in the basic anatomy of the affected, making it a particularly difficult situation for managing the airway. Challenging intubation scenarios have been widely explored in the literature; however, difficult to ventilate situations have been undermined. We describe a case of a 35-year-old female who presented with a history of animal attack on the face. The extent of penetrating facial trauma warranted the need to secure the airway. Preserving spontaneous breathing and using an oral endotracheal tube for oxygenation saved the airway manager from cannot intubate and cannot oxygenate situation in a facial trauma patient.

Difficult to mask ventilate while arranging for a definitive airway can be more pressing and challenging for the emergency physician. It also jeopardizes the patient's life, whose survival may only depend on acquiring the patency of the airway. Facial trauma patients may be conscious and spontaneously breathing, leading to the missed or delayed intervention in the airway; hence, prompt assessment and management of the airway in all facial trauma are of utmost importance.

Mandibular Condylar Fractures

Mandibular condyle fractures can result in short-term and long-term morbidity. As a weak area of the mandible, the condyle is vulnerable to injury by a direct impact or an indirect force. Current treatment recommendations aim to better match the severity of the fracture with the choice of closed or open approach. Long-term follow-up of patients provides the best opportunity to monitor the degree of functional restoration after treatment. There is a growing consensus regarding the use of standardized fracture classification methods and outcomes measures that will allow better assessment of treatment results and strengthen the quality of outcomes research.

Surgical Dilemmas in Multiple Facial Fractures - Coronal Flap Versus Minimally Invasive: Case Report and Literature Review

The Rationale:

Pan-facial fracture is a complex trauma that involves the upper, middle, and lower third of the facial bones. The surgical management of such complex cases is either by the posterior approach (coronal flap) or anterior approach through local incisions.

Patient Concerns:

This report describes the case of severe pan-facial trauma in a 52-year-old male who sustained a severe pan-facial trauma.

Diagnosis:

He suffered from multiple facial fractures that included: Frontal bone, skull base, Naso-orbitoethmoid (NOE), zygomatic and sub-condylar fractures.

Treatment:

He was managed by minimally local periorbital and lynch incisions.

Outcomes:

Fractures were properly reduced with resultant symmetrical facial dimensions. No postoperative complications were demonstrated including facial nerve function.

Take-away Lessons:

We should consider minimally invasive local incisions in pan-facial fractures when there is no need to restore the frontal sinus and the anterior-posterior dimensions of the zygomatic arch.

Experience with Airway Management and Sequencing of Repair of Panfacial Fractures: A Single Tertiary Healthcare Appraisal in Najran, Kingdom of Saudi Arabia - A Retrospective Study

Introduction:

Special cooperation is required among surgeons and anesthetists in airway management during repair of panfacial fractures, due to problems of shared airway and occlusion. Several methods have been proposed for airway management and sequencing of repair of panfacial fractures. The main objective of the current study was to share our experience in the airway management and sequencing of repair of panfacial fractures.

Methods:

This was a retrospective study of panfacial fractures in the Kingdom of Saudi Arabia from January 2008 to December 2018. Data collected included demographics, type of airway management, sequence of repair (as primary variables), and outcome of surgery (secondary variable), while surgeon and anesthetic expertise are confounders. Data were analyzed using IBM SPSS Statistics for Windows Version 25 (Armonk, NY, USA: IBM Corp). Results were presented as simple frequencies and descriptive statistics. Pearson Chi-square was used to compare categorical variables such as airway management and sequencing of repair with the panfacial fractures. Statistical significance was set at P ≤ 0.05.

Results:

Overall, 1057 patients sustained different categories of maxillofacial bone fractures with 23 females and 1034 males (M:F of 46:1). A total of 43 male patients out of 1057 patients had panfacial fractures during the study period, giving a prevalence rate of 4.1%. Only the 43 male patients with panfacial fractures were analyzed. All cases were as a result of motor vehicular accident. Six (13.9%) patients had tracheostomy while 37 (86.1%) patients had submental intubation. “Bottom-up” and “outside-in” approach was used in 33 (76.7%) patients, while “top-bottom” and “inside-out” approach was used in 10 (23.3%) patients.

Discussion:

Submental intubation was the major airway management of panfacial fracture, and “bottom-up” and “outside-in” approach was the main sequence of repair in our series. These approaches have been mentioned in the literature.

Conclusion:

From our study, victims of pan-facial fractures were found to be exclusively male with MVA as the sole etiological factor. Barring severe head injuries, which may necessitate the use of tracheostomy to sustain breathing over a longer period, submental intubation is extremely reliable as a mode of airway management during surgical treatment of panfacial fractures. The sequencing of repair of panfacial fractures can only be determined according to the case presentation rather than a predetermined one.

Comparative study of outcomes between locking plates and three-dimensional plates in mandibular fractures

Objectives

The objective was to compare the efficiency and assess postoperative complications of 2.00 mm unicortical locking plates and three-dimensional (3D) plates in surgical correction of uncomplicated mandibular fracture.

Materials and Methods

A prospective cohort study of twenty patients of uncomplicated mandibular fractures, who were operated either by noncompression unicortical 2-mm locking mini-plate or by noncompression unicortical 2-mm 3D mini-plate, were enrolled and followed up for the study outcomes such as operative time, postoperative infection, and postoperative occlusion.

Results

Majority of the patients (90%) were male who had road traffic accident. In 80% of cases, mandibular fracture site was parasymphysis. The mean operating time for 3D plates (43.20 min) was significantly lower than that for locking plates (54.82 min), P < 0.001. All cases operated by 3D plates compared to 60% by locking mini-plates did not need intermaxillary fixation, P = 0.025. The 80% of cases operated by 3D plates did not require postoperative occlusion correction compared to 30% in another group, P = 0.01. For other parameters such as postoperative sensory disturbance, postoperative infection, incidence tooth damage, vertical displacement of mandible, feeling of plate after platting, and chewing efficiency after 1 week, there were no statistical significant differences between the two groups.

Conclusions

The outcome of 2.0mm 3D mini-plate is better in terms of operating time required, post-operative need of intermaxillary fixation and occlusal correction. While the outcome is similar to the use of non-compression unicortical 2.00mm locking miniplate in parameters like infection rate and incidence of tooth damage etc.

Securing the Airway in Maxillofacial Trauma Patients: A Systematic Review of Techniques

Study Design

The present study is a systematic review of the literature.

Objective

The goal of this study is to review our experience and the current literature on airway management techniques in maxillofacial trauma.

Methods

Independent searches of the PubMed and MEDLINE databases were performed from January 1, 2019 to February 1, 2019. Articles from the period of 2008 to 2018 were collected. All studies which described both airway management and maxillofacial trauma using the Boolean method and relevant search term combinations, including "maxillofacial," "trauma," and "airway," were considered.

Results

A total of 452 relevant articles in total were identified. Articles meeting inclusion criteria by abstract review included 68 total articles, of which 16 articles were focused on airway management techniques for maxillofacial trauma in the general population and were deemed appropriate for inclusion in the literature review.

Conclusions

Establishing an effective and stable airway in patients with maxillofacial trauma is of paramount concern. In both the acute setting and during delayed reconstruction, special considerations must be taken when securing a reliable airway in this patient population. The present article provides techniques for securing the airway and algorithms for utilization of these techniques, including both during the initial evaluation and the definitive operative management.

Difficult Intubation due to Penetrating Trauma from a Crossbow Bolt

We present the case of a patient with penetrating neck and craniofacial trauma from a self-inflicted crossbow bolt injury. This case highlights the challenges involved in prehospital airway management related to an in situ foreign object penetrating the oral cavity. We review the complications associated with such injuries and considerations for effective prehospital airway management.

Emergency Tracheostomy in Two Airway Trauma Patients Suspected of COVID-19: A Case Report

Coronavirus disease 2019, known as COVID-19, was first identified in Wuhan, China, in December 2019 and became a pandemic on Mar 11, according to the World Health Organization report. In the epidemic of COVID-19, many patients admitted to hospitals for other reasons may be silent carriers of COVID-19 and have the risk of infecting medical personnel. Thus, meticulous personal protection measures should be considered in suspicious patients, especially when close contact with the patient’s airway is anticipated. We introduce two airway trauma patients suspected of COVID-19 who required emergency tracheostomy. Patient one was a 29-year-old man who suffered facial trauma following a car accident. A chest CT scan showed peripheral ground-glass opacities suggestive for COVID-19. The second patient was a young elevator mechanic who experienced maxillofacial trauma after an elevator crash. The methods of anesthesia and airway protection and safety precautions are described.

Vertically unstable fractured mandibular segment with attached genial tubercles as a parameter for difficulty during intubation for general anaesthesia-substantiation with computed tomographic (CT) scan evidence

PURPOSE

To study and evaluate the anatomic alterations in the suprahyoid musculature, the hyoid bone, and the laryngeal inlet in patients with vertically unstable fractured mandibular segment with attached genial tubercles using computer tomography for substantiation of the clinical evidence and hypothesis of difficulty during intubation for general anaesthesia.

MATERIALS AND METHOD

Random sampling methodology was used to enrol patients with mandibular bilateral parasymphysis fracture qualifying for the classification of vertically unstable fractured mandibular segment with attached genial tubercles for group A patients. Patients with unilateral parasymphysis fracture with vertically stable mandibular segment were included in group B. Forty patients with parasymphysis fracture and no other associated facial fracture/injury were evaluated prospectively by comparing their pre-operative computer tomography (CT) images with post-operative CT images taken after the reduction of the fracture. Parameters evaluated were variation in the radiologic anatomy of the laryngeal inlet shape and alteration in the suprahyoid musculature after open reduction and internal fixation of the fracture when compared with pre-operative CT images.

RESULTS

The following were the results/observations from this study among group A patients: (1) The distance between the genial tubercles and the hyoid was found to be reduced. (2) Dorsal bodily movement of the hyoid was observed suggesting loss of anterior hyoid support. (3) The posttraumatic changes in the shape of the laryngeal inlet were observed in cases with vertically unstable bilateral parasymphysis fracture. (4) Restoration of morphology of the laryngeal inlet and anterior-posterior distance between genium and hyoid after reduction.

CONCLUSION

Computer tomographic findings confirm that the displacement of fractured mandible and resultant displacement of the genial musculature have their effect on the laryngeal morphology. These posttraumatic changes in cases with dorsally displaced vertically unstable fractured mandibular segment with attached genial tubercles should be considered as a vital parameter for assessing difficulty during intubation.

Trauma Airway Management: Induction Agents, Rapid Versus Slower Sequence Intubations, and Special Considerations

Trauma patients who require intubation are at higher risk for aspiration, agitation/combativeness, distorted anatomy, hemodynamic instability, an unstable cervical spine, and complicated injuries. Although rapid-sequence intubation is the most common technique in trauma, slow-sequence intubation may reduce the risk for failed intubation and cardiovascular collapse. Providers often choose plans with which they are most comfortable. However, developing a flexible team-based approach, through recognition of complicating factors in trauma patients, improves airway management success.

Improving Postoperative Nasal Airway Patency in Le Fort-Based, Maxillofacial Trauma Patients Via a Modified Nasal Packing Technique

INTRODUCTION

Combined mid-face and nasal apparatus trauma injuries pose a significant challenge to airway patency (AW), in the immediate postoperative setting following fracture reduction. As such, the authors describe a modified technique with the goal of maintaining a patent nasal AW, while at the same time, minimizing nasopharyngeal bleeding and nasal AW edema-which can complicate patients requiring intermaxillary fixation (IMF) in the setting of pan-facial trauma.

METHODS

A modified technique was devised to assist the reconstruction surgeon in avoiding the risks associated with tracheostomy placement. In an effort to avoid surgical AW complications and improve nasal AW patency in the setting of concurrent IMF and nasal trauma, the authors developed a 2-stage technique drawing upon knowledge from the literature and the authors' own experiences.

TECHNIQUE

Following safe extubation, the authors insert open lumen nasal splints in both the nostrils, and suture them together to the nasal septum. If additional inner nasal support is required, polyvinyl alcohol nonabsorbable nasal packing dressing is covered with antibiotic ointment, and then placed within the nasal cavity lateral to the open lumen splints-as a way to further bolster the internal valve and mid-vault anatomy.

DISCUSSION

Given the fact that traditional nasal packing with merocele/gauze dressing in concomitant to IMF reduced patients ability to ventilate, the authors felt that a modified technique should be applied. The authors' preferred materials in such patients are open lumen splint, which provides nasal AW patency along with some septum support accompanied by merocele dressing. The authors feel that by applying this technique they achieve dual objectives by supporting the traumatized nose and maintaining nasal AW patency.

Failed Mask Ventilation due to Air Leakage around the Orbit in a Patient with a History of Radical Maxillofacial Surgery with Orbital Exenteration

A 72-year-old male (height: 160 cm, weight: 53 kg) was scheduled to undergo left renal and male with ans uterine tract resection. The patient had previously undergone right radical maxillofacial surgery with orbital exenteration 14 years before the present operation to treat squamous cell carcinoma of the right maxillary sinus, with tumour invasion to the orbital floor. An anaesthesiologist encountered difficulty in performing mask ventilation during the induction of anaesthesia in the patient, despite a good mask fit on the face, because the adhesive tape around the orbit had moved. Urgent endotracheal intubation was successful without desaturation. A postoperative examination revealed that a communication between the nasal cavity and the orbit was visible on computed tomograms obtained nine years before the surgery. The patient felt the air leakage around the adhesive tape. The anaesthesiologist should have removed the adhesive tape to directly observe the lesion and should have realised that the communication might cause difficulty in mask ventilation. Careful examination of the airways using computed tomography and precise interviews may improve the understanding of patients' airways and may help avoid similar events.

A Randomized Control Trial of Awake Oral to Submental Conversion versus Asleep Technique in Maxillofacial Trauma

Aim

This study was designed to evaluate the efficacy of awake oral to submental conversion over asleep technique.

Materials and Methods

This randomized clinical study was conducted in maxillofacial department of a tertiary care hospital in patients who had panfacial or mandibular fractures requiring elective surgical correction. The patients were randomly divided into two groups of 12 patients each, asleep fiberoptic-assisted submental intubation (SMI) (Group G; n = 12) and awake fiberoptic-assisted SMI (Group A; n = 12). The primary predictor was mean conversion time of oral to SMI while other predictors were overall success rate, ease of conversion, and complications. Data are presented as mean (±standard deviation) and frequencies (%) as appropriate. Statistical analysis done using unpaired t-test or Chi-square test was performed and P < 0.05 was considered statistically significant.

Results

Twenty-four patients (19:5;Male:Female) aged 18-55 years (Group G = 35.96; Group A = 32.43 years) were included in the study. SMI was successful in all except two patients in group G. Overall success rate was similar in both groups. Time to convert orotracheal intubation to SMI was significantly less in group A (Group G = 9.55 ± 1.42, Group A = 5.67 ± 1.73; P < 0.001). Ease of SMI was found Grade I in 30% and 83% of the patients of group G and A, respectively. No serious complications were observed except 2 cases of bleeding, and 1 case of tube damage.

Conclusion

Awake oral to submental conversion requires lesser time in comparison to asleep technique besides improving the ease (Δ = 53%) of the procedure.

Facial injuries: Triage and applying damage control principles

Facial trauma varies widely in its severity and is also frequently associated with other injuries which can make prioritisation of injuries difficult. An effective method of triage is important to ensure this. This article describes one such approach and discusses the application of damage control principles to facial injuries. Both these issues commonly impact on the management of multiply injured patients with coexisting facial injuries during the initial stages of resuscitation or soon afterwards. Understanding facial trauma is based in part, on parallels with orthopaedic trauma.