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Address reprint requests and correspondence: Jessyka G. Lighthall, MD, The Pennsylvania State University, Director, Facial Plastic and Reconstructive Surgery, Medical Director, Esteem Penn State Health Cosmetic Associates, Department of Otolaryngology-Head and Neck Surgery, 500 University Drive, P.O. Box 850 H091, Hershey, PA 17033.
Director, Facial Plastic and Reconstructive Surgery, Department of Otolaryngology – Head and Neck Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
Consideration of the airway is paramount in management of facial fractures in both the acute setting and delayed repair. As experts in laryngotracheal surgery, otolaryngologists often play a key role in airway management in both settings. On presentation, soft tissue edema and prolapse or presence of blood in the airway may complicate placement of an endotracheal tube and may necessitate emergent intervention. During planned fracture repair, surgeons and anesthesiologists must collaborate to determine a precise airway plan due to the inherent conflict of a need for a secure airway and a need for surgical access. It is our goal to review current techniques for securing the difficult airway in these patients.
Facial trauma poses a unique set of complexities when considering a difficult airway. Not only can the pharynx become inflamed and edematous, but fractures of the face, skull base and neck can impair use of various techniques utilized in standard difficult airway situations. Adequate understanding of facial anatomy and patterns of facial trauma affords knowledge of what techniques can be employed and which should be avoided. Specifically, review of the main structural components of the face identifies focus areas that can be disrupted in facial trauma and gravely alter normal airway anatomy. As evidence continues to show the benefit of early surgical management in the reconstruction of facial fractures, physicians must be proficient in the management of edematous and traumatized airway of trauma victims in both the acute setting and during the surgical repair.
Craniomaxillofacial Fractures in Relation to the Airway
The face as a whole is supported by regions of increased bone density, known commonly as buttresses. These buttress systems provide strength, facial height and width, and make up the scaffolding upon which soft tissues of the face insert to build individual facial features.
Fractures of the facial skeleton tend to occur in distinct patterns such as zygomaticomaxillary fractures or LeFort fractures, but may occur in isolation.
Certain types of fractures and maxillofacial trauma may predispose patients to having more difficult airway management in the acute setting as depicted in Figure 1. Anterior mandibular fractures may cause the tongue position to be more posterior and obstruct the glottis or supraglottic airway. Dentoalveolar fractures may result in teeth becoming dislodged and aspirated. Posterior displacement of the maxilla in bilateral midface fractures (LeFort or panfacial) may occlude the nasopharyngeal airway. Comminuted fractures of the anterior skull base may increase the risk of intracranial placement of an endotracheal tube. Hemorrhage from nasal or oral cavities may be difficult to control and cause aspiration or prevent visualization of the larynx, particularly in an obtunded or noncompliant patient. Massive facial soft tissue and bony trauma, including in gunshot wound injuries, may distort the normal anatomical facial features, produce free bony fragments that may be aspirated, and cause severe bleeding and soft tissue edema (Figure 2). Finally, blunt or penetrating trauma directly to the neck may cause significant upper airway edema, laryngeal fractures or mucosal injury.
Additionally, severe craniomaxillofacial trauma often coincides with other severe intracranial or cervical spinal injuries which require stabilization and increase the difficulty of airway placement (eg, need to maintain cervical spinal neutrality and immobilization).
Figure 1Factors contributing to a difficult airway in craniomaxillofacial trauma.
Acute Airway Intervention in Craniomaxillofacial Trauma
During initial assessment of trauma patients, airway management is of the upmost importance and is the first step in Advanced Trauma Life Support protocols for evaluating trauma victims. The American College of Surgeons has identified maxillofacial trauma specifically as an area requiring advanced knowledge and consideration given the increased risk of such patients presenting with difficult airways.
While the minority of maxillofacial trauma patients present with airway instability upon initial presentation, airway compromise is one of the leading causes of mortality in critical care trauma patients. Upon review of trauma patient deaths after admission to inpatient care, Gruen et al determined that 16% of error-related deaths of trauma patients were secondary to failure to adequately protect the patient airway.
Standard practices in obtaining an airway include bag mask ventilation, oral, nasal and supraglottic airway devices, endotracheal tubes, tracheotomy and cricothyroidotomy, all of which have unique indications and contraindications in the setting of facial trauma. In certain instances, a submental intubation may be warranted. Though anatomic variations can pose a challenge in any difficult airway situation, trauma patients present with additional assumed complications including a full-stomach with increased risk of aspiration, C-spine precautions, and a high likelihood of active bleeding.
Aspiration Prevention
High power suctioning of the oropharynx can clear secretions, pooled blood, and small debris from the airway, improving visualization of the vocal cords and minimizing the risk of aspiration. As trauma patients are assumed to be at high risk of aspiration, gastric emptying with orogastric or nasogastric tube suctioning (see Figure 1) should be performed; though, nasogastric tube placement should be avoided in cases of suspected base of the skull injury to avoid accidental intracranial tube placement.
Despite conjecture that application of cricoid pressure can prevent aspiration of gastric contents during intubation, recent studies indicate minimal benefit to this technique and favor direct emptying of the stomach with gastric suctioning.
Current recommendations to prevent aspiration in high risk patients involves rapid sequence induction without application of cricoid pressure in order to ensure optimized view for intubation and minimize further trauma to the airway.
Trauma patients presenting with any form of head, face, or neck injury are assumed to have an unstable cervical spine (C-spine) until proven otherwise. In initial trauma evaluation, C-spine precautions must be maintained to mitigate the risk of further disrupting spine alignment, which may worsen injury and place the patient at increased risk of neural dysfunction. Though recent studies indicate that spinal manipulation involved in direct laryngoscopy for intubation has a low risk of C-spine injury, protocols continue to suggest maintenance of C-spine precautions until stability status is confirmed in secondary assessment. In the past, physicians have attempted to use manual inline stabilization techniques when C-spine motion is needed to optimize intubation positioning. However, there is now rising concern that such techniques fail to adequately protect the entire cervical region. In many cases, application of inline stabilization may worsen the view of the larynx, without adding the benefit of improving patient safety.
When concern for C-spine injury is high, image-assist devices such as a flexible fiberoptic device and Glidescope video-laryngoscope may be employed on the first intubation attempt to minimize spinal motion and maximize the likelihood for a successful single trial intubation. The use of image assisted devices allows indirect view of the vocal cords and allows for controlled tube placement even when the head is suboptimally positioned. Use of video-assisted intubation devices is, however, complicated by obscuring of the lens by airway secretions and hemorrhage. Use of a flexible fiberoptic scope with suction capabilities may help overcome this issue.
Physicians must quickly recognize and address modifiable factors contributing to the difficult airway situation to increase likelihood of success on initial intubation attempts. Various forms of oxygen delivery have been trialed and each have unique benefits and pitfalls, especially in the unique setting of facial trauma. Though a cuffed endotracheal tube is considered the most desirable when resuscitating trauma patients, challenges with placement of the tube should not delay patient oxygenation. When faced with a trauma related difficult airway, providers should be armed with an understanding of various oxygenation methods and intubation techniques and ultimately utilize whatever necessary to prevent hypoxia.
Mask Ventilation
Though often considered the most fundamental of all airway management techniques, bag mask ventilation can prove difficult in trauma settings when disruption of normal facial anatomy interferes with mask seal and C-spine precautions hinder optimal head positioning for efficient oxygen delivery to the lungs. Additionally, trauma to the face, head and neck can cause significant edema and displacement of soft tissue structures and subsequent obstruction of the airway.
Obtaining a mask seal in massive facial soft tissue trauma such as a self-inflicted gunshot setting is often problematic due to loss of or distortion of soft tissues and bony skeleton. Providers attempting mask ventilation must continuously monitor and re-evaluate the patient, as even in cases in which an adequate face-mask seal is obtained, mucosal lacerations from concurrent laryngopharyngeal trauma could provide an access into surrounding soft tissues. In such cases, continued delivery of oxygen through the face mask may result in formation or worsening of subcutaneous emphysema and pneumomediastinum.
When mask ventilation, and therefore optimized preoxygenation, is not possible, rapid placement of a supraglottic device or endotracheal tube is essential to prevent frank hypoxemia. Supraglottic airways, such as the laryngeal mask airways (LMAs) are incorporated into difficult airway algorithms, as they are inserted without visualization of the cords and can serve as bridging airway, allowing for subsequent placement of an endotracheal tube through the LMA.
However, LMAs may have reduced utility in the setting of maxillofacial trauma. Similar to mask ventilation, oxygen delivery through an LMA may force air entry through a false lumen. Several case reports exist indicating that blind insertion of the device into an airway with abnormal anatomy from surrounding trauma may induce laryngeal or pharyngeal perforation, worsening the condition of an already critical patient.
In cases of trauma localized to the face and maxilla, LMA placement is likely safe but may not be feasible. Given their large size relative to a traditional endotracheal tube, the LMA may be difficult to pass into the supraglottic area when edema reduces the size of the oropharynx. Additionally, it is essential to remember that supraglottic devices, though useful in delivering oxygen to the trachea, do not truly provide a secure airway, as vomitus and gastric contents can still be regurgitated and aspirated around the device.
Orotracheal or Nasotracheal Intubation
Obtaining a secure airway by standard means is often possible, even in the massive maxillofacial trauma setting with or without fiberoptic guidance. As mentioned above, in the facial trauma setting, there may be multiple fractured bony segments with posterior displacement causing oropharyngeal obstruction or soft tissue distortion due to soft tissue loss. It is imperative to recall in these settings that loose tissue may be manually mobilized. For example, in a patient with oropharyngeal obstruction due to bilateral anterior mandible fractures, the displaced bony segment or tongue may be grasped with a penetrating towel clamp and manually distracted anteriorly to open up the oropharyngeal airway and assist in obtaining an adequate view for a standard endotracheal airway.
Emergency Surgical Airway
When all other attempts fail, a cricothyroidotomy can be performed to establish an emergency airway to save the life of a decompensating patient (Figure 3). Though the vast array of airway devices has significantly reduced the need for such emergency procedures, surgical airways can prevent devastating outcomes. Cricothyroidotomy, by which an airway is secured via the cricothyroid membrane, is largely limited to the prehospital and or emergency room setting, where intubation techniques and assist technology is limited. However, it is paramount that surgeons remain confident in cricothyroidotomy technique, given it is the final option in the ACTL difficult airway algorithm.
Tracheostomies and cricothyroidotomies provide surgeons with guaranteed secure airway management in a variety of settings and are considered to be largely safe in most cases of facial trauma. Though these techniques certainly provide stable airways in a variety of cases, they are considered relatively invasive and generally require long-term management, particularly in the case of cricothyroidotomy, which necessitates conversion to a formal tracheostomy to minimize the risk of adverse airway complications. An emergent tracheostomy can also be performed to avoid the increased complications of a cricothyroidotomy. Potential complications include external cervical scar, tracheal stenosis, injury to the thyroid gland, disruption of major blood vessels, direct laryngeal injury, persistent tracheocutaneous fistula, and vocal cord paralysis through damage to the recurrent laryngeal nerve.
Approach to the Airway During Delayed Maxillofacial Trauma Repair
Delayed repair of facial fractures following stabilization of the patient also has special considerations in a patient with maxillofacial trauma. After the airway is secured and other life-threatening injuries have been addressed, trauma patients require a thorough physical exam as well as extensive imaging to fully evaluate the extent of injuries. In the setting of maxillofacial trauma, this includes thin-cut CT of the head, face and neck.
CT images in the axial, sagittal and coronal planes are used to confirm and characterize all fractures. Additionally, these images can be digitally modified to create a 3-D reconstruction of the facial skeleton to aid in operative planning. Patients with multiple, complex, comminuted fractures can be challenging, as the surgical team must balance the need for internal reduction and fixation of fractures and repair of soft tissue structures while maintaining safe and effective patient ventilation. Since many repair techniques utilize intraoral incisions and application of maxillomandibular fixation for reducing and fixating facial fractures, traditional placement of an oral endotracheal tube may obstruct the surgical field and may not be feasible.
In the past, this dilemma has been addressed through intraoperative exchange between oral and nasal endotracheal tubes based on surgeon need. More recent airway management techniques have replaced the need to manipulate and exchange the airway intraoperatively. These techniques provide safer ways to secure airways while allowing surgeons access to the surgical site.
Retromolar Intubation
Retromolar intubation utilizes a reinforced tube placed via traditional mechanisms with subsequent positioning of the tube in the retromolar space (Figure 4). Positioning can be secured by suturing the tube to the buccal mucosa. Alternatively, an eyelet wire secured to the most posterior molar can anchor the tube to the retromolar space. Such techniques allow manipulation of dentition into full occlusion intraoperatively without the need for additional skin incisions.
However, the risk of tube interference in the surgical field is greater in cases using retromolar intubations than in many other intubation techniques. Additionally, a smaller than recommended tube size may be needed to assure the reinforced tube fits in the retromolar space, which can alter respiratory mechanics and be problematic in the setting of increased secretions.
In the maxillofacial trauma setting, orotracheal intubation may cause significant challenges in approaching facial fractures. Thus, nasotracheal intubation may be a viable option to maintain the airway without precluding surgical access. To prevent extubation during surgery, it is best to first position the nasotracheal tube cephalically towards the head of the bed to remove it from the surgical field. The tube can be anchored by taping it across the forehead, or by suturing it through the nasal septum as seen in Figure 5. It is important to protect the soft tissue triangle of the nose as pressure necrosis is a known complication of this method.
This is best avoided by confirming no pressure on the ala after securing of the tube. A nonabsorbable nasal pack can also be placed between the tube and soft tissue triangle. Traditionally, advancement of airway devices through the nasal passage in skull base fractures is contraindicated as disruption of the skull base leaves intracranial structures vulnerable to trauma from passage of the tube.
However, flexible fiberoptic guidance allows for the safe placement of a nasal tube in patients with limited base of the skull fractures.
Figure 5A stable method for securing a nasotracheal tube in the setting of maxillofacial trauma. Note the nasal pack protecting the soft tissue triangle and ala.
Submental intubations provide an alternative to tracheostomy during open reduction internal fixation operative management of maxillofacial trauma as they temporarily divert the airway away from the surgical field. They can be safely placed in cases involving base of the skull injury and eliminate the need for intraoperative oral-to-nasal tube conversion. Additionally, this techniques takes roughly half the time required to complete a tracheostomy.
In executing a submental intubation, a spiral reinforced ET tube is first placed orally, similar to traditional endotracheal intubation. Using the inferior border of the mandible as a landmark, a 2.0 cm transverse submental skin incision is made medial and parallel to the mandibular border. Throughout the subsequent soft tissue dissection, care is taken to avoid disruption of the lingual nerve—a rare complication cited by Jundt et al as occurring in 1 out of 842 cases
—and Wharton's duct through tracing the lingual surface of the mandibular body. Blunt dissection proceeds from the skin incision through the subcutaneous tissue, platysma, deep cervical fascia and mylohyoid muscle. Finally, a small intraoral incision at the junction of the lingual gingiva and the oral mucosa to create a passage from floor of the mouth to external submental region (Figure 6).
Various methods have been trialed to facilitate passage of the endotracheal tube (after removal of tube connector) through the submental opening. Some utilize dilators to widen the space before attempting to pass the tube while others prefer to simply pull the end of the tube through the dissected space with hemostats. Regardless of technique, it is advised to cover the distal end of the tube with a sterile surgical glove or lubricating jelly, allowing it to slide more easily through the surgical opening. Once the tube is passed, reconnected to the anesthesia circuit and confirmed to be in proper position for patient ventilation, the tube is sutured in place.
The submental approach maintains a variety of options for postoperative management of the patient. At the conclusion of the procedure, the suture is removed, tube is disconnected from breathing circuit and pulled back into the oral cavity, where it can remain in traditional orotracheal position until the patient is ready for extubation. The submental defect can then be closed with suture before anesthetic emergence. The submental scar is generally well hidden under the chin line and the oral mucosal incision is either closed or left to heal by secondary intention. Alternatively, if the surgical team decides intraoperatively that the patient must remain in maxillomandibular fixation for a period of time, the endotracheal tube can remain in the submental position.
Planned Tracheotomy
Planned preoperative tracheostomy is a useful approach to intraoperative airway management based on the degree of facial trauma or when prolonged postoperative ventilatory support is anticipated. During this procedure, a horizontal skin incision is made and deepened to the level of the strap muscles. The strap muscles are divided vertically and retracted laterally to expose the isthmus of the thyroid, which is either retracted or divided. A horizontal incision is then made into the trachea between the 2nd and 3rd tracheal rings and a tracheotomy tube is placed and secured to the skin with permanent sutures and/or a trach tie (Figure 7) .
Patients with panfacial factures including both naso-orbital-ethmoid fractures and maxillary/mandibular fractures present challenges in choosing a secure airway. A nasotracheal tube interferes with correction of nasoseptal and naso-orbital-ethmoid fractures. Retromolar intubation may allow for maxillomandibular fixation for correcting occlusion but may still interfere with plating midface and mandibular angle fractures. Submental intubation avoids these issues, however the repetitive movement of the head during surgery may cause dislodgement of the tube. In the event of a submental endotracheal tube being displaced, it may be difficult to re-secure the airway, particularly if maxillomandibular fixation is in place. Additionally, a submental tube may interfere with the transcutaneous approach to comminuted mandibular fractures in combination with other facial fractures. Many surgeons still advocate for a planned tracheostomy as the most secure and least obstructive method for securing the airway with the given operative field in mind. This is ideal for panfacial fractures with significant bony and soft tissue injury. Furthermore, in the presence of neurologic or cardiopulmonary injury, tracheostomy may be necessary for prolonged ventilatory support following surgery.
Conclusion
In conclusion, in the setting of massive facial trauma, one must be aware of other severe injuries and clear the airway with suctioning. Mask ventilation, if possible, will allow for oxygenation until a secure airway can be obtained. Although supraglottic airways may be a temporizing maneuver to maintain an airway, definitive endotracheal intubation should be obtained. Flexible fiberoptic guidance with a suction port may be a useful adjunct to safely obtain an orotracheal or nasotracheal airway. When soft tissue injury or edema are present and this cannot be relieved with anterior mobilization of the soft tissue, an emergent cricothyroidotomy or tracheotomy should be performed. Finally, careful preoperative planning between the surgical and anesthesia teams can provide safe and nonobstructive airways during delayed repair of facial fractures.
Disclosure
The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in this article.
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