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Anaesthesia for facial trauma
DENTAL AND MAXILLOFACIAL ANAESTHESIA
Anaesthesia for facial trauma
Learning objectives After reading this article you should be able to: C identify likely causes and patterns of facial trauma injuries C select appropriate airway management techniques in the emergency setting C perform airway management for specific maxillofacial injuries in the stable patient C formulate anaesthetic management plans for patients with facial trauma
Cristina Niciu Val Cunningham Kevin Fitzpatrick
Abstract Facial trauma is common and can produce both physical and psychological problems for patients. Managing patients in both the emergency setting and elective theatre environment can be extremely challenging, so airway interventions should be carefully planned so the safest and most effective technique can be chosen. This may mean that direct laryngoscopy may not be the safest or most straightforward option and awake fibreoptic intubation, videolaryngoscopy, submental intubation or awake tracheostomy may be a better choice in a given set of circumstances. An understanding of common mechanisms of injury and pathologies and the likely difficulties that will be present are essential. Senior anaesthetic input and effective teamwork are required to provide excellent levels of care for these patients.
Keywords
Airway;
anaesthesia;
facial
trauma;
Aetiology Patients present with isolated facial trauma or facial trauma in combination with other significant injuries. Individuals with a single facial fracture have been shown to have an incidence of cervical fracture at 5e8% and head injury 20e80%, and those with at least two facial fractures have a 7e10% incidence of cervical fracture and a 65e89% incidence of head injury.2 Between 55% and 70% of patients presenting with facial trauma have been shown to have other significant injuries.3,4 Polytrauma is likely to be a combination of both penetrating and blunt force trauma. The two most common causes of facial trauma are assault and road traffic accidents, with blunt trauma more common than penetrating trauma.1 Other causes include sports injuries (most often football, rugby, hockey, boxing and cycling), falls, accidents, dog bites and gunshot injuries. Improved road safety measures including seat belts, airbags and a reduction in people driving under the influence of alcohol have reduced the trauma association with road traffic accidents over the past 30 years.1 The use of helmets by bicyclists reduces the risk of head, brain and severe brain injury by 63e88%, providing equal protection for crashes involving motor vehicles (69%) and crashes from all other causes (68%). Additionally, injuries to the upper and mid-facial areas are reduced by 65%.5 Prevention of injuries caused by violent assaults is also clearly important and local initiatives may help in this regard. Examples of such initiatives exist throughout the UK. One example in Scotland is the ‘Medics against violence’ programme. This organization was started by healthcare professionals in Scotland and is supported by the Scottish Government. It consists of a school education programme consisting of anti-violence lessons to pupils about 13 years of age, and a domestic abuse training programme.6
intubation;
maxillofacial Royal College of Anaesthetists CPD Matrix: 1B02, 1C01, 1C02, 2A01, 2A02, 3A01, 3A10
Background Facial trauma can significantly affect patients in both the short and long term, producing aesthetic, functional and psychological problems. Functionally, it can affect mastication, eyesight, sense of smell, taste, swallowing, and breathing depending on the site of injury. Facial trauma may be associated with concurrent polytrauma and/or vascular complications. It is possible that these factors in combination with aesthetic complications may have a profound psychological impact on a person’s life. Patients may present with injuries requiring immediate medical treatment in the emergency department, commonly due to either haemorrhage or airway compromise,1 or may present in a more stable situation allowing more time to assess injuries and formulate treatment plans.
Anatomical considerations Anaesthetic management of facial trauma requires understanding of maxillofacial anatomy. The human skull is divided in two major parts, the cranial skeleton which contains and protects the brain and the facial skeleton, which can be subdivided into three parts: the upper face: frontal bone and fronto-zygomatic processes mid-face: orbits, nasal bone, ethmoid, zygoma and maxilla lower face: mandible. The facial skeleton has natural points of weakness and strong dense bones called buttresses, and in the context of trauma, acts as a crumple zone to protect the brain. Fractures occur in
Cristina Niciu FRCA is a Specialty Registrar in Anaesthetics at the Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow, UK. Conflicts of interest: none declared. Val Cunningham FRCA is a Consultant Anaesthetist at the Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow, UK. Conflicts of interest: none declared. Kevin Fitzpatrick FRCA is a Consultant Anaesthetist at the Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow, UK. Conflicts of interest: none declared.
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Please cite this article in press as: Niciu C, et al., Anaesthesia for facial trauma, Anaesthesia and intensive care medicine (2017), http://dx.doi.org/ 10.1016/j.mpaic.2017.06.003
DENTAL AND MAXILLOFACIAL ANAESTHESIA
characteristic points where the bone is weak, and may be unilateral or bilateral. Comminuted fractures imply high-energy transfer. High-impact force will cause trauma to the supraorbital rim, frontal bone, maxilla and mandible, whereas the nasal bones and zygoma can be damaged even in low impact trauma. The rich blood supply to the face can lead to bleeding during trauma. But in the context of hypovolaemic shock in a trauma patient other causes of haemorrhage should be sought. Rarely, a major bleed from facial trauma can occur from end branches of the maxillary artery or from epistaxis.
Le Fort fracture lines a Le Fort 1 fracture
Classification Maxillofacial trauma can be classified as: soft tissue injury with no underlying bone trauma bony skeleton fractures, upper, middle and lower; middle facial fractures are further classified as LeFort I, II, III laryngeal and tracheal trauma.
Soft tissue facial injury
b Le Fort 2 fracture
Extensive soft tissue injury around the nose and face can lead to difficult face mask ventilation.
Facial fractures Upper facial fractures Fractures involve the frontal bone, sinuses and orbit. Anterior skull base fracture can occur with cerebrospinal fluid (CSF) leak and risk of infection. Although not absolute contraindication, care with nasal intubation, nasogastric tube and temperature probe is required. Middle facial fractures Fractures of the mid-face are classified as LeFort I, II and III (Figure 1). LeFort fractures can commonly involve fractures of the mandible. LeFort I horizontal fracture separates the teeth and the lower maxillary part from the upper facial structures. The patient will have facial oedema and mobility of hard palate and teeth. LeFort II triangular fracture that separates the maxilla from the zygoma. The maxilla may be displaced backwards in the facial skeleton and free floating. The patient will have facial oedema, epistaxis requiring packing and possible CSF leak. LeFort III complete dissociation of facial skeleton from cranial skeleton. The patient may present with significant facial oedema, flat dish face deformity, epistaxis and CSF leak with associated base of skull fracture. If the maxilla is displaced posteriorly it may act to close off the posterior airway. In middle facial fractures, epistaxis may lead to significant blood loss and need to be controlled with packing, which may make bag/valve/mask ventilation difficult. Due care with NG tubes and temperature probes is required if base of skull fracture is suspected. CNS infection if CSF leak is present should be considered. Nasal intubation may be contraindicated which is discussed in more detail later.
c Le Fort 3 fracture
a The Le Fort 1 fracture line passes through the inferior wall of the antrum and allows the tooth-bearing segments of the upper jaw to move in relation to the nose. b In a Le Fort 2 fracture the maxilla and nose can move as a block in relation to the frontal bone and zygoma. c In a Le Fort 3 fracture the facial bones are able to move separately from the base of the skull. Le Fort 2 and 3 fractures may be associated with a dural tear resulting from fracture of the cribriform plate of the ethmoid bones. In Le Fort 3 fracture the base of skull bones (sphenoid and /or temporal) are involved.
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Figure 1 LeFort classification of middle facial fractures. (Reproduced from: Joy E Curran. Anaesthesia for facial trauma. Anaesthesia and Intensive Care Medicine 2014).
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DENTAL AND MAXILLOFACIAL ANAESTHESIA
General management principles
Lower facial fractures Fractures of the mandible present with a painful jaw and malocclusion of teeth. As a ring structure the mandible is usually broken in two or more places. Posterior inferior displacement of the jaw can cause airway obstruction. Bilateral mandibular fractures can cause difficulties in airway management: mouth opening may be limited the tongue which is attached to the anterior mandible by the genioglossal muscles may fall back and occlude the airway, which in an unconscious patient can be fatal posterior inferior displacement of jaw can cause airway obstruction, as can backward displacement of mid-face fractures during attempted bag/valve/mask ventilation lingual or pharyngeal oedema/haematoma can make laryngoscopy difficult teeth can become loose and avulsed, and fall into the airway. It is important to differentiate between reduced mouth opening caused by pain which will usually resolve following opioid analgesia or induction of anaesthesia, and that caused by a mechanical limitation in mouth opening that will not improve with analgesia or anaesthesia.
There are several general principles which can assist in making a safe and effective management plan. Three such principles to consider are: How much time do I have? Do I expect to be able to face mask ventilate? What view do I expect at laryngoscopy? Is it likely the patient will deteriorate if there is delay? This would mostly commonly be due to either swelling or haemorrhage. Voice changes, stridor or difficulty swallowing may indicate injury of the laryngopharynx and/or developing pharyngeal oedema. Examination of the patient looking for blood-stained saliva, and for tongue or other intraoral swellings is fundamental. Always give other injury consideration in the patient with facial trauma as they may also have intraoral or laryngeal injuries. It may be that assessment with a fibreoptic scope will help assess this either as a nasendoscopy or oral fibreoptic. Common sense needs be applied if there is intraoral bleeding as easy measures may be taken under local anaesthetic to stop this prior to induction, for example suturing buccal lacerations or using lignocaine with adrenaline injection or as an adrenaline-soaked swab. Simple compression or packing may be useful. Conscious patients with this degree of bleeding should be allowed to sit forward. Mask ventilation may be difficult or impossible in the presence of significant facial injuries where there may be tissue loss, swelling and ongoing bleeding. It may not be possible to get a good enough mask seal on the face to manage effective ventilation. It is useful to palpate the submental region for swelling and induration indicating the possibility of a fixed tongue. This may result in a poor view at direct laryngoscopy even in the presence of good mouth opening, so would be better managed by a device such as a videolaryngoscope which allows an indirect view to be obtained. In this circumstance it will be useful to use either an endotracheal tube pre-loaded with an appropriately shaped introducer or use a gum elastic bougie as the initial plan. In general, the presence of multiple facial injuries with or without bleeding can lead to a more challenging situation and hence awake intubation may be the most appropriate and safe initial plan. However, fibreoptic intubation in the presence of bleeding may be extremely difficult. If there is no time to wait until bleeding stops, an awake tracheostomy may be required rather than awake fibreoptic intubation. For example, in a patient with laryngeal injury as well as facial trauma, or in a patient with multiple facial injuries, as well as ongoing bleeding, intraoral oedema, and expected difficulty laryngoscopy awake tracheostomy may be the safest option. This may be performed with or without intravenous sedation, although it may be safer to avoid sedation in a crisis situation. Neither awake fibreoptic intubation (AFOI) nor awake tracheostomy is easy if the patient has intraoral bleeding as both distortion of view in AFOI and inability to lie flat in the awake tracheostomy make the procedure more difficult for the operator and more traumatic for the patient.
Laryngeal trauma Simple tears, dislocation of the arytenoids, disruption of cricothyroid joint and bleeding can occur. The patient may present with subtle voice changes, hoarseness, stridor and hypoxia. Cervical spinal injury and pneumothorax can be associated. Close attention should be paid to the mechanism of injury which may raise suspicion of an increased chance of laryngeal injury.
Emergency management Facial trauma can lead to airway challenge for the anaesthetist with oedema, bleeding, difficult bag valve mask ventilation and laryngoscopy. The patient may have major trauma and should be assessed with advanced trauma life support primary and secondary survey in an appropriate critical care area with senior anaesthetic input. It is important to note patients with facial trauma may have other injuries affecting management, such as: significant airway compromise requiring an advanced airway technique, with senior anaesthetist/ENT/maxillofacial surgeons required unstable C spine, with manual in-line stabilization traumatic brain injury with reduced Glasgow Coma Scale score requiring intracranial pressure management and neurosurgical input basal skull fracture, with CSF leak, avoidance of nasal instrumentation major haemorrhage with hypovolaemic shock from other injuries e thoracic, intra-abdominal, long bone or pelvic fractures. Acute management is required by a multidisciplinary team. Often patients requiring intubation in the emergency department will be managed with a rapid sequence induction with the neck immobilized followed by oral intubation, but it is possible the patient may require either fibreoptic intubation or tracheostomy both of which will be challenging in that setting.
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Preoperative considerations In the stable situation without ongoing bleeding and worsening intraoral swelling a comprehensive airway assessment should be performed. Airway assessment should include inspection of swelling, nasal patency and degree of mouth opening. Tongue
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DENTAL AND MAXILLOFACIAL ANAESTHESIA
protrusion as an assessment of difficulty at intubation due to submental swelling and/or other trauma-related pathologies should not be forgotten as a warning sign for difficulty even if mouth opening is good. It is important to discuss the operative plan with the surgeon. The route of repair should be considered and whether nasal, oral, submental intubation or tracheostomy is required. The need for throat pack, facial nerve monitoring and postoperative intermaxillary fixation should also be discussed. The requirement of steroids to reduce postoperative swelling and antibiotic prophylaxis should be addressed. Preoperative imaging, such as CT scans, should be reviewed to identify significant intraoral or airway swelling, or bony injury that may cause a mechanical limitation to mouth opening. Backup airway management plans should be discussed with the team in advance of induction of anaesthesia in case difficulties are encountered. Appropriate planning should reduce risks of complications if initial airway plans prove unsuccessful as these can and sometimes fail as demonstrated in the 4th National Audit Project (NAP4).7
Figure 2 Three-dimensional reconstructions from facial CT scan demonstrating the left zygomatic arch displaced posteriorly against the coronoid process of the mandible which will mechanically limit mouth opening.
Anaesthetic management for common bony facial injuries Orbital floor fractures Plating of an orbital floor fracture requires a south-facing oral endotracheal tube and a throat pack. The main challenges for the anaesthetist are avoiding intraoperative bradycardias when working within the orbit and coughing on extubation as this can result in orbital haematoma which will necessitate return to theatre. The options to minimize coughing include changing the endotracheal tube for a laryngeal mask airway (LMA) at the end of the procedure, running a remifentanil infusion, or attempting a deep extubation. These techniques require there to be no ongoing bleeding from co-existing intraoral injuries to be safe options. There is no perfect solution but in our centre the majority of these patients would have an LMA exchange at the end of the procedure and a remifentanil infusion continued until the patient is awake.
In edentulous patients or patients where occlusion is unnecessary and base of skull fracture is present oral intubation may be used. It is common practice for a throat pack to be inserted to avoid pharyngeal contamination or increasing the intragastric blood load. On assessment the majority of these patients will have reduced mouth opening due to pain rather than a structural cause for limitation and following induction of anaesthesia the patient’s mouth will often open fully. The exceptions to this are either a fracture involving the temporomandibular joint or a delayed presentation complicated by haematoma or infection causing masseter spasm. If there is doubt as to the cause of reduced mouth opening then an option would be to give a dose of a short-acting strong opioid (e.g. 1 mg alfentanil) in the anaesthetic room prior to induction and the patient will often demonstrate significantly improved mouth opening. In patients presented for surgery acutely after injury there is often intraoral bleeding due to the compound nature of many mandibular fractures. Patients may have swallowed a significant amount of blood and continue to have blood-stained saliva. Careful consideration should be given to rapid sequence induction in any patient suspected to have ongoing oral bleeding or pain due to injury as these promote emesis, increase gastric volume, and reduce gastric emptying. As mentioned above, blunt force trauma to the nose can result in base of skull fracture, diagnosed with rhinorrhoea and also with CT imaging. The problem caused by this is the relative contraindication to pass tubes through the nose acutely when these patients need surgery to fix mandibular and mid-face fractures. Depending on the extent of basal skull fracture the anaesthetists must decide whether to perform a nasal intubation despite the fracture, in which case it should be done under direct vision using a fibreoptic scope, or whether to avoid intubating through the nose altogether. If the decision is that nasal intubation is contraindicated and occlusion of the teeth is required, the options are either tracheostomy or submental intubation. Submental intubation (Figures 4 and 5) is a safe and effective option when the patient only requires intubated for the duration
Zygomatic fracture These fractures are common and present with swelling, a bony step, visual disturbance, enopthalmus, or malocclusion of the upper teeth. Zygomatic arch or body fractures may mechanically limit mouth opening if displaced posteriorly against the coronoid process of the mandible (Figures 2 and 3). Zygomatic fractures are often left until swelling subsides prior to fixation unless there is uncontrolled haemorrhage that needs managed. While surgeons prefer to operate within 1e2 weeks it is possible to defer operation due to concurrent morbidity for several weeks although the necessity for osteotomy increases with time. A south-facing oral tube and throat pack are used for the procedure. Straightforward procedures may be performed with a laryngeal mask provided nasal bleeding is not expected. Intraoperatively it is possible to get marked bradycardia on elevation of the zygoma, which may require glycopyrrolate or atropine treatment. Mandibular (and mid-face) fractures Mandibular (and mid-face) fractures require intraoperative occlusion to be performed to check the fracture has been reduced and fixed in a suitable position. A nasal intubation is normally performed to allow a good operative view and occlusion of the teeth.
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DENTAL AND MAXILLOFACIAL ANAESTHESIA
Figure 4 A patient following oral intubation with a reinforced endotracheal tube with the floor of mouth marked prior to performing submental intubation. Figure 3 Three-dimensional reconstructions from facial CT scan demonstrating the left zygomatic arch displaced posteriorly against the coronoid process of the mandible which will mechanically limit mouth opening.
Postoperative management Most patients following maxillofacial fracture fixation are safe to return to the surgical ward. Those with multiple injuries and potential to deteriorate may be better managed in high-care areas. Postoperative complications include swelling and haematoma. Oedema can worsen in the first 48 hours especially with LeFort II and III fractures. In addition, postoperative haematoma can occur and compromise the airway, especially after floor of mouth surgery. Emergency decompression of the haematoma is required by removing clips or sutures and manually evacuating the haematoma with suction. While this will reduce swelling due to the haematoma, any associated oedema will not be relieved and the airway may still remain difficult to manage.7 Multimodal analgesia should be used including paracetamol, non-steroidal anti-inflammatory drugs and a long-acting opioid if there are no contraindications.
of the procedure and there is no other indication for tracheostomy.8 To perform a submental intubation, the patient initially has an oral intubation. In theatre, the tube is then held firmly as it is pulled through a dissected plane in the floor of the mouth from a submental incision that is done by the surgical team and then secured. At the end of the procedure the reverse is done. The tube is brought back into the mouth, wound sutured, and the patient is extubated normally. A disposable intubating LMA tube is ideal for submental intubation as it allows a reinforced tube to be used and is the only reinforced tube with a removable connector. The patient with multiple injuries that will be unable to be extubated at the end of the procedure due to significant airway swelling is likely to require a tracheostomy. If this is the case an oral intubation followed by surgical tracheostomy, before proceeding to fixation of mandible is the best option.
Major reconstructive procedures following facial trauma Facial trauma injuries resulting in significant tissue loss may require significant reconstructive surgery including free tissue transfer surgery. These type of injuries may require either soft tissue and/or composite (soft tissue and bone) free flap surgery
Extubation Other than the specific case of orbital floor repairs, the facial trauma patient should be extubated awake following removal of throat pack and direct vision suction of the mouth, including the nasopharynx, where blood and clots can accumulate particularly following nasal intubation. Wire cutters or scissors for elastic band fixation should be available if wires or bands have been used, and the surgical team should be in attendance until safe extubation has been achieved. Complete reversal of muscle relaxation should be ensured and the use of sugammadex in the difficult airway patient should be considered, particularly if there are other risk factors such as high body mass index and respiratory disease. The Difficult Airway Society extubation guidelines ‘at-risk’ algorithm provides a structured approach to managing the extubation process when there is concern that re-intubation may be difficult if required in the immediate post-operative period.9 Patients that are deemed unsafe to extubate due to severity of facial injuries and intraoral swelling would be best managed with a tracheostomy, although on occasions they may be managed intubated and sedated in intensive care until swelling subsides.
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Figure 5 A patient after completion of the submental intubation procedure.
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DENTAL AND MAXILLOFACIAL ANAESTHESIA
Figure 6 Three-dimensional reconstruction of CT scan of a patient following gunshot injury to mandible resulting in massive soft tissue and bone loss. The gun pellet fragments are clearly visible on the scan.
(Figures 6, 7 and 8). The reconstruction often needs to be done at an early stage to prevent contraction of remaining tissues. Threedimensional modelling using CT scans and software packages make accurate planning for these cases possible and patients can get excellent results despite seemingly devastating initial injuries.
Conclusion
Figure 8 The same patient from Figures 6 and 7 in the immediate postoperative period. Tracheostomy, nasogastric tube and bilateral neck drains are visible.
Managing facial trauma patients can prove extremely challenging to the anaesthetist and the entire team looking after the patient. Effective planning, teamwork, and communication are required.
Senior anaesthetic involvement is necessary to safely manage maxillofacial trauma patients with significant injuries. A REFERENCES 1 Kirkpatrick N. Facial and orbital injuries. Surgery 2004; 22: 185e90. 2 Mulligan RP, Mahabir RC. The prevalence of cervical spine injury, head injury or both with isolated and multiple craniomaxillofacial fractures. Plat Reconstr Surg 2010; 126: 1647e51. 3 Shere JL, Boole JR, Holtel MR, Amoroso PJ. An analysis of 3599 midface and 1141 orbital blowout fractures among 4426 USA soldiers 1980e2000. Otolaryngol Head Neck Surg 2004; 130: 164e70. 4 Hussain K, Wijetunge DB, Grubnic S, Jackson IT. A comprehensive analysis of craniofacial trauma. J Trauma 1994; 36: 34e47. 5 Thompson DC, Rivara F, Thompson R. Helmets for preventing head and facial injuries in bicyclists. Cochrane Database Syst Rev 1999; 4: CD001855, http://dx.doi.org/10.1002/14651858.CD001855. 6 We are medics against violence. We are about one thing e preventing violence. http://medicsagainstviolence.co.uk/ (accessed 31 Jan 2017). 7 Cook T, Woodall N, Frerk C, eds. 4th National Audit Project: major complications of airway management in the United Kingdom. London: RCOA, 2011. 8 Gadre KS, Waknis PP. Transmylohyoid/submental intubation: review, analysis, and refinements. J Craniofac Surg 2010; 21: 516e9. 9 Difficult Airway Society. DAS extubation guidelines. https://www.das. uk.com/guidelines/das-extubation-guidelines1 (accessed 31 Jan 2017).
Figure 7 Three-dimensional reconstruction of the same patient from Figure 6 following both radial forearm free flap and deep circumflex iliac artery bone-free flap surgery. The plated bony reconstruction is demonstrated.
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Please cite this article in press as: Niciu C, et al., Anaesthesia for facial trauma, Anaesthesia and intensive care medicine (2017), http://dx.doi.org/ 10.1016/j.mpaic.2017.06.003
Anaesthesia for facial trauma
Learning objectives After reading this article you should be able to: C identify likely causes and patterns of facial trauma injuries C select appropriate airway management techniques in the emergency setting C perform airway management for specific maxillofacial injuries in the stable patient C formulate anaesthetic management plans for patients with facial trauma
Cristina Niciu Val Cunningham Kevin Fitzpatrick
Abstract Facial trauma is common and can produce both physical and psychological problems for patients. Managing patients in both the emergency setting and elective theatre environment can be extremely challenging, so airway interventions should be carefully planned so the safest and most effective technique can be chosen. This may mean that direct laryngoscopy may not be the safest or most straightforward option and awake fibreoptic intubation, videolaryngoscopy, submental intubation or awake tracheostomy may be a better choice in a given set of circumstances. An understanding of common mechanisms of injury and pathologies and the likely difficulties that will be present are essential. Senior anaesthetic input and effective teamwork are required to provide excellent levels of care for these patients.
Keywords
Airway;
anaesthesia;
facial
trauma;
Aetiology Patients present with isolated facial trauma or facial trauma in combination with other significant injuries. Individuals with a single facial fracture have been shown to have an incidence of cervical fracture at 5e8% and head injury 20e80%, and those with at least two facial fractures have a 7e10% incidence of cervical fracture and a 65e89% incidence of head injury.2 Between 55% and 70% of patients presenting with facial trauma have been shown to have other significant injuries.3,4 Polytrauma is likely to be a combination of both penetrating and blunt force trauma. The two most common causes of facial trauma are assault and road traffic accidents, with blunt trauma more common than penetrating trauma.1 Other causes include sports injuries (most often football, rugby, hockey, boxing and cycling), falls, accidents, dog bites and gunshot injuries. Improved road safety measures including seat belts, airbags and a reduction in people driving under the influence of alcohol have reduced the trauma association with road traffic accidents over the past 30 years.1 The use of helmets by bicyclists reduces the risk of head, brain and severe brain injury by 63e88%, providing equal protection for crashes involving motor vehicles (69%) and crashes from all other causes (68%). Additionally, injuries to the upper and mid-facial areas are reduced by 65%.5 Prevention of injuries caused by violent assaults is also clearly important and local initiatives may help in this regard. Examples of such initiatives exist throughout the UK. One example in Scotland is the ‘Medics against violence’ programme. This organization was started by healthcare professionals in Scotland and is supported by the Scottish Government. It consists of a school education programme consisting of anti-violence lessons to pupils about 13 years of age, and a domestic abuse training programme.6
intubation;
maxillofacial Royal College of Anaesthetists CPD Matrix: 1B02, 1C01, 1C02, 2A01, 2A02, 3A01, 3A10
Background Facial trauma can significantly affect patients in both the short and long term, producing aesthetic, functional and psychological problems. Functionally, it can affect mastication, eyesight, sense of smell, taste, swallowing, and breathing depending on the site of injury. Facial trauma may be associated with concurrent polytrauma and/or vascular complications. It is possible that these factors in combination with aesthetic complications may have a profound psychological impact on a person’s life. Patients may present with injuries requiring immediate medical treatment in the emergency department, commonly due to either haemorrhage or airway compromise,1 or may present in a more stable situation allowing more time to assess injuries and formulate treatment plans.
Anatomical considerations Anaesthetic management of facial trauma requires understanding of maxillofacial anatomy. The human skull is divided in two major parts, the cranial skeleton which contains and protects the brain and the facial skeleton, which can be subdivided into three parts: the upper face: frontal bone and fronto-zygomatic processes mid-face: orbits, nasal bone, ethmoid, zygoma and maxilla lower face: mandible. The facial skeleton has natural points of weakness and strong dense bones called buttresses, and in the context of trauma, acts as a crumple zone to protect the brain. Fractures occur in
Cristina Niciu FRCA is a Specialty Registrar in Anaesthetics at the Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow, UK. Conflicts of interest: none declared. Val Cunningham FRCA is a Consultant Anaesthetist at the Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow, UK. Conflicts of interest: none declared. Kevin Fitzpatrick FRCA is a Consultant Anaesthetist at the Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow, UK. Conflicts of interest: none declared.
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Please cite this article in press as: Niciu C, et al., Anaesthesia for facial trauma, Anaesthesia and intensive care medicine (2017), http://dx.doi.org/ 10.1016/j.mpaic.2017.06.003
DENTAL AND MAXILLOFACIAL ANAESTHESIA
characteristic points where the bone is weak, and may be unilateral or bilateral. Comminuted fractures imply high-energy transfer. High-impact force will cause trauma to the supraorbital rim, frontal bone, maxilla and mandible, whereas the nasal bones and zygoma can be damaged even in low impact trauma. The rich blood supply to the face can lead to bleeding during trauma. But in the context of hypovolaemic shock in a trauma patient other causes of haemorrhage should be sought. Rarely, a major bleed from facial trauma can occur from end branches of the maxillary artery or from epistaxis.
Le Fort fracture lines a Le Fort 1 fracture
Classification Maxillofacial trauma can be classified as: soft tissue injury with no underlying bone trauma bony skeleton fractures, upper, middle and lower; middle facial fractures are further classified as LeFort I, II, III laryngeal and tracheal trauma.
Soft tissue facial injury
b Le Fort 2 fracture
Extensive soft tissue injury around the nose and face can lead to difficult face mask ventilation.
Facial fractures Upper facial fractures Fractures involve the frontal bone, sinuses and orbit. Anterior skull base fracture can occur with cerebrospinal fluid (CSF) leak and risk of infection. Although not absolute contraindication, care with nasal intubation, nasogastric tube and temperature probe is required. Middle facial fractures Fractures of the mid-face are classified as LeFort I, II and III (Figure 1). LeFort fractures can commonly involve fractures of the mandible. LeFort I horizontal fracture separates the teeth and the lower maxillary part from the upper facial structures. The patient will have facial oedema and mobility of hard palate and teeth. LeFort II triangular fracture that separates the maxilla from the zygoma. The maxilla may be displaced backwards in the facial skeleton and free floating. The patient will have facial oedema, epistaxis requiring packing and possible CSF leak. LeFort III complete dissociation of facial skeleton from cranial skeleton. The patient may present with significant facial oedema, flat dish face deformity, epistaxis and CSF leak with associated base of skull fracture. If the maxilla is displaced posteriorly it may act to close off the posterior airway. In middle facial fractures, epistaxis may lead to significant blood loss and need to be controlled with packing, which may make bag/valve/mask ventilation difficult. Due care with NG tubes and temperature probes is required if base of skull fracture is suspected. CNS infection if CSF leak is present should be considered. Nasal intubation may be contraindicated which is discussed in more detail later.
c Le Fort 3 fracture
a The Le Fort 1 fracture line passes through the inferior wall of the antrum and allows the tooth-bearing segments of the upper jaw to move in relation to the nose. b In a Le Fort 2 fracture the maxilla and nose can move as a block in relation to the frontal bone and zygoma. c In a Le Fort 3 fracture the facial bones are able to move separately from the base of the skull. Le Fort 2 and 3 fractures may be associated with a dural tear resulting from fracture of the cribriform plate of the ethmoid bones. In Le Fort 3 fracture the base of skull bones (sphenoid and /or temporal) are involved.
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Figure 1 LeFort classification of middle facial fractures. (Reproduced from: Joy E Curran. Anaesthesia for facial trauma. Anaesthesia and Intensive Care Medicine 2014).
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DENTAL AND MAXILLOFACIAL ANAESTHESIA
General management principles
Lower facial fractures Fractures of the mandible present with a painful jaw and malocclusion of teeth. As a ring structure the mandible is usually broken in two or more places. Posterior inferior displacement of the jaw can cause airway obstruction. Bilateral mandibular fractures can cause difficulties in airway management: mouth opening may be limited the tongue which is attached to the anterior mandible by the genioglossal muscles may fall back and occlude the airway, which in an unconscious patient can be fatal posterior inferior displacement of jaw can cause airway obstruction, as can backward displacement of mid-face fractures during attempted bag/valve/mask ventilation lingual or pharyngeal oedema/haematoma can make laryngoscopy difficult teeth can become loose and avulsed, and fall into the airway. It is important to differentiate between reduced mouth opening caused by pain which will usually resolve following opioid analgesia or induction of anaesthesia, and that caused by a mechanical limitation in mouth opening that will not improve with analgesia or anaesthesia.
There are several general principles which can assist in making a safe and effective management plan. Three such principles to consider are: How much time do I have? Do I expect to be able to face mask ventilate? What view do I expect at laryngoscopy? Is it likely the patient will deteriorate if there is delay? This would mostly commonly be due to either swelling or haemorrhage. Voice changes, stridor or difficulty swallowing may indicate injury of the laryngopharynx and/or developing pharyngeal oedema. Examination of the patient looking for blood-stained saliva, and for tongue or other intraoral swellings is fundamental. Always give other injury consideration in the patient with facial trauma as they may also have intraoral or laryngeal injuries. It may be that assessment with a fibreoptic scope will help assess this either as a nasendoscopy or oral fibreoptic. Common sense needs be applied if there is intraoral bleeding as easy measures may be taken under local anaesthetic to stop this prior to induction, for example suturing buccal lacerations or using lignocaine with adrenaline injection or as an adrenaline-soaked swab. Simple compression or packing may be useful. Conscious patients with this degree of bleeding should be allowed to sit forward. Mask ventilation may be difficult or impossible in the presence of significant facial injuries where there may be tissue loss, swelling and ongoing bleeding. It may not be possible to get a good enough mask seal on the face to manage effective ventilation. It is useful to palpate the submental region for swelling and induration indicating the possibility of a fixed tongue. This may result in a poor view at direct laryngoscopy even in the presence of good mouth opening, so would be better managed by a device such as a videolaryngoscope which allows an indirect view to be obtained. In this circumstance it will be useful to use either an endotracheal tube pre-loaded with an appropriately shaped introducer or use a gum elastic bougie as the initial plan. In general, the presence of multiple facial injuries with or without bleeding can lead to a more challenging situation and hence awake intubation may be the most appropriate and safe initial plan. However, fibreoptic intubation in the presence of bleeding may be extremely difficult. If there is no time to wait until bleeding stops, an awake tracheostomy may be required rather than awake fibreoptic intubation. For example, in a patient with laryngeal injury as well as facial trauma, or in a patient with multiple facial injuries, as well as ongoing bleeding, intraoral oedema, and expected difficulty laryngoscopy awake tracheostomy may be the safest option. This may be performed with or without intravenous sedation, although it may be safer to avoid sedation in a crisis situation. Neither awake fibreoptic intubation (AFOI) nor awake tracheostomy is easy if the patient has intraoral bleeding as both distortion of view in AFOI and inability to lie flat in the awake tracheostomy make the procedure more difficult for the operator and more traumatic for the patient.
Laryngeal trauma Simple tears, dislocation of the arytenoids, disruption of cricothyroid joint and bleeding can occur. The patient may present with subtle voice changes, hoarseness, stridor and hypoxia. Cervical spinal injury and pneumothorax can be associated. Close attention should be paid to the mechanism of injury which may raise suspicion of an increased chance of laryngeal injury.
Emergency management Facial trauma can lead to airway challenge for the anaesthetist with oedema, bleeding, difficult bag valve mask ventilation and laryngoscopy. The patient may have major trauma and should be assessed with advanced trauma life support primary and secondary survey in an appropriate critical care area with senior anaesthetic input. It is important to note patients with facial trauma may have other injuries affecting management, such as: significant airway compromise requiring an advanced airway technique, with senior anaesthetist/ENT/maxillofacial surgeons required unstable C spine, with manual in-line stabilization traumatic brain injury with reduced Glasgow Coma Scale score requiring intracranial pressure management and neurosurgical input basal skull fracture, with CSF leak, avoidance of nasal instrumentation major haemorrhage with hypovolaemic shock from other injuries e thoracic, intra-abdominal, long bone or pelvic fractures. Acute management is required by a multidisciplinary team. Often patients requiring intubation in the emergency department will be managed with a rapid sequence induction with the neck immobilized followed by oral intubation, but it is possible the patient may require either fibreoptic intubation or tracheostomy both of which will be challenging in that setting.
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Preoperative considerations In the stable situation without ongoing bleeding and worsening intraoral swelling a comprehensive airway assessment should be performed. Airway assessment should include inspection of swelling, nasal patency and degree of mouth opening. Tongue
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DENTAL AND MAXILLOFACIAL ANAESTHESIA
protrusion as an assessment of difficulty at intubation due to submental swelling and/or other trauma-related pathologies should not be forgotten as a warning sign for difficulty even if mouth opening is good. It is important to discuss the operative plan with the surgeon. The route of repair should be considered and whether nasal, oral, submental intubation or tracheostomy is required. The need for throat pack, facial nerve monitoring and postoperative intermaxillary fixation should also be discussed. The requirement of steroids to reduce postoperative swelling and antibiotic prophylaxis should be addressed. Preoperative imaging, such as CT scans, should be reviewed to identify significant intraoral or airway swelling, or bony injury that may cause a mechanical limitation to mouth opening. Backup airway management plans should be discussed with the team in advance of induction of anaesthesia in case difficulties are encountered. Appropriate planning should reduce risks of complications if initial airway plans prove unsuccessful as these can and sometimes fail as demonstrated in the 4th National Audit Project (NAP4).7
Figure 2 Three-dimensional reconstructions from facial CT scan demonstrating the left zygomatic arch displaced posteriorly against the coronoid process of the mandible which will mechanically limit mouth opening.
Anaesthetic management for common bony facial injuries Orbital floor fractures Plating of an orbital floor fracture requires a south-facing oral endotracheal tube and a throat pack. The main challenges for the anaesthetist are avoiding intraoperative bradycardias when working within the orbit and coughing on extubation as this can result in orbital haematoma which will necessitate return to theatre. The options to minimize coughing include changing the endotracheal tube for a laryngeal mask airway (LMA) at the end of the procedure, running a remifentanil infusion, or attempting a deep extubation. These techniques require there to be no ongoing bleeding from co-existing intraoral injuries to be safe options. There is no perfect solution but in our centre the majority of these patients would have an LMA exchange at the end of the procedure and a remifentanil infusion continued until the patient is awake.
In edentulous patients or patients where occlusion is unnecessary and base of skull fracture is present oral intubation may be used. It is common practice for a throat pack to be inserted to avoid pharyngeal contamination or increasing the intragastric blood load. On assessment the majority of these patients will have reduced mouth opening due to pain rather than a structural cause for limitation and following induction of anaesthesia the patient’s mouth will often open fully. The exceptions to this are either a fracture involving the temporomandibular joint or a delayed presentation complicated by haematoma or infection causing masseter spasm. If there is doubt as to the cause of reduced mouth opening then an option would be to give a dose of a short-acting strong opioid (e.g. 1 mg alfentanil) in the anaesthetic room prior to induction and the patient will often demonstrate significantly improved mouth opening. In patients presented for surgery acutely after injury there is often intraoral bleeding due to the compound nature of many mandibular fractures. Patients may have swallowed a significant amount of blood and continue to have blood-stained saliva. Careful consideration should be given to rapid sequence induction in any patient suspected to have ongoing oral bleeding or pain due to injury as these promote emesis, increase gastric volume, and reduce gastric emptying. As mentioned above, blunt force trauma to the nose can result in base of skull fracture, diagnosed with rhinorrhoea and also with CT imaging. The problem caused by this is the relative contraindication to pass tubes through the nose acutely when these patients need surgery to fix mandibular and mid-face fractures. Depending on the extent of basal skull fracture the anaesthetists must decide whether to perform a nasal intubation despite the fracture, in which case it should be done under direct vision using a fibreoptic scope, or whether to avoid intubating through the nose altogether. If the decision is that nasal intubation is contraindicated and occlusion of the teeth is required, the options are either tracheostomy or submental intubation. Submental intubation (Figures 4 and 5) is a safe and effective option when the patient only requires intubated for the duration
Zygomatic fracture These fractures are common and present with swelling, a bony step, visual disturbance, enopthalmus, or malocclusion of the upper teeth. Zygomatic arch or body fractures may mechanically limit mouth opening if displaced posteriorly against the coronoid process of the mandible (Figures 2 and 3). Zygomatic fractures are often left until swelling subsides prior to fixation unless there is uncontrolled haemorrhage that needs managed. While surgeons prefer to operate within 1e2 weeks it is possible to defer operation due to concurrent morbidity for several weeks although the necessity for osteotomy increases with time. A south-facing oral tube and throat pack are used for the procedure. Straightforward procedures may be performed with a laryngeal mask provided nasal bleeding is not expected. Intraoperatively it is possible to get marked bradycardia on elevation of the zygoma, which may require glycopyrrolate or atropine treatment. Mandibular (and mid-face) fractures Mandibular (and mid-face) fractures require intraoperative occlusion to be performed to check the fracture has been reduced and fixed in a suitable position. A nasal intubation is normally performed to allow a good operative view and occlusion of the teeth.
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DENTAL AND MAXILLOFACIAL ANAESTHESIA
Figure 4 A patient following oral intubation with a reinforced endotracheal tube with the floor of mouth marked prior to performing submental intubation. Figure 3 Three-dimensional reconstructions from facial CT scan demonstrating the left zygomatic arch displaced posteriorly against the coronoid process of the mandible which will mechanically limit mouth opening.
Postoperative management Most patients following maxillofacial fracture fixation are safe to return to the surgical ward. Those with multiple injuries and potential to deteriorate may be better managed in high-care areas. Postoperative complications include swelling and haematoma. Oedema can worsen in the first 48 hours especially with LeFort II and III fractures. In addition, postoperative haematoma can occur and compromise the airway, especially after floor of mouth surgery. Emergency decompression of the haematoma is required by removing clips or sutures and manually evacuating the haematoma with suction. While this will reduce swelling due to the haematoma, any associated oedema will not be relieved and the airway may still remain difficult to manage.7 Multimodal analgesia should be used including paracetamol, non-steroidal anti-inflammatory drugs and a long-acting opioid if there are no contraindications.
of the procedure and there is no other indication for tracheostomy.8 To perform a submental intubation, the patient initially has an oral intubation. In theatre, the tube is then held firmly as it is pulled through a dissected plane in the floor of the mouth from a submental incision that is done by the surgical team and then secured. At the end of the procedure the reverse is done. The tube is brought back into the mouth, wound sutured, and the patient is extubated normally. A disposable intubating LMA tube is ideal for submental intubation as it allows a reinforced tube to be used and is the only reinforced tube with a removable connector. The patient with multiple injuries that will be unable to be extubated at the end of the procedure due to significant airway swelling is likely to require a tracheostomy. If this is the case an oral intubation followed by surgical tracheostomy, before proceeding to fixation of mandible is the best option.
Major reconstructive procedures following facial trauma Facial trauma injuries resulting in significant tissue loss may require significant reconstructive surgery including free tissue transfer surgery. These type of injuries may require either soft tissue and/or composite (soft tissue and bone) free flap surgery
Extubation Other than the specific case of orbital floor repairs, the facial trauma patient should be extubated awake following removal of throat pack and direct vision suction of the mouth, including the nasopharynx, where blood and clots can accumulate particularly following nasal intubation. Wire cutters or scissors for elastic band fixation should be available if wires or bands have been used, and the surgical team should be in attendance until safe extubation has been achieved. Complete reversal of muscle relaxation should be ensured and the use of sugammadex in the difficult airway patient should be considered, particularly if there are other risk factors such as high body mass index and respiratory disease. The Difficult Airway Society extubation guidelines ‘at-risk’ algorithm provides a structured approach to managing the extubation process when there is concern that re-intubation may be difficult if required in the immediate post-operative period.9 Patients that are deemed unsafe to extubate due to severity of facial injuries and intraoral swelling would be best managed with a tracheostomy, although on occasions they may be managed intubated and sedated in intensive care until swelling subsides.
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Figure 5 A patient after completion of the submental intubation procedure.
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DENTAL AND MAXILLOFACIAL ANAESTHESIA
Figure 6 Three-dimensional reconstruction of CT scan of a patient following gunshot injury to mandible resulting in massive soft tissue and bone loss. The gun pellet fragments are clearly visible on the scan.
(Figures 6, 7 and 8). The reconstruction often needs to be done at an early stage to prevent contraction of remaining tissues. Threedimensional modelling using CT scans and software packages make accurate planning for these cases possible and patients can get excellent results despite seemingly devastating initial injuries.
Conclusion
Figure 8 The same patient from Figures 6 and 7 in the immediate postoperative period. Tracheostomy, nasogastric tube and bilateral neck drains are visible.
Managing facial trauma patients can prove extremely challenging to the anaesthetist and the entire team looking after the patient. Effective planning, teamwork, and communication are required.
Senior anaesthetic involvement is necessary to safely manage maxillofacial trauma patients with significant injuries. A REFERENCES 1 Kirkpatrick N. Facial and orbital injuries. Surgery 2004; 22: 185e90. 2 Mulligan RP, Mahabir RC. The prevalence of cervical spine injury, head injury or both with isolated and multiple craniomaxillofacial fractures. Plat Reconstr Surg 2010; 126: 1647e51. 3 Shere JL, Boole JR, Holtel MR, Amoroso PJ. An analysis of 3599 midface and 1141 orbital blowout fractures among 4426 USA soldiers 1980e2000. Otolaryngol Head Neck Surg 2004; 130: 164e70. 4 Hussain K, Wijetunge DB, Grubnic S, Jackson IT. A comprehensive analysis of craniofacial trauma. J Trauma 1994; 36: 34e47. 5 Thompson DC, Rivara F, Thompson R. Helmets for preventing head and facial injuries in bicyclists. Cochrane Database Syst Rev 1999; 4: CD001855, http://dx.doi.org/10.1002/14651858.CD001855. 6 We are medics against violence. We are about one thing e preventing violence. http://medicsagainstviolence.co.uk/ (accessed 31 Jan 2017). 7 Cook T, Woodall N, Frerk C, eds. 4th National Audit Project: major complications of airway management in the United Kingdom. London: RCOA, 2011. 8 Gadre KS, Waknis PP. Transmylohyoid/submental intubation: review, analysis, and refinements. J Craniofac Surg 2010; 21: 516e9. 9 Difficult Airway Society. DAS extubation guidelines. https://www.das. uk.com/guidelines/das-extubation-guidelines1 (accessed 31 Jan 2017).
Figure 7 Three-dimensional reconstruction of the same patient from Figure 6 following both radial forearm free flap and deep circumflex iliac artery bone-free flap surgery. The plated bony reconstruction is demonstrated.
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Please cite this article in press as: Niciu C, et al., Anaesthesia for facial trauma, Anaesthesia and intensive care medicine (2017), http://dx.doi.org/ 10.1016/j.mpaic.2017.06.003