Indian Journal of Anaesthesia, October 2008(P.G.

Issue) Indian Journal of Anaesthesia 2008;52:Suppl (5):688-698

Maxillofacial and Upper Airway Injuries Anaesthetic Impact

Jayashree Sood

Summary
Maxillofacial injuries are commonly seen in the emergency department due to increase in trauma and are often accompanied by cervical spine and head injuries. Anatomical distortion and residual swelling can lead to a difficult airway scenario. There should be a high suspicion of upper airway trauma in such situations. Evaluation should follow the ABCs of Advanced Trauma Life Support Protocol. A patent airway should be immediately established. Definitive care of the maxillofacial injury should be rendered only after a thorough multisystem evaluation of airway, blood loss, head and cervical spine. Perioperative care is a challenge since it requires expertise in management of the airway, which is shared by the surgeon and the anaesthesiologist. The anaesthetic technique should include rapid induction, maintenance with minimal physiological changes and rapid emergence. Difficult airway cart should be available. Intermaxillary fixation precludes oral intubation and alternative routes of intubation should be planned. The tracheal tube may be retained in the postoperative period for immobilization. Extubation requires smooth emergence with an awake patient, able to maintain the airway. Key words Maxillofacial trauma, Upper airway trauma, Tracheal intubation; Nasotracheal, Submental, Retromolar, Tracheostomy

Introduction
Maxillofacial injury has been described in the medical literature as early as 2500BC. 1 It is becoming increasingly common due to fast vehicular traffic on the highways. Its gruesome appearance may distract the clinician from less obvious, but more critical, injuries.2 Although these injuries look very frightening, they are life threatening only if they obstruct the airway. Most patients with isolated maxillofacial trauma do not require emergency surgery unless significant hemorrhage or airway compromise is present. Patients do not die of facial trauma but patients with facial trauma die from associated injuries.3,4 The surgical correction has an enormous aesthetic importance as well. These injuries are of utmost concern to anaesthesiologists, because of their close association with the airway. Maxillofacial injury may be accompanied by injury of the upper airway. Concomitant laryngotracheal injury, if not recognized, may cause progres-

sive dyspnoea in unintubated patients in the absence of airway obstruction from the maxillofacial injury.1,5 To manage patients with maxillofacial and upper airway trauma it is important to know, both, the anatomy of the maxillofacial and neck region and the mechanism by which the injury can occur. This will help the anaesthesiologist to understand the type of injury, associated fractures especially skull base injury and likelihood of airway involvement.6 The topic will be discussed under the following headings:
Anatomy Maxillofacial Neck Diagnosis Complications Management & Anaesthesia technique Monitoring Postoperative care Conclusion References

Mechanism of injury Airway management

Chairperson, Correspondence to: Jayashree Sood , Deptt. of Anaesthesiology, Pain and Perioperative Medicine, Sir Ganga Ram Hospital, New Delhi., Email:jayashreesood@hotmail.com 688

Jayashree Sood. Maxillofacial and airway trauma

Anatomy
Maxillofacial anatomy 1,7 The facial skeleton has anatomically been divided into three anatomic regions.

A LeFort 1 fracture is a horizontal fracture that separates the palate and upper alveolar ridge from the rest of the face. A LeFort II fracture line separates the maxilla and the medial orbit from the zygomatic arch and the skull. A LeFort III fracture line extends through the lateral orbit, the zygomatic arch and the pterygoid plate, separating the midfacial structures from the cranium. The mid-face skeleton is completely detached from the base of the skull and suspended only by soft tissues and characterized by dish face deformity. LeFort II and III fractures are frequently associated with basilar skull fractures and dural tears, and the cribriform plate is usually also damaged. A maxillofacial fracture that extends into the frontal bones is frequently referred to as a LeFort IV fracture, with clinical conditions similar to the LeFort III injuries.

Lower third
The lower third comprises the mandible which is the third most frequently fractured facial bone.8 It is made up of six regions: symphysis, body, ramus, condyle, coronoid process and the temporomandibular joint. Fractures of the mandible may be unilateral, bilateral or communited. While unilateral are relatively stable, bilateral or communited tend to be unstable.

Middle third
The middle third is composed of nine bones, chief among which are the maxilla, zygoma, and the bones that comprise the orbital and nasal complexes. Rene LeFort in France reported his maxillary fracture classification in 1901 however, various combinations of these patterns are usually seen(Fig 1).

Upper third
The upper third consists of the frontal bone and the cranium. Neck anatomy 9 It is divided into three zones: Zone I, the lowest section, is the area behind the clavicles upto the cricoid cartilage. Zone II, the middle section, is bounded by the cricoid cartilage below and the angle of the mandible above. It contains portion of airway, oesophagus, major blood vessels and cervical spine and is relatively vulnerable to injury. Zone III is the section between the angle of the mandible and base of skull.

Mechanism of injury 8, 10
A knowledge of the mechanism of injury is important in determining the degree of damage and in assessing the possibility of additional injuries like airway
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Fig 1 Classification of LeFort fractures

Indian Journal of Anaesthesia, October 2008(P.G.Issue)

trauma. Maxillofacial injury is caused by either blunt or penetrating trauma. Low-force injuries, such as those resulting from sports mishaps or interpersonal altercations, usually affect the nasal bones and zygomatic arches and do not usually affect the airway. High-force injuries, like motor-vehicle crashes or high-velocity weapons, may cause fractures of the mandible or maxilla and are much more likely to cause airway compromise. The majority of laryngotracheal injuries are caused by blunt trauma, others include penetrating trauma, inhalation of noxious or hot gases; aspiration of foreign bodies and iatrogenic injuries.10, 11

The inhalation of extremely hot steam, gas, or other noxious fumes will tend to injure the larynx and cervical trachea.

Intubation injury 10
The most frequent intubation injury is chronic cicatrix with stenosis requiring tracheal resection and reconstruction.

Diagnosis
Maxillofacial and upper airway injuries produce a spectrum of signs and symptoms like local tenderness, alteration in voice, hemoptysis, subcutaneous emphysema, or partial-to-complete airway obstruction. Diagnosis involves detailed history, physical examination,10 radiologic studies 14 and direct visualization techniques like laryngoscopy, bronchoscopy and oesophagoscopy.

Blunt injuries
The larynx or cervical trachea is injured in < 1% of patients admitted to the hospital for blunt trauma.10 Most blunt injuries to the upper airway are due to direct blows or severe flexion/extension injuries. Direct blows are most likely to injure the cartilages of the larynx, while flexion/extension injuries are most commonly associated with tracheal tears or laryngotracheal separation. The prevailing site of tracheal transection is the junction of the cricoid with the trachea, because the connective tissue in this area is relatively weak.12 35% of laryngeal injuries above the cricoid, 15% involving the cricoid cartilage, 45% involving the cervical trachea and 5% involving other sites have been reported in blunt injuries to the upper airway.13 Thyroid cartilage is the most commonly fractured site in blunt and penetrating laryngeal injuries (47%), followed by arytenoid cartilage (24%), and cricoid cartilage (22%).13

Complications 1,7,15
Likely complications associated with maxillofacial and upper airway injuries are Airway compromise Haemorrhage Trismus Cervical spine injury Pneumoencephalus Injury to oesophagus Subcutaneous emphysema and pneumomediastinum

Penetrating injuries 10
The trachea is the structure most commonly injured by stab wounds. The larynx is injured in approximately one-third of upper airway injuries, with the cervical trachea accounting for the remaining two third.

Airway compromise
Hypoxic brain injury or death from acute airway obstruction and hypoxemia may follow after complex maxillofacial and upper airway injuries.16 Several factors contribute to airway compromise such as anatomic
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Inhalation injury 10

Jayashree Sood. Maxillofacial and airway trauma

deformity or loss of structural support of the air passages, blood clots, tooth fragments, dentures, foreign body aspiration or oedema.13 In a LeFort III fracture, the facial bones are displaced downward toward the pharynx, the mid-face instability contributes to soft-tissue airway obstruction. Mandible plays an important role in the patency of upper airway by supporting tongue and hyoid bone, the latter in turn supports epiglottis.17 Bilateral condylar fractures (Andy Gump fracture) with a symphyseal fracture or a bilateral body fracture of the mandible may cause loss of support of the glossal and suprahyoid musculature, thereby allowing the soft tissues to fall posteriorly, obstructing the oropharynx thus obstructing airflow. 1 Uncooperative or intoxicated patients, due to alcohol or drug abuse, may contribute to difficulty in managing the airway. In upper airway injury oedema fluid can rapidly accumulate in the supraglottic and the subglottic submucosa. Subglottic endolaryngeal swelling tends to be circumferential, increasing the possibility of airway obstruction. Air dissecting within the submucosal space can further reduce the luminal diameter of the larynx and trachea, while subcutaneous emphysema may produce epiglottic emphysema and narrowing of the supraglottic airway.10

out much difficulty. After several days, mouth opening may be restricted secondary to oedema, scarring, or infection. Zygomatic arch fractures that are significantly depressed may cause mechanical interference with the movement of the coronoid process of the mandible.4,7

Cervical spine injury 5

All patients with maxillofacial and upper airway injuries should be considered to have cervical spine injuries unless proved otherwise.12 A relationship between mandibular fractures and fractures of the upper cervical spine and facial soft tissue injuries with fractures of the lower cervical spine has been documented. 7

Cerebrospinal fluid rhinorrhea and otorrhea

Cerebrospinal fluid rhinorrhea and otorrhea result when the base of the cranium is fractured.4,7

Pneumocephalus
Fractures through the posterior table of the frontal sinus with dural tears and LeForte II and III fractures are all associated with pneumocephalus.3,4,7

Injury to oesophagus
Besides injury to cervical spine and vascular structures, severe laryngotracheal trauma can produce oesophageal injuries. 18

Haemorrhage
Bleeding from soft tissue lacerations, mouth and nose is a common feature of facial injuries.1 Vascular injuries are common in penetrating neck trauma.10

Subcutaneous emphysema and pneumomediastinum

These are uncommon complications of maxillofacial injury. Air from maxillary sinuses communicate with the fascial planes of the neck and then with the mediastinum. In upper airway injuries, too, air may travel to the mediastinum.5,10

Trismus
Fractures that involve the condyles or impinge on the temporomandibular joint (TMJ) may interfere with the mechanical opening of the jaw. Injuries to the mandible may cause trismus due to muscle spasm and pain on opening the mouth. Once the patient is sedated or anaesthetized, the mouth can usually be opened with691

Management In the Emergency Department

Indian Journal of Anaesthesia, October 2008(P.G.Issue)

Severely injured patients should be evaluated by following the ABCs of the primary survey of Advanced Trauma Life Support protocol. 1,15,19,20 The primary aim is to protect the airway from aspiration, not to create a situation from which retreat is impossible and to have a valid backup plan to fall back on, if the primary maneuver fails.21 A patent airway should be immediately established by placing the patient in the lateral position and pulling the mandible or maxilla forward thus allowing blood and secretions to drain out of the oropharynx. Fractured teeth, foreign bodies, and blood should be cleared from the oral cavity. Attempts to control the bleeding including direct pressure, acute reduction of fractures, and placement of nasal packs or nasal airways should be done.22 Significant maxillofacial injury with anatomic disruption or severe haemorrhage may require immediate airway protection with endotracheal intubation. Nasopharyngeal bleeding may be controlled with nasal packing or a balloon-tipped catheter placement.3,7

way assessment is essential. The presence of blood, bone fragments and loose teeth makes airway evaluation difficult. Certain medical problems e.g. acute myocardial infarction, acute alcohol intoxication and drug abuse must be kept in mind. Besides cervical spine injury, others like intracranial injury, pneumothorax, flail chest and abdominal trauma should always be excluded. Relevant biochemical and radiological assay including blood crossmatch is essential.

Anaesthetic technique
The anaesthetic management of a patient with maxillofacial trauma is a challenge.23,24 Maxillary fractures are treated surgically by reduction and immobilization (intermaxillary fixation). They are long procedures with significant blood loss requiring controlled hypotension technique. The airway is shared by the surgeon and the anaesthesiologist.7 When the facial fracture disrupts the dental occlusion, maxillomandibular fixation is required during the operative course of management. The method of securing an airway that does not interfere with the technical aspect of repair and ensures safe postoperative care must be planned.16 Detailed discussion with the surgeon regarding securing the airway, route of intubation, type and size of the tracheal tube (TT), alternative methods of intubation and securing the TT is of paramount importance.25

Surgical repair of maxillofacial trauma

Majority of patients with isolated maxillofacial trauma do not require emergency surgery unless significant haemorrhage, airway compromise or associated trauma is present. 1 Definitive care of the maxillofacial injury should be rendered only after a thorough multisystem evaluation, which must include airway examination, excessive blood loss and central nervous system (head and cervical spine) for injury. 16 Fracture reduction, fixation and immobilization can usually be scheduled when swelling has subsided. Majority of the surgical reductions are done transorally to avoid facial scarring.

Monitoring
Monitoring includes SpO2, EtCO2, NIBP, ECG, temperature and urine output. Arterial blood gas may be done for prolonged surgery.

Airway management
Securing the airway with a tracheal tube is of prime importance.26 Majority of mishaps are due to inadequate ventilation, inability to ventilate, an unrecognized
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Preoperative evaluation 7,8,10

A thorough preoperative evaluation including air-

Jayashree Sood. Maxillofacial and airway trauma

oesophageal intubation and unanticipitated difficult tracheal intubation. A difficult airway cart with laryngeal mask airways, combitubes, fastrach (intubating laryngeal mask airway), fiberoptic bronchoscope, cricothyroidotomy kit,27 tracheal tube introducer, Eschmann stylet gum elastic bougie, ETT changer with jet ventilation capability, Sanders jet ventilator, tracheostomy tray and retrograde intubation kit should be kept ready.7,8 Factors which determine the possible technique of securing the airway are: 1.Anticipated difficult airway 2.Patients ability to open the mouth 3.Possibility of cervical spine fracture 4.Possibility of concurrent base skull fracture Various methods available are: 1.Awake vs anaesthetized patient 2.Orotracheal vs nasotracheal intubation 3.Direct /blind nasal intubation/ fiberoptic laryngoscopy 4.Anterograde vs retrograde 5.Cricothyroidotomy, transtracheal jet ventilation, tra cheostomy

and pharyngeal wall may be anaesthetized with lidocaine flavoured liquid. Superior laryngeal block is given on both sides at the level of the hyoid cornu, 2ml 2% lidocaine on each side. A translaryngeal block is administered through the cricothyroid membrane (4ml of 2% lidocaine).26

Blind nasotracheal intubation

If the patient has an anticipitated difficult airway which requires an awake intubation and is also unable to open the mouth (mechanical obstruction); blind nasotracheal intubation may be done. This technique requires expertise; and monitors like pulse oximeter and EtCO2 are helpful in guiding the tracheal tube into the larynx. It may also be performed in anaesthetized patients breathing spontaneously. The tracheal tube must be secured and placement confirmed by capnography and auscultation before induction of general anaesthesia.

Fiberoptic intubation
Although fiberoptic intubation may be the safest way to secure the airway in a suspected cervical spine injury patient, it can be almost impossible to see the larynx through a pool of blood. 29

Awake intubation
If the patient has an anticipated difficult airway, an awake look on direct laryngoscopy to see whether the laryngeal inlet is visible is helpful. Failure to fit an anaesthesia mask and ventilation may be difficult in the patient with mid-face injury.28 Attempts at positive pressure ventilation may force air into the facial soft tissues. Local anaesthesia of the upper airway is essential for an awake oral / nasal intubation. It is achieved by naso-oral topical, superior laryngeal and translaryngeal block. Nasal or oral mucosa may be anaesthetized with topical 2% or 4% lidocaine. Addition of adrenaline produces vasoconstriction, increases the size of nasal passage and decreases the risk of local trauma during nasotracheal intubation. The oral cavity, base of tongue
693

Intubation after induction of general anaesthesia

If the airway is unobstructed and patient can breathe adequately, intubation after induction of general anaesthesia is preferred.30 Many patients with upper airway injuries may be successfully managed using traditional techniques to establish an airway. Airway management in patients with neck trauma is based upon a high index of clinical suspicion for cricoid or cervical tracheal injuries.13 Induction of general anaesthesia using a potent volatile agent and spontaneous ventilation is generally considered to be the safest technique to induce anaesthesia in patients with possible airway injuries.31 How-

Indian Journal of Anaesthesia, October 2008(P.G.Issue)

ever thiopentone or propofol may be necessary if the patient is confused or uncooperative. The use of neuromuscular blocking agents should generally be avoided until the airway is secured. Positive pressure ventilation by mask may become impossible under such conditions, and may worsen subcutaneous emphysema requiring immediate tracheostomy. Once anaesthetized, the airway may be secured by passing a rigid bronchoscope or a tracheal tube into the distal airway beyond the point of injury. An endobronchial intubation sometimes is necessary to accomplish this. Endotracheal intubation must be performed under direct vision. A blind attempt at intubation carries a risk of introducing the TT into a false passage. Once a tracheal tube has been placed distal to the site of injury, controlled positive pressure ventilation can begin. 9,10,31

space.33,34 Intubation with north polar preformed tracheal tubes for mandibular fractures allows intermaxillary fixation and assessment of dental occlusion. The patency of nostrils is determined by asking the patient to breathe out through each nostril. The more patent nostril is selected for intubation.35 The nasal passage should be well prepared with a vasoconstrictor and a topical anaesthetic. The tip of the TT may be softened in warm, sterile water.36

Orotracheal intubation
Preoxygenation along with aspiration prophylaxis with metoclopramide, glycopyrrolate and ranitidine is recommended. Orotracheal intubation with south polar preformed tracheal tube is usually the technique of choice with isolated midface fractures. General anaesthesia with muscle relaxants relieve trismus due to pain allowing the mouth to open. If a patient requires immediate airway control, rapid sequence induction and oral intubation with manual in-line axial stabilization is the technique of choice; however, this technique can be difficult in uncooperative patients.32 After achieving intubation, the tracheal tube should be well secured with a tape or the surgeon may wire it in place around the teeth.A nondepolarizing muscle relaxant should only be administered after ensuring correct TT placement (capnography, auscultation).

Fig 2 Nasotracheal intubation

If a difficult airway is not anticipated, the tracheal tube is passed through the nose after induction of anaesthesia and neuromuscular blockade. This is followed by direct laryngoscopy to forward the tube into the trachea under direct vision by either manipulating the tube directly or using Magill forceps. 37 The laryngeal mask airway can be very useful in stenting the upper airway. The fastrach LMA facilitates formal tracheal intubation and is an important tool in difficult airway situations.38

Submental intubation (Fig. 3)

Nasotracheal intubation (Fig. 2)

This route is commonly employed in patients undergoing maxillofacial surgery,27 but is contraindicated in nasal fractures and those with a basilar skull fracture because of the possibility of placing the TT or spread of contaminated material into the subarachnoid
694

Fig 3 Submental intubation

Jayashree Sood. Maxillofacial and airway trauma

When both nasal and oral intubation are deemed unsuitable, control of the airway can be achieved with submental intubation 39-43 After induction of general anaesthesia orotracheal intubation is achieved with an armoured tracheal tube (with a detachable connector). Under all sterile conditions, a 1.5cm skin incision is made in the submental region just medial to the lower border of mandible. An artery forcep is introduced through the submental incision towards the floor of the mouth. An incision is given in the floor of the mouth, and the deflated pilot tube cuff along with the tube is pulled out through the submental incision. The connector is reattached and ventilation achieved. At the end of the surgery, the tube is pulled back into the oral cavity and trachea extubated when the patient is awake.44 Since submental intubation requires adequate mouth opening for the initial orotracheal intubation, this technique may not be possible in maxillofacial trauma with restricted mouth opening. Retrograde submental intubation with the help of a pharyngeal loop assembly has been performed successfully in such situations. 45

Retromolar positioning of the tracheal tube in the retromolar trigone 47 during intermaxillary fixation provides an optimal intraoperative control of dental occlusion. 48 The tube is fixed at the angle of the mouth. At the end of the procedure, extubation can be achieved from the retromolar space, when the patient is awake. A wire cutter should always be kept beside the patient in case of emergency. 44

Retrograde intubation
A retrograde wire passed through the suction port of the fiberoptic bronchoscope may guide the scope into the trachea if flexible fiberoptic bronchoscopy is not possible either because of distorted anatomy or blood. 49

Transtracheal jet ventilation (TTJV)

The fear of every anaesthesiologist is the inability to intubate and ventilate a hypoxic patient, even with a laryngeal mask airway or combitube. When an experienced surgeon is not immediately available and the anaesthesiologist is inexperienced in procuring a surgical airway technique, then TTJV can be a life-saving alternative.50

Retromolar intubation (Fig. 4, 5) 46

Surgical techniques Cricothyroidotomy 4,7, 15

If repeated attempts at endotracheal intubation fail, emergency cricothyroidotomy should be done. This procedure is contraindicated in coexisting laryngeal injury as the cannula may enter a false passage. Since cricothyroidotomy is a temporary measure, it should be converted to a tracheostomy once acute hypoxia is relieved. For less emergent situations, tracheostomy13 (Fig. 6) under local anaesthesia is recommended.

Fig 4 Retromolar intubation

Maintenance of Anaesthesia 7, 8
After successful intubation, maintenance of anaesthesia may be achieved with a muscle relaxant, vola695

Fig 5 Retromolar intubation

Indian Journal of Anaesthesia, October 2008(P.G.Issue)

References
1. Capan LM, Miller SM, Glickman R. Management of Facial Injuries. In: Trauma Anaesthesia And Intensive Care. Capan LM, Miller SM, Turndorf H (eds). JB Lippincott Company 1991; Chapter 12, pg 385-05. Nakhgevany KB, LiBassi M, Esposito B. Facial trauma in motor vehicle accidents: Etiological factors. Am Emerg Med 1994; 12: 160-63. SheKfd SM, Lippe MS. Maxillofacial trauma: A potentially fatal injury. Ann Plast Surg 1991; 27: 281-83. David DJ, Simpson DA. Craniomaxillofacial Trauma. Churchill Livingstone, New York 1995. Capan LM, Miller S, Turndorf H. Management of Neck Injuries. In: Trauma Anaesthesia And Intensive Care. Capan LM, Miller SM, Turndorf H (eds). JB Lippincott Company 1991; Chapter 13, pg 409-40. Seyfer AE, Hansen JE. Facial Trauma. In: Mattox, Feliciano, Moore (eds). Trauma. 4th edn. McGraw Hill 2000; pg.415-36. Shearer VE, Gardner J, Murphy MT. Perioperative anesthetic management of maxillofacial trauma including ophthalmic injuries. Anesthesiology Clinics of North America 1999; 17: 141-52. Skerman JH. Anaesthetic management of craniofacial trauma and trauma to the airway. The Middle East Journal of Emergency Medicine 2002;2:2. Britt LD, Peyser MB JE. Penetrating and Blunt Neck Trauma. In: Mattox, Feliciano, Moore (eds). Trauma. 4th edn. McGraw Hill 2000; pg.437-50. Hurford WE, Peralta R. Management of tracheal trauma. Can J Anesth 2003; 50: R1-R6. Mathisen DJ, Gtillo HC. Laryngotracheal trauma. Ann Thorac Surg 1987; 43: 254. Trone TH, Schaefer SD, Carder HM. Blunt and penetrating laryngeal trauma: a 13-year review. Otolaryngol Head Neck Surg 1980; 88: 257-61. Cicala RS, Kudsk KA, Butts A, et al. Initial evaluation and management of upper airway injuries in trauma patients. J Clin Anesth 1991; 3: 91-8. Angood PB, Attia EL, Brown RA, Mulder DS. Extrinsic civilian trauma to the larynx and cervical trachea-important predictors of long-term morbidity. J Trauma 1986; 26: 869-73. Matson MD. Injuries to the Face and Neck. In: Russ Zajtchuk, C. Grande. Anaesthesia and Perioperative Care of the Combat Casualty 1995. Manson PN. Facial Fractures. In: Plastic Surgery. The

2.

3.

Fig 6 Tracheostomy

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tile agent or opioids. N2O is avoided if a pneumocephalus is suspected.

Extubation 22,30
6.

Antiemetics are recommended to prevent vomiting after intermaxillary fixation.

7.

Patients with maxillofacial injuries require a smooth emergence and the ability to maintain their open airways at extubation. The decision to extubate the trachea is always a clinical judgment; when in doubt, dont take it out. 7

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Postoperative care
Patients require a high dependency unit for postoperative care.30 If IMF is in place, wire cutters must always be kept next to the patient for emergency (vomiting, airway obstruction, bleeding) and the staff must be taught its use. The head end is elevated to improve venous drainage and limit soft tissue swelling. Maxillofacial injuries are on the rise due to increase in vehicular trauma. These injuries do not pose an immediate threat to life unless they compromise the airway. Associated injuries, particularly of cervical spine and head region must be suspected during airway management. Anaesthetic management of maxillofacial injuries is a challenge requiring expertise in airway management techniques. Extubation should be attempted only when the patient is fully conscious. Postoperative care in a high dependency unit is essential.
696

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10. 11. 12.

13.

14.

15.

16.

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head and neck Part 2, Mathes (ed) 2nd edn. Saunders Elsevier Philadelphia 2006: 77. 17. 18. Rowe NL, Williams JL. Maxillofacial Injuries. 2nd Edn, Edinburgh, Churchill Livingstone 1995. Kelly JP, Webb WR, Moulder PV, et al. Management of airway trauma: Combined injuries of the trachea and esophagus. Ann Thorac Surg 1987; 43: 160-63. Suri YV, Qasba KK, Mahajan TR. Militancy Trauma: maxillofacial injury, anaesthesia and critical care. Medical Journal Armed Forces India 1996; 52: 23-6. Chan J, Koltai PJ. Principles of Trauma. In: Head And Neck Surgery. Bailey BJ, Johnson JT New land (eds). 4th edn. Lippincott Williams & Wilkins Philadelphia 2006; 920-23. Grande CM, Stene JK, Bernhard WN. Airway management: Considerations in the trauma patient. Crit Care Clinics 1990; 6: 37-59. Dutton RP, McCunn M. Anaesthesia for Trauma in Miller RD (eds). Millers Anaesthesia 6th edn. Philadelphia. Churchill Livingstone 2005; 2451-95. Williams JP, Krekorian TD. Neck trauma. In: Emergency Anaesthesia. Adams AP, Hewitt PB, Grande CM (eds). 2nd edn. London; Arnold 1998: 186-96. Shearer VE. Facio-maxillary, ear, nose and throat emergencies. In: Emergency Anaesthesia. Adams AP, Hewitt PB, Grande CM (eds). 2nd edn. London: Arnold 1998:197215. Gotta AW. Maxillofacial trauma: Anesthetic consideration. ASA Refresher Course 1987;15:39. Grande CM, Wyman CI, Bernard WN. Perioperative anesthetic management of maxillofacial and ocular trauma: injuries of the craniocervico facial complex. In Stene JK, Grande CM (eds). Trauma Anesthesia. Baltimore, Williams & Wilkins 1991. Piepho T, Thierbach A, Werner C. Nasotracheal intubation: look before you leap. Br J Anaesth 2005; 94: 85960. Doroudian M. Anesthetic management of total traumatic avulsion of mandible. J of Research in Med Scien 2004; 3: 148-51. Coe TR, Human M. The peri-operative complications of nasal intubation: a comparison of nostril side. Anaesthesia 2001; 56: 44750. Hewitt PB. Anesthesia for dental and orofacial surgery. In:. Wylie and Churchill-Davidsons Healy TEJ, Knight PR (eds). A Practice of Anaesthesia. Arnold. 7th edn. 2003; Pg 829-34. Flood LM, Astley B. Anaesthetic mangement of acute 697 38. 33. laryngeal trauma. Br J Anesth 1982; 54: 1339-43. 32. Dutton RP. Airway Trauma. In: Fun-Sun F. Yao. Problem Oriented Patient Medicine, 6th Edn. Lippincott Williams & Wilkins 2007, pg 993. Lettieri S. Facial Trauma. In: Plastic Surgery. Indications, Operations and Outcomes. Achauer BM, Eriksson E, Guyuron B (eds). Volume 2, Craniomaxillofacial Cleft and Pediatric Surgery. Mosby Inc St. Louis, Missouri 2000; 923. Muzzi DA, Losasso T, Cucchinara RF. Complication from a nasopharyngeal airway in a patient with a basilar skull fracture. Anesthesiology 1991; 74: 366-8. Smith JE, Reid AP. Identifying the more patent nostril before nasotracheal intubation. Anaesthesia 2001; 56: 25862. Kim YC, Lee SH, Noh GJ, et al. Thermosoftening treatment of the nasotracheal tube before intubation can reduce epistaxis and nasal damage. Anesth Analg 2000; 91: 698701. Benumof JL. Conventional (laryngoscopic) orotracheal and nasotracheal intubation (single-lumen tube). In: Airway ManagementPrinciples and Practice. Benumof JL (eds). St Louis, MO: MosbyYear Book, 1996; 261 76. Kannan S, Chestnut N, McBride G. Intubating LMA guided awake fiberoptic intubation in severe Maxillofacial Injury. Can J Anaesth 2000; 47: 989-91. Caron G, Pasquin R, Lessard M, Landry PE. Submental endotracheal intubation: an alternative to tracheostomy in patients with midfacial and panfacial fractures. J Trauma 2000; 48: 235-40. Hrenandez Altmir F. The submental route for endotracheal intubation a new technique. Journal of Maxillofacial Surgery 1986; 14:64-5. Paetkau D, Strand M, One B. Submental orotracheal intubation for maxillofacial surgery. Anesthesiology 2000; 92: 912-4. Amin M, Dill-Russell P, Manisalr M, et al. Facial fractures and submental tracheal intubation. Anaesthesia 2002; 57: 1195-212. Chandu A, Smith ACH, Gebert R. Submental intubation: an alternative to short-term tracheostomy. Anaesth Intensive Care 2000; 28: 193-5. Rungta N. Technique of retromolar and submental intubation in facio-maxillary trauma patients. Ind J Trauma Anaesth Crit Care 2007; 8; 573-5. Arya VK, Kumar A, Makkar SS et al. Retrograde submental intubation by pharyngeal loop technique in a

19.

34.

20.

35.

21.

36.

22.

37.

23.

24.

25. 26.

39.

40.

27.

41.

28.

42.

29.

43.

30.

44.

45.

31.

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patient with faciomaxillary trauma and restricted mouth opening. Anesth Analg 2005; 100: 534-37. 46. 47. Malhotra N. Retromolar intubation. A technical note. Ind J Anaesth 2005; 49: 467-8. Sharma PK, Schuller De, Baker SR. Malignant neoplasms of the oral cavity. In: Otolarngology Head & Neck Surgery. Cummings CW, Fredrickson JM, Harker LA, Krause CJ, Schuller DE, Richardson MA (eds). 3rd edn. St. Louis: Mosby; 1998:1422. 48. Dutta A, Kumar V, Saha SS, Sood J et al. Retromolar tracheal tube positioning for patients undergoing faciomaxillary surgery. Can J Anesth 2005; 52:341. Ghatge SK, Joshi MA, Despande AM. Retrograde intubation: the choice for difficult airway in complex faciomaxillary injuries. A case report. Ind J Anaesthesia 1994; 42: 359-62. Benumof JL, Scheller MS. The importance of transtracheal jet ventilation in the management of the difficult airway. Anesthesiology 1989; 71:769-78.

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Attention All & Branch Secretaries

New Membership Notification
As per the decisions taken during the Annual General Body Meeting at Visakhapatnam1. Enrollment Fees of Indian Society of Anaesthesiologists for Life Membership and Life Asso ciate Membership has been enhanced to Rs.5000.00 (Rupees Five thousand only) from 1st April 2008. 2. Henceforth no Annual Membership will be enrolled in ISA. 3. Membership through State Branch: branch Secretaries would be required to send Rs.3750.00 (Rupees three thousand seven hundred fifty only) for each new member to ISA Head Quarter along with forwarded application. 4. Membership through City Branch: Branch Secretaries would be required to send: a) Rs. 3750.00 (Rupees three thousand seven hundred fifty only) for each new member to ISA Head Quarter along with forwarded application. b) Rs. 500.00 (Rupees five hundred only) along with a copy of Membership application form to State HQ. The money had to be remitted through DD favoring Indian Society of Anaesthesiologists payable at Kolkata.

Dr.Anjan Datta Hon.Secretary, ISA(HQ) Email : sys9@vsnl.net, isanhq@gmail.com

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