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

sive dyspnoea in unintubated patients in the absence of

airway obstruction from the maxillofacial injury.1,5

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.

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

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-

Management & Anaesthesia

technique
Monitoring

Mechanism of injury Airway management

Diagnosis

Postoperative care

Complications

Conclusion
References

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

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.

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

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

Fig 1 Classification of LeFort fractures

689

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 inhalation of extremely hot steam, gas, or other

noxious fumes will tend to injure the larynx and cervical
trachea.

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

Diagnosis

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

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

Complications 1,7,15
Likely complications associated with maxillofacial and upper airway injuries are
Airway compromise
Haemorrhage

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

Trismus
Cervical spine injury
Pneumoencephalus
Injury to oesophagus
Subcutaneous emphysema and pneumomediastinum

Penetrating injuries 10

Airway compromise

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.

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

Inhalation injury 10
690

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

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

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

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

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

Cerebrospinal fluid rhinorrhea and otorrhea

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

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

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 with-

Management
In the Emergency Department
691

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

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.

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

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

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

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

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

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

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

Preoperative evaluation 7,8,10

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

A thorough preoperative evaluation including air-

692

Jayashree Sood. Maxillofacial and airway trauma

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

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

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.

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

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
Intubation after induction of general
anaesthesia

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.

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

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

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 How693

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

Fig 2 Nasotracheal intubation

Preoxygenation along with aspiration prophylaxis

with metoclopramide, glycopyrrolate and ranitidine is
recommended.

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

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).

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

Fig 3 Submental intubation

694

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

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

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

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, vola-

Fig 5 Retromolar intubation

695

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

References

Fig 6 Tracheostomy

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

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.

2.

Nakhgevany KB, LiBassi M, Esposito B. Facial trauma

in motor vehicle accidents: Etiological factors. Am Emerg
Med 1994; 12: 160-63.

3.

SheKfd SM, Lippe MS. Maxillofacial trauma: A potentially fatal injury. Ann Plast Surg 1991; 27: 281-83.

4.

David DJ, Simpson DA. Craniomaxillofacial Trauma.

Churchill Livingstone, New York 1995.

5.

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.

6.

Seyfer AE, Hansen JE. Facial Trauma. In: Mattox,

Feliciano, Moore (eds). Trauma. 4th edn. McGraw Hill
2000; pg.415-36.

7.

Shearer VE, Gardner J, Murphy MT. Perioperative anesthetic management of maxillofacial trauma including
ophthalmic injuries. Anesthesiology Clinics of North
America 1999; 17: 141-52.

8.

Skerman JH. Anaesthetic management of craniofacial

trauma and trauma to the airway. The Middle East Journal of Emergency Medicine 2002;2:2.

9.

Britt LD, Peyser MB JE. Penetrating and Blunt Neck

Trauma. In: Mattox, Feliciano, Moore (eds). Trauma. 4th
edn. McGraw Hill 2000; pg.437-50.

10.

Hurford WE, Peralta R. Management of tracheal trauma.

Can J Anesth 2003; 50: R1-R6.

11.

Mathisen DJ, Gtillo HC. Laryngotracheal trauma. Ann

Thorac Surg 1987; 43: 254.

12.

Trone TH, Schaefer SD, Carder HM. Blunt and penetrating laryngeal trauma: a 13-year review. Otolaryngol
Head Neck Surg 1980; 88: 257-61.

13.

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.

14.

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.

15.

Matson MD. Injuries to the Face and Neck. In: Russ

Zajtchuk, C. Grande. Anaesthesia and Perioperative Care
of the Combat Casualty 1995.

16.

Manson PN. Facial Fractures. In: Plastic Surgery. The

Extubation 22,30
Antiemetics are recommended to prevent vomiting after intermaxillary fixation.
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

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

Jayashree Sood. Maxillofacial and airway trauma

head and neck Part 2, Mathes (ed) 2nd edn. Saunders
Elsevier Philadelphia 2006: 77.
17.

Rowe NL, Williams JL. Maxillofacial Injuries. 2nd Edn,

Edinburgh, Churchill Livingstone 1995.

18.

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.

19.

Suri YV, Qasba KK, Mahajan TR. Militancy Trauma:

maxillofacial injury, anaesthesia and critical care. Medical Journal Armed Forces India 1996; 52: 23-6.

20.

21.

22.

laryngeal trauma. Br J Anesth 1982; 54: 1339-43.

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.

23.

Williams JP, Krekorian TD. Neck trauma. In: Emergency

Anaesthesia. Adams AP, Hewitt PB, Grande CM (eds).
2nd edn. London; Arnold 1998: 186-96.

24.

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.

25.

Gotta AW. Maxillofacial trauma: Anesthetic consideration. ASA Refresher Course 1987;15:39.

26.

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.

32.

Dutton RP. Airway Trauma. In: Fun-Sun F. Yao. Problem Oriented Patient Medicine, 6th Edn. Lippincott Williams & Wilkins 2007, pg 993.

33.

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.

34.

Muzzi DA, Losasso T, Cucchinara RF. Complication from

a nasopharyngeal airway in a patient with a basilar skull
fracture. Anesthesiology 1991; 74: 366-8.

35.

Smith JE, Reid AP. Identifying the more patent nostril

before nasotracheal intubation. Anaesthesia 2001; 56:
25862.

36.

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.

37.

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.

38.

Kannan S, Chestnut N, McBride G. Intubating LMA

guided awake fiberoptic intubation in severe Maxillofacial Injury. Can J Anaesth 2000; 47: 989-91.

39.

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.

40.

Hrenandez Altmir F. The submental route for endotracheal intubation a new technique. Journal of Maxillofacial Surgery 1986; 14:64-5.

27.

Piepho T, Thierbach A, Werner C. Nasotracheal intubation: look before you leap. Br J Anaesth 2005; 94: 85960.

41.

Paetkau D, Strand M, One B. Submental orotracheal intubation for maxillofacial surgery. Anesthesiology 2000;
92: 912-4.

28.

Doroudian M. Anesthetic management of total traumatic

avulsion of mandible. J of Research in Med Scien 2004;
3: 148-51.

42.

Amin M, Dill-Russell P, Manisalr M, et al. Facial fractures and submental tracheal intubation. Anaesthesia
2002; 57: 1195-212.

29.

Coe TR, Human M. The peri-operative complications of

nasal intubation: a comparison of nostril side. Anaesthesia 2001; 56: 44750.

43.

Chandu A, Smith ACH, Gebert R. Submental intubation:

an alternative to short-term tracheostomy. Anaesth Intensive Care 2000; 28: 193-5.

30.

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.

44.

Rungta N. Technique of retromolar and submental intubation in facio-maxillary trauma patients. Ind J Trauma
Anaesth Crit Care 2007; 8; 573-5.

45.

Arya VK, Kumar A, Makkar SS et al. Retrograde submental intubation by pharyngeal loop technique in a

31.

Flood LM, Astley B. Anaesthetic mangement of acute

697

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

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.

49.

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.

50.

Benumof JL, Scheller MS. The importance of transtracheal jet ventilation in the management of the difficult
airway. Anesthesiology 1989; 71:769-78.

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

698