DENTAL & MAXILLOFACIAL ANAESTHESIA

Anaesthesia for Learning objectives

maxillofacial trauma After reading this article, you should be able to:
C identify likely causes and patterns of facial trauma injuries

Kathryn Harper C select appropriate airway management techniques in the emer-

Cristina Niciu gency setting

C perform airway management for specific maxillofacial injuries in
Kevin Fitzpatrick
the stable patient
C formulate anaesthetic management plans for patients with facial

trauma
Abstract
Facial trauma is common and can produce both physical and
psycho-logical problems for patients. Managing patients in both
the emer-gency setting and elective theatre environment can be Aetiology
extremely challenging, so airway interventions should be carefully
planned so the safest and most effective technique can be chosen. Approximately 3 million facial injuries occur commonly, but most
This may mean that direct laryngoscopy may not be the safest or do not involve maxillofacial fractures. The adult male-to-female
most straight-forward option and awake tracheal intubation, video- ratio is 3:1.2 Patients can present with isolated facial trauma,
laryngoscopy, submental intubation or awake tracheostomy may with nasal fractures as the most common,3 or facial trauma in
be a better choice in a given set of circumstances. An understanding combination with other significant injuries. Between 55% and
of common mechanisms of injury and pathologies and the likely dif- 70% of patients presenting with facial trauma have been shown to
ficulties that will be present are essential. Senior anaesthetic input have other significant injuries.4,5 Individuals with a single facial
and effective teamwork are required to provide excellent levels of fracture have been shown to have an incidence of associated
care for these patients. cervical fractures of 4.9e8% and head injury of 20e80%. Those
with at least two facial fractures have a 7e10% incidence of cer-
Keywords Airway; anaesthesia; facial trauma; intubation;
vical fracture and a 65e89% incidence of head injury.6
maxillofacial
Maxillofacial fractures result from blunt or penetrating
Royal College of Anaesthetists CPD Skills Framework: ENT, maxillo-facial trauma. Blunt injuries are far more common, with the two most
and dental surgery common causes being road traffic accidents and assaults. Other
causes of blunt trauma are sports-related trauma, occupational
injuries and falls, with penetrating injuries including gunshot
wounds, stabbings, and explosions.1 Improved road safety
measures including seat belts, airbags and a reduction in people
Background
driving under the influence of alcohol have reduced the trauma
Facial trauma can significantly affect patients in both the short association with road traffic accidents over the past 30 years.1
and long term, producing aesthetic, functional and psychological The use of helmets by bicyclists reduces the risk of head, brain
problems. Functionally, it can affect mastication, eyesight, sense and severe brain injury by 63e88%, providing equal protection
of smell and taste, swallowing and breathing depending on the for crashes involving motor vehicles (69%) and crashes from all
sight of injury. Facial trauma may be associated with concurrent other causes (68%). Additionally, injuries to the upper and mid
polytrauma and/or vascular complications. It is possible that facial areas are reduced by 65%.7
these factors in combination with aesthetic complications may Prevention of injuries caused by violent assaults is also clearly
have a profound psychological impact on a person’s life. important and local initiatives may help in this regard.
Patients may present with injuries requiring immediate med-
ical treatment in the emergency department, commonly due to Anatomical considerations
either haemorrhage or airway compromise,1 or may present in a
more stable situation allowing more time to assess injuries and Anaesthetic management of facial trauma requires understanding
formulate treatment plans. 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:
Kathryn Harper FRCA is a Specialty Registrar in Anaesthetics at the  the upper face: frontal bone and fronto-zygomatic
Institute of Neurological Sciences, Queen Elizabeth University processes
Hospital, Glasgow, UK. Conflicts of interest: none declared.  midface: orbits, nasal bone, ethmoid, zygoma and maxilla
Cristina Niciu FRCA is a Consultant Anaesthetist at the Institute of  lower face: mandible.
Neurological Sciences, Queen Elizabeth University Hospital, The facial skeleton has natural points of weakness and strong
Glasgow, UK. Conflicts of interest: none declared. dense bones called buttresses, and in the context of trauma, acts
Kevin Fitzpatrick FRCA is a Consultant Anaesthetist at the Institute of as a crumple zone to protect the brain. Fractures occur in char-
Neurological Sciences, Queen Elizabeth University Hospital, acteristic points where the bone is weak and may be unilateral
Glasgow, UK. Conflicts of interest: none declared. or bilateral. Comminuted fractures imply high-energy transfer.

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 DENTAL & MAXILLOFACIAL ANAESTHESIA

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.
a
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.

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

Extensive soft tissue injury around the nose and face can lead to b
difficult face mask ventilation.

Facial fractures
Upper facial 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 (NG)
tube and temperature probe is required.

Middle facial fractures of the mid-face are classified as Le Fort 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 c
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 frac-
ture is suspected. Central nervous system infection if CSF leak is (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
present should Figure 1 be considered. Nasal intubation may be
to the nose. (b) In a Le Fort 2 fracture the maxilla and nose can move as a
best avoided which is discussed in more detail later. 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
Lower facial fractures of the mandible present with a painful and 3 fractures may be associated with a dural tear resulting from fracture of
jaw and malocclusion of teeth. As a ring structure, the mandible the cribriform plate of the ethmoid bones. In Le Fort 3 fracture the base of
is usually broken in two or more places. Posterior inferior skull bones (sphenoid and /or temporal) are involved.
(Reproduced from: Joy E Curran. Anaesthesia for facial trauma.
displacement of the jaw can cause airway obstruction. Anaesthesia and Intensive Care Medicine 2014).
Bilateral mandibular fractures can cause difficulties in airway
management: Figure 1

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 DENTAL & MAXILLOFACIAL ANAESTHESIA

 Mouth opening may be limited. should ideally be performed in an environment with access to
 They permit posterior displacement of the tongue with the skilled assistance, drugs, equipment and space. This should be
potential for airway obstruction in the obtunded patient in the operating theatre if time allows.8
the supine position. This is a particular risk associated with If the patient also has a suspected or confirmed cervical spine
bilateral anterior fractures as the tongue is attached to the injury, traditionally, RSI has been performed with manual in-line
anterior mandible by the genioglossal muscles. stablization (MILS),9 but this has been challenged in a recent
 Posterior inferior displacement of jaw can cause airway narrative review due to the increased potential for difficult
obstruction, as can backward displacement of mid-face intubation and the paucity of evidence for improved spinal sta-
fractures during attempted bag/valve/mask ventilation. bilization associated with MILS.9 As highlighted by the review,
 Lingual or pharyngeal oedema/haematoma can make more research is required in this area but the recommendations
laryngoscopy difficult. are that the technique which is most likely to be successful and
 Teeth can become loose and avulsed, and fall into the which causes the least cervical spine movement is the one which
airway. should be utilised and this may vary depending on the skillset of
It is important to differentiate between reduced mouth open- the clinicians and the particular details of the case.
ing caused by pain, which will usually resolve following opioid
analgesia or induction of anaesthesia, and that caused by a me- General management principles
chanical limitation in mouth opening that will not improve There are several general principles which can assist in making a
with analgesia or anaesthesia. safe and effective management plan. Three such principles to
consider are:
Laryngeal trauma  How much time do I have?
Simple tears, dislocation of the arytenoids, disruption of the  Do I expect to be able to ventilate with a face mask?
cricothyroid joint and bleeding can occur. The patient may pre-  What view do I expect at laryngoscopy?
sent with subtle voice changes, hoarseness, stridor and hypox- Is it likely the patient will deteriorate if there is delay? This
ia. Cervical spinal injury and pneumothorax can be associated. would mostly commonly be due to either swelling or haemor-
Close attention should be paid to the mechanism of injury which rhage. Airway assessment including history, examination and
may raise suspicion of an increased chance of laryngeal injury. appropriate investigations is indicated for all patients. Voice
changes, stridor or difficulty swallowing may indicate injury of
Emergency management
the laryngopharynx and/or developing pharyngeal oedema. Ex-
Facial trauma may be associated with the greatest operator- amination of the patient looking for blood stained saliva, and
related physical, mental and psychological stress of all airway for tongue or other intraoral swellings is fundamental. Always
management interventions. It can lead to airway challenge for give consideration to other injury in the patient with facial
the anaesthetist with oedema, bleeding, difficult bag/valve/mask trauma as they may also have intraoral or laryngeal injuries.
ventilation and laryngoscopy. The patient may have associated Nasal or oral examination using a flexible bronchoscope can be
major trauma and should be assessed with Advanced Trauma useful in assessing this possibility. When confronted with
Life Support (ATLS) primary and secondary survey in an intraoral bleeding, straightforward measures may be taken under
appropriate critical care area with competent senior staff.8 It is local anaesthetic to stop this prior to induction, for example su-
important to note patients with facial trauma may have other turing buccal lacerations or using lidocaine with adrenaline in-
injuries affecting management: jection or an adrenaline-soaked swab. Simple compression or
 significant airway compromise requiring advanced airway packing may be useful. Post-induction, utilizing the ‘Suction-
technique, with senior anaesthetist/ear, nose and throat/ assisted Laryngoscopy Airway Decontamination’ (SALAD) tech-
maxillofacial surgeons required nique whereby there is pre-emptive continuous use of rigid
 unstable cervical spine suction during intubation can assist with reducing aspiration risk
 traumatic brain injury with reduced Glasgow Coma Scale and improving success rates.10
(GCS) score requiring intra-cranial pressure management Awake, neurologically intact patients without neck pain
and neurosurgical input should be allowed to position themselves however they are most
 basal skull fracture, with CSF leak, where nasal instrumen- comfortable to prevent tissue obstruction and allow drainage of
tation should be avoided unless deemed absolutely blood and secretions. This is most likely to be sitting forward.
essential They may be given a rigid suction catheter to use themselves,
 major haemorrhage with hypovolaemic shock from other which is often better tolerated, more effective, and less likely to
injuries e thoracic, intra-abdominal, long bone or pelvic stimulate a gag and resultant vomiting than a member of the
fractures. medical team using the suction. Strict adherence to protocols
Acute management should involve effective planning and requiring rigid spinal immobilization and supine positioning may
communication with the multidisciplinary team.8 Often patients result in catastrophe due to airway obstruction in the presence of
requiring intubation in the emergency department will be significant intraoral bleeding.11
managed with a rapid sequence induction (RSI) followed by oral The intubator should presume that preoxygenation e and re-
intubation. It is possible the patient may require either awake oxygenation if first intubation attempt is unsuccessful e in pa-
tracheal intubation or awake tracheostomy both of which will be tients with facial trauma may be difficult. Patients may tolerate
challenging in that setting therefore, consideration of appropri- positive pressure ventilation poorly, as disruption of tissues may
ateness of location is essential. High-risk tracheal intubations result in worsening bleeding and significant subcutaneous

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 DENTAL & MAXILLOFACIAL ANAESTHESIA

emphysema11 in cases of associated lower airway trauma. Mask intubation or front of neck access has been unsuccessful or is
ventilation may be difficult or impossible in the presence of inappropriate, then a high-risk general anaesthetic is the only
significant facial injuries where there may be tissue loss, swelling remaining option. In this scenario, the operator should formulate
and ongoing bleeding. It may not be possible to get a good an achievable A to D airway management strategy informed by
enough mask seal on the face to manage effective ventilation. any unsuccessful attempts at awake tracheal intubation and
The use of high flow nasal oxygen to optimize pre-oxygenation based on the 2015 DAS guidelines, recognizing that they are
and reduce the possibility of desaturation during intubation primarily for the unanticipated difficult tracheal intubation. This
may be extremely beneficial. However, its use should be avoided strategy should include an intravenous induction of anaesthesia
in patients with basal skull fracture and CSF rhinorrhoea. In the with full neuromuscular blockade. First attempt at tracheal
presence of significant active intranasal or intraoral bleeding it intubation in this scenario should be with a videolaryngoscope
may worsen rather than improve the situation. and surgical staff scrubbed with tracheostomy equipment open if
The choice of approach is based on the patient’s ability to the intubation attempt is unsuccessful. Operators may wish use a
maintain a patent airway, their oxygenation status and under- hybrid technique, ‘video-assisted flexible intubation’ (VAFI), to
standing that structural collapse of the airway may occur dur- benefit from the advantages of both techniques. All attempts with
ing asleep intubation.11 any device should be performed by the most appropriately skilled
If the patient is maintaining adequate oxygenation, the clini- clinician present.8
cian should proceed with a focused physical examination to
assess the specific pattern of facial injury and plan accordingly.11 Preoperative considerations
It is useful to palpate the submental region for swelling and
In the stable situation without ongoing bleeding and worsening
induration indicating the possibility of a fixed tongue. This may
intraoral swelling, a comprehensive airway assessment should
result in a poor view at direct laryngoscopy even in the presence
be performed. Airway assessment should include inspection of
of good mouth opening, so would be better managed by a device
swelling, nasal patency and degree of mouth opening. Tongue
such as a videolaryngoscope which allows an indirect view to be
protrusion as an assessment of difficulty at intubation due to
obtained. In this circumstance it will be helpful to use either an
submental swelling and or other trauma-related pathologies
endotracheal tube pre-loaded with an appropriately shaped
should not be forgotten as a warning sign for difficulty even if
introducer or use a gum elastic bougie as the initial plan.
mouth opening is good.
In general, the presence of multiple facial injuries with or
Preoperative imaging, such as CT scans, should be reviewed
without bleeding can lead to a more challenging situation with
to identify significant intraoral or airway swelling, or bony injury
anticipated difficulty during intubation, mask ventilation, and
that may cause a mechanical limitation to mouth opening. It is
possibly supraglottic airway rescue11 and hence awake tracheal
important to discuss these images and the operative plan with the
intubation has a favourable safety profile because both sponta-
surgeon. The route of repair should be considered and whether
neous ventilation and intrinsic airway tone are maintained
nasal, oral, submental intubation or tracheostomy is required.
until the trachea is intubated.8 However, intubation with a flex-
The need for throat pack, facial nerve monitoring and post-
ible bronchoscope in the presence of bleeding may be extremely
operative intermaxillary fixation should also be discussed. The
difficult. Until recently, all awake tracheal intubations have been
requirement of steroids to reduce postoperative swelling and
performed using a flexible bronchoscopy, and the vast majority
antibiotic prophylaxis should be addressed. Back-up airway
continue to be done this way. However, awake tracheal in-
management plans should be discussed with the team in advance
tubations using videolaryngosopy have been described and
of induction of anaesthesia in case difficulties are encountered.
shown to have a comparable success rate and safety profile to
Appropriate planning should reduce risks of complications if
awake tracheal using a flexible bronchoscope (both 98.3%).12 It
initial airway plans prove unsuccessful, as these can and some-
may be that awake tracheal intubation in the presence of
times fail as demonstrated in NAP4.13
intraoral bleeding is better performed using videolaryngoscopy
rather than with a flexible bronchoscope.8
Anaesthetic management for common bony facial injuries
Depending on the degree of bleeding and the urgency of the
situation, awake tracheostomy may be required rather than Orbital floor fractures
awake tracheal intubation. For example, in a patient with Orbital floor fractures are associated with potentially sight threat-
laryngeal injury as well as facial trauma, or in a patient with ening retrobulbar haemorrhage. Signs and symptoms of this include
multiple facial injuries (with ongoing bleeding, intraoral oedema severe pain behind the eye, proptosis, visual deficit, reduced reac-
and expected difficulty laryngoscopy), awake tracheostomy may tion to light and reduced extraocular movements. Immediate
be the safest option. This may be performed with or without management options include intravenous dexamethasone, acet-
intravenous sedation, although it may be safer to avoid sedation azolamide, mannitol, digital ocular massage and lateral canthot-
in a crisis situation. Neither awake tracheal intubation nor awake omy. Retrobulbar haemorrhage is also a recognized complication of
tracheostomy is easy if the patient has intraoral bleeding. zygomatic fractures involving the lateral orbital wall.
Distortion of view in the awake tracheal intubation and inability Plating of an orbital floor fracture requires a south-facing oral
to lie flat in the awake tracheostomy make the procedure more endotracheal tube and a throat pack. The main challenges for the
difficult for the operator and more traumatic for the patient. anaesthetist are avoiding intraoperative bradycardias when
The Difficult Airway Society (DAS) has developed an algo- working within the orbit and coughing on extubation as this can
rithm for unsuccessful awake tracheal intubation. They advise result in orbital haematoma which will necessitate return to
that if an emergency airway is essential and awake tracheal theatre. The options to minimize coughing include changing the

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 DENTAL & MAXILLOFACIAL ANAESTHESIA

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.

Zygomatic fracture
These fractures are common and present with swelling, a bony
step, visual disturbance, enophthalmos 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 sur-
geons prefer to operate within 1e2 weeks it is possible to defer Figure 3 Three-dimensional reconstructions from facial CT scan
demonstrating the left zygomatic arch displaced posteriorly against
operation due to concurrent morbidity for several weeks
the coronoid process of the mandible which will mechanically limit
although the necessity for osteotomy increases with time. A mouth opening.
south-facing oral tube and throat pack is used for the procedure.
Straightforward procedures may be performed with a laryngeal
mask provided nasal bleeding is not expected. Intraoperatively, it intragastric blood load. On assessment, the majority of these
is possible to get marked bradycardia on elevation of the zygoma, patients will have reduced mouth opening due to pain rather
which may require glycopyrrolate or atropine treatment. than a structural cause for limitation and following induction of
anaesthesia the patient’s mouth will often open fully. The ex-
Mandibular (and mid-face) fractures ceptions to this are either a fracture involving the temporoman-
Mandibular (and mid-face) fractures require intraoperative oc- dibular joint or a delayed presentation complicated by haema-
clusion to be performed to check the fracture has been reduced toma or infection causing masseter spasm. If there is doubt as to
and fixed in a suitable position. A nasal intubation is normally the cause of reduced mouth opening, then an option would be to
performed to allow a good operative view and occlusion of the give a dose of a short-acting strong opioid, e.g. 1 mg alfentanil, in
teeth. In edentulous patients or patients where occlusion is un- the anaesthetic room prior to induction and the patient will often
necessary, and base of skull fracture is present, oral intubation demonstrate significantly improved mouth opening. In patients
may be used. It is common practice for a throat pack to be presented for surgery acutely after injury, there is often intraoral
inserted to avoid pharyngeal contamination or an increase in the 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 RSI in any patient suspected to
have ongoing oral bleeding or pain due to injury as these pro-
mote emesis, increase gastric volume, and reduce gastric
emptying.
As mentioned above, blunt force trauma to the nose can result
in a base of skull fracture, diagnosed with rhinorrhoea and also
with CT imaging. The problem caused by this is the relative
contraindication to passing 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
anaesthetist must decide whether to perform a nasal intubation
despite the fracture, in which case it should be done under direct
vision using a flexible scope, or whether to avoid intubating
through the nose altogether. If the decision is that nasal intuba-
tion is contraindicated and occlusion of the teeth is required,
then 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 intubation for the duration
Figure 2 Three-dimensional reconstructions from facial CT scan
demonstrating the left zygomatic arch displaced posteriorly against of the procedure and there is no other indication for tracheos-
the coronoid process of the mandible which will mechanically limit tomy.14 To perform a submental intubation, the patient initially
mouth opening. has an oral intubation. In theatre, the tube is then held firmly as

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 DENTAL & MAXILLOFACIAL ANAESTHESIA

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.
Patients who have had an awake tracheal intubation due to
difficult airway management are at higher risk of complications
at tracheal extubation and require an appropriate tracheal extu-
bation strategy. Again, laryngoscopy may provide useful infor-
mation for risk stratification of tracheal extubation and any
subsequent airway management. The view at laryngoscopy may
be altered by the presence of a tracheal tube. Therefore, verifi-
cation of laryngoscopy grade may rule out, but not rule in,
Figure 4 A patient following oral intubation with a reinforced endo- easy subsequent asleep tracheal reintubation if required.8 The ‘at
tracheal tube with the floor of mouth marked prior to performing risk’ algorithm of the DAS extubation guidelines provides a
submental intubation.
structured approach to managing the extubation process when
there is concern that re-intubation may be difficult if required in
it is pulled through a dissected plane in the floor of the mouth the immediate postoperative period.15 Patients that are deemed
from a submental incision that is done by the surgical team and unsafe to extubate due to severity of facial injuries and intraoral
then secured. At the end of the procedure the reverse is done. swelling would be best managed with a tracheostomy, although
The tube is brought back into the mouth, the wound sutured and on occasions they may be managed intubated and sedated in
the patient is extubated normally. A disposable intubating LMA intensive care until swelling subsides.
(ILMA) tube is ideal for submental intubation as it allows a
reinforced tube to be used and is the only reinforced tube with a Postoperative management
removable connector.
Most patients following maxillofacial fracture fixation are safe to
The patient with multiple injuries that will be unable to be
return to the surgical ward. Those with multiple injuries and
extubated at end of procedure due to significant airway swelling
potential to deteriorate may be better managed in high care
is likely to require a tracheostomy. If this is the case an oral
areas. Postoperative complications include swelling and haema-
intubation followed by surgical tracheostomy, before proceeding
toma. Oedema can worsen in the first 48 hours, especially with
to fixation of mandible, is the best option.
Le Fort II and III fractures. In addition, postoperative haematoma
can occur and compromise the airway, especially after floor of
Extubation
mouth surgery. Emergency decompression of the haematoma is
Other than the specific case of orbital floor repairs, the facial required by removing clips or sutures and manually evacuating
trauma patient should be extubated awake following removal of haematoma with suction. While this will reduce swelling due to
throat pack and laryngoscopy (direct laryngoscope or video- the haematoma, any associated oedema will not be relieved, and
laryngoscope) to perform suction of the mouth and nasopharynx. the airway may still remain difficult to manage.13
Where blood and clots can accumulate particularly following
nasal intubation. Wire cutters or scissors for elastic band fixation

Figure 6 Three-dimensional reconstruction of CT scan of a patient

Figure 5 A patient after completion of the submental intubation following gunshot injury to mandible resulting in massive soft tissue
procedure. and bone loss. The gun pellet fragments are clearly visible on the scan.

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 DENTAL & MAXILLOFACIAL ANAESTHESIA

transfer surgery. These types of injuries may require either soft

tissue and/or composite (soft tissue and bone) free flap surgery
(Figures 6e8). The reconstruction often needs to be done at an
early stage to prevent contraction of remaining tissues. Three-
dimensional modelling using CT scans and software packages
makes accurate planning for these cases possible and patients
can get excellent results despite seemingly devastating initial
injuries.

Conclusion
Managing facial trauma patients can prove extremely challenging
for the entire team. Effective planning, teamwork, and commu-
nication are required. Senior anaesthetic involvement is neces-
sary to safely manage maxillofacial trauma patients with
significant injuries. A

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Figure 8 The same patient from Figures 6 and 7 in the immediate 15 Difficult Airway Society. DAS extubation guidelines. https://www.
postoperative period. Tracheostomy, nasogastric tube and bilateral das.uk.com/guidelines/das-extubation-guidelines1 (accessed 28
neck drains are visible. June, 2023).

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