Difficult nasoendotracheal intubation in a patient with severe maxillofacial trauma.

Dental occlusion is key point for proper maxillofacial reconstruction. In this way nasal airway management is extremely important for both oral and maxillofacial surgeons and anesthesiologists. We report a challenging case with severe maxillofacial trauma and nasal obstruction that it managed with a novel anesthetic - surgical procedure.

INTRODUCTION

Maxillofacial injuries need special attention due to many anesthetic and surgical reasons. Skillful experienced personnel are mandatory. In order to have a good outcome with minimal risks and maximal success in airway management, should be in collaboration with the anesthesiologist or trauma team leader is must.[1] Hutchinson et al. addressed six specific situations associated with maxillofacial trauma, which may adversely affect the airway: 1. Postero-inferior displacement of a fractured maxilla parallel to the inclined plane of the skull base, 2. bilateral fracture of the anterior mandible, 3. hemorrhage, 4.soft tissue swelling and edema, 5.trauma to the larynx and trachea, 6.foreign bodies – dentures, debris, shrapnel, exfoliated teeth, bone fragments.[2]

On the other hand, nasal intubation is common procedure for airway management during maxillofacial surgery especially for those that they need intermaxillary fixation like panfacial fractures. Dental occlusion is the key point for proper reconstruction during surgery even in post operative period. In many instances, comminuted fracture of maxilla concomitant with nasal floor and septum may block nasal route due to its accordion type of fractured segments and overlapping of fractured bones. Moreover, folding of their overlying mucosa is the main cause of nasal obstruction. In this situation, forcefully nasal intubation may cause severe bleeding. Hemorrhage occurs more frequently with this route of intubation than with the orotracheal route. In emergency situation it may manage by cricothyrotomy in operating room.[3] If a difficult airway is not anticipated, the tracheal tube is passed through the nose after induction of anesthesia 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.[4] We report a case who suffered from combine crashed lefort I lefort III and zigomatico-orbital fracture due to the road traffic accident and a difficult nasal intubation during anesthesia. Patient airway was managed using a novel technique.

CASE REPORT

A 27-year-old male patient after discharging from neurosurgery ward with GCS 15 was referred to maxillofacial surgery department for treatment of his left lefort III, right lefort II, lefortI, bilateral orbital, and left blow out fractures. He presented dish face configuration on his lateral profile view [Figure 1]. Past medical history did not show any remarkable systemic diseases and nasal obstruction due to his septal deviation. The patient was traumatized severely on a crashed road traffic accident 5 days ago without any brain involvement and unconsciousness [Figure 2]. Surgeon and anesthesiologist made a joint bedside consultation about evaluation of patient airway management during and after surgery. Patient presented acceptable neck movements; Mallampati test was not performed due to being painful and inability of the patient in mouth opening, open nasal airway tests, which were not acceptable in both sides and normal thyromental distance. Overall, due to the multiple fractures in both sides of the face, patient was considered as a difficult intubation case, so required equipments including video laryngoscope, fiber optic laryngoscope, difficult intubation set with its complete equipments and emergency tracheostomy set were standby. He was scheduled for surgery using mandibular dental arch as a base reference for repositioning of other displaced facial compartments. The goal of anesthesia was to secure the airway immediately after induction with ready available equipments. The induction of anesthesia was achieved with lidocaine%2 (1 mg/kg), midazolam (0.03 mg/kg), fentanil (2 μgr/kg), propofol (2 mg/kg) and atracorium (0.6 mg/kg). Patient was being ventilated properly with oral airway and face mask.

Figure 1

Preoperative dish face profile view of patient

Figure 2

Axial CT scan shows crashed midface fracture

Anesthesiologist faced a difficult intubation due to the obstruction of the nasal route. Nasal fiberoptic endoscopic investigation and computed tomography (CT) scan showed obstruction of nasal airway by folding and overlapping of nasal mucosa because of the severe retrusion of the midface and crashed maxillary bone. A 30 cm 0.4 stainless ligature wire inserted from distal interdental space of first premolars embrasures. Flouting midface pulled forward and slightly downward by surgeon hand force. By this maneuver overlapped bony segments concomitant with overlying mucosa were straightened up and nasal obstruction was opened. Nasal fiberoptic endoscope passed through nasal fossa into the trachea then fiber optic nasotracheal intubation easily was performed. Nasotracheal tube was softened with warm normal saline and it lubricated for prevention of mucosal laceration [Figure 3]. Other surgical procedures were performed routinely by the surgical team. The patient did not present any airway obstructive complications immediate post surgically and latter six months follow-up.

Figure 3

Forward movement maneuver with ligature wire and surgeon hand force

DISCUSSION

Nasal intubation is a routine technique for majority of oral and maxillofacial surgeries. Dental occlusion is essential reference for surgical reconstruction of displaced facial bony fragments in panfacial fractured patients. During operation surgical team needs to check the patient's dental occlusion for proper reduction and fixation of fractured bone. Elective tracheostomy is another airway management, but it has its own side effects and complications. In the case of maxillofacial fractures without fractures of skull base and brain involvement nasal intubation can be a favorite airway management for both surgeon and anesthesiologist due to its low postoperative complication rate and its safe airway management during the surgery.

Nasal obstruction can occur due to severe septal deviation, massive turbinate hypertrophy, tumors, foreign bodies, comminuted maxillofacial fractures. In the case of lefort type floating maxilla, obstruction can be owing to the overlapping of fractured nasal floor and maxillary bone and their mucosa. Forward movement of crashed maxilla aligns fractured bony segments inside of periostal sac and crooked overlying nasal mucosas were unfolded. Present technique provides a good visualization for fiberoptic nasal endoscopy and consequently safe nasal intubation; moreover it may prevent anterior dental damage in the case of direct laryngoscoy. Retruded position of dental occlusion due to the backward fractured maxilla causes some difficulties during laryngoscopy.

Close cooperation between anesthesiologist and the surgical team is essential for proper performance of this technique. Present technique can be performed only before fibrosis and consolidation of the fracture segments in early post traumatic period. Overlapped cartilaginous and bony segments of nasal septum can be straightened by this maneuver during intubation.

CONCLUSION

Based on above mentioned points, maxillary forward movement technique can be an extremely useful maneuver for nasal intubation of patients with midface fractures. Additionally, it can be considered an alternative technique beside the other airway management methods for early reconstruction of panfacial fractures. Close multidisciplinary patient management is an important point for appropriate performance of this technique.