Fiberoptic bronchoscope assisted difficult airway management in maxillofacial trauma.

Dear Sir,

Airway maintenance with cervical spine control is the first priority in the assessment and management of any patient suffering from trauma.[1] We report a case wherein a potential difficult airway was successfully managed using the fiber optic bronchoscope (FOB).

A 45-year-old male was brought to the Emergency Department after a firearm injury. He was conscious, responsive with Glassgow Coma Score (GCS) 15/15, stable hemodynamic parameters and a large wound on the right side of the face [Figure 1]. Non-contrast computed tomography (NCCT) revealed right parietal extradural hematoma (EDH), right front temporo parietal (FTP) acute subdural hematoma (SDH), right globe rupture with fracture roof of orbit and squamous temporal bone [Figure 2]. NCCT cervical spine showed no abnormality. Right FTP decompressive craniotomy, evacuation of parietal EDH, duraplasty along with enucleation of eye ball, debridement of facial wound and removal of pellets were planned. Airway was secured by awake orotracheal FOB-guided intubation [Figure 3]. Upper airway was anesthetized using ultrasonic nebulisation of 5 ml of 4% xylocaine for 10 min. Anesthesia was induced with propofol, fentanyl and rocuronium and maintained with 60% nitrous oxide in oxygen, isoflurane, fentanyl and vecuronium. Post-operatively, ventilation was continued in the Intensive Care Unit. Five days post-operatively, he was tracheostomised, anticipating prolonged ventilation. The patient succumbed as a consequence of sepsis 12 days post-injury.

Figure 1

Patient after gunshot injury

Figure 2

Non-contrast computed tomography showing globe rupture

Figure 3

Bronchoscopic view of the vocal cords

Anatomic distortion of airway in the form of bony disruption, soft tissue swelling and an increased potential for aspiration of body fluids in massive facial trauma poses major risks in airway management.[2] The facial disfiguration caused ineffective mask ventilation. The advantage of skillful, experienced personnel in airway management has been established in several studies. Schmidt et al. prospectively investigated emergent tracheal intubations[34] and found that supervision by an attending anesthesiologist was associated with a decreased incidence of complications. The challenge in performing endotracheal intubation arises mainly from the difficulty in visualizing the vocal cords. Numerous airway devices and equipments have been developed to overcome this obstacle.[56] FOB intubation under local anesthesia is the technique of choice for the management of the anticipated difficult intubation and mask ventilation.[7] The option of FOB intubation is suitable for elective procedures, but has been considered difficult in maxillofacial trauma patients with intraoral bleed. Blood, vomitus and secretions in the patient's airway hamper proper visualization by fiberoptic instruments. In addition, accomplishing effective local anesthesia in the traumatized region is difficult. Furthermore, the patient's cooperation is essential for such an approach. The final option is creating a surgical airway. The major complications of FOB include pneumothorax, pulmonary hemorrhage and respiratory failure. The minor complications include laryngospasm, vomiting, bronchospasm and episodes of vasovagal syncope. In our patient, upper airway anesthesia was successfully achieved using ultrasonic nebulisation, and FOB could be performed as there was no active bleed inside the oropharynx. This avoided the necessity for a surgical airway, which has its inherent complications. Extubation was deferred anticipating a high risk for complications in the post-operative period.[8]

A cooperative patient, availability of the fiberoptic scope and the expertise of the anesthesiologist enabled us to manage the procedure. Fiberoptic scope is a useful adjunct to emergency airway management in facial trauma.