Adult face mask for inhalational induction in a child with maxillofacial injury.

We report the anesthetic management in a 4-year-old child with maxillofacial injuries for emergency reduction of mandibular fracture. The problem of leakage of anesthetic gases through the externally communicating wound was successfully overcome by the use of an adult-sized face mask for inhalational induction of anesthesia in this case.

INTRODUCTION

Facial injuries with fracture of maxilla and mandible commonly result from road traffic accidents and gunshots. Distortion of the airway from the injury, emergent management, and other serious coexisting injuries complicate the airway management in patients with maxillofacial injuries. Apart from concerns about cervical spine injury and full stomach, airway problems include (a) disrupted anatomy, edema, and blood in the airway; (b) inability to obtain the adequate seal with face mask to facilitate mask ventilation; (c) inability to effectively ventilate the lungs; (d) difficulty in the visualization of the vocal cords due to blood, secretions, debris, soft tissue, and bone fractures. Airway management in pediatric cases with maxillofacial injuries is highly challenging because awake intubation is not an option in most of these cases. In this report, we describe the airway management in a child with maxillofacial injuries and the timely adaptation of using an adult face mask for anesthetic induction.

CASE REPORT

A 4-year-old child weighing 20 kg was brought to the casualty with maxillofacial injuries following road traffic accident. Examination revealed edematous face, mobile dentoalveolar segments in the anterior aspect of both upper jaw and lower jaw; lacerated wound (4 × 3 × 1 cm) over right chin that was communicating externally and a fragment of bone of the lower jaw with four teeth still in place protruding through this wound [Figure 1]. There was no history of loss of consciousness, ENT bleed, vomiting, or seizures. The child was a known case of bronchial asthma on regular medications. The child was conscious and hemodynamically stable. Radiological imaging revealed no head or cervical spine injury. A gentle oral suctioning was done; IV access was secured and routine blood investigations including grouping and cross matching was sent. The child was scheduled for emergency reduction of the mandibular fracture.

Figure 1

Externally communicating wound over lower jaw

Airway examination revealed fragmented dentoalveolar ridges in both the jaws, mouth opening less than one finger breadth, and temporomandibular joint was tender. Neck movements appeared adequate. Considering the possibility of “full stomach” secondary to swallowed blood, intravenous (IV) injections of ranitidine 15 mg and metoclopramide 2 mg were administered 30 min prior to shifting to the operating room (OR). Salbutamol nebulization was given.

For pain relief and to facilitate parental separation small aliquots of IV midazolam and fentanyl were given (total midazolam 0.5 mg and fentanyl 10 mcg) in the preoperative holding area. Child's breathing was closely monitored to look for any airway obstruction. IV Glycopyrrolate 0.1 mg and nasal oxymetazoline two drops were administered. The anesthetic plan was to do a fiberoptic bronchoscope helped intubation under deep inhalational anesthesia with preservation of spontaneous respiration. As a rescue measure, it was ensured that an ENT surgeon was present in the OR prepared to do tracheostomy if required.

In the OR, standard monitoring was initiated. During preoxygenation, mask fit over the face seemed problematic. The adequate seal was not obtained with the pediatric masks due to leak through the communicating-lacerated wound over the chin. Attempt to close the wound by gently placing soft gauze over the wound failed to prevent the leak. So to include the externally communicating wound also within the mask we decided to use the adult size mask (size three anesthesia mask with adjustable air cushion, Intersurgical®, Berkshire, UK). With titration of air injected into the soft seal of the mask and the chin of the child included within the mask a good seal was obtained [Figure 2]. Probably the facial edema helped to attain a better seal. No attempt was made to hold the mask tightly and no pressure was applied on the soft tissues acknowledging that the wound was painful. By this modification, we confirmed adequate ventilation through the face mask during spontaneous respiration.

Figure 2

Use of the adult face mask for ventilation

After denitrogenation, inhalational induction of anesthesia was done with sevoflurane (1% to 8% v/v) in oxygen. After attaining adequate depth of anesthesia, a lubricated nasopharyngeal airway was inserted through the left nostril. Anesthetic circuit was connected to this to maintain anesthesia by continued administration of sevoflurane in oxygen. However, with this, the seal obtained was poor despite closing the mouth, the contralateral nostril and the externally communicating wound with the gauze piece. Since the problem was with the leak and not airway obstruction, we decided to use increments of 10 mg IV propofol to maintain the depth of anesthesia during the procedure.

After gentle oral suctioning, pediatric fiberoptic bronchoscope already loaded with a 4.5 mm ID cuffed tracheal tube was passed through the right nostril. Anatomical structures had a “red out” view. However, epiglottis and vocal cords could be identified and intubation was successful in first attempt. Subsequent anesthetic management was uneventful. After the surgery, the child was shifted to ICU for elective ventilation in view of the possibility of airway edema. Twelve hours later tracheal extubation was done. Recovery was uneventful.

DISCUSSION

Disrupted airway anatomy, tissue edema, and bleeding following maxillofacial trauma leave few options to secure an intact airway.[12] Awake intubation following airway topicalization is the gold standard in such cases. In very severe cases, infraglottic access to airway may be the only option.[1] Situations associated with facial trauma, which may adversely affect the airway, have been reviewed elsewhere.[3]

In this case, the patient being a child, awake intubation was not possible. Mobile dentoalveolar fragments in both the jaws with edema of tongue and airway would have made direct laryngoscopy extremely difficult. Hence, we chose to use fiberoptic-guided intubation under general anesthesia with spontaneous respiration preserved. In such cases, airway obstruction can set in at any time once the child is anesthetized. Hence, we were extremely cautious while injecting IV midazolam and fentanyl preoperatively; they were given in small increments closely monitoring respiration. Increments of IV propofol were injected only when we were convinced about the absence of airway obstruction following inhalational induction of anesthesia. Fiberoptic intubation is not a panacea in such situations. Due to blood and airway edema visualization of glottic structures could be impossible. Hence, as a backup plan, we had a prepared ENT surgeon in the operating room to do tracheostomy if needed.

Inhalational induction of anesthesia with the conventional pediatric face mask would have been difficult in this case due to the lacerated externally communicating wound over the lower jaw through which anesthetic gases were leaking. To overcome this problem, we used an adult face mask for induction of anesthesia. This bigger mask enclosed the communicating wound and prevented the leak of anesthetic gases. Use of the pediatric mask for ventilation in adults has been described.[45] But we are not aware of reports of use of the adult face mask for pediatric cases.

Some of the innovations that are described with respect to airway management in maxillofacial trauma include use of modified nasal trumpet to facilitate uninterrupted delivery of oxygen and anesthetic gases during fiberoptic intubation.[6] It also serves as a channel to perform nasopharyngeal suctioning. We did apply this technique during the management of this case. The split nasopharyngeal airway is another modification of the nasopharyngeal airway to facilitate atraumatic nasal fiberoptic intubation.[7] It allows for nasal fiberoptic endoscopy to be performed with little distress to the patient. It requires a much lighter plane of sedation and or anesthesia, if any. Since the split nasopharyngeal airway can be peeled off the bronchoscope, it facilitates atraumatic tracheal intubation to be performed. Blind nasotracheal intubation in spontaneously breathing anesthetized child taking cues from breath sounds and exhaled carbon dioxide (detected by capnograph) would have been an option to intubate in the absence of fiberoptic bronchoscope. However, blind maneuvering of the tracheal tube can aggravate the airway injury if one is not careful to be gentle. Nasotracheal intubation with light wand is another option. But edema of the tissues can obscure the midline glow with the light wand. In very severe forms of maxillofacial injuries one is left with no other option but tracheostomy (with or without sedation depending on the extent of airway compromise) to secure a definitive airway.[8]

To conclude, the adult face mask may be useful in ventilation in pediatric cases of maxillofacial injury. Timely appropriate adaptations as these can provide solution to some of the problems encountered in maxillofacial trauma.