airway management for oral and maxillofacial surgery

8/13/2019 Airway Management for Oral and Maxillofacial Surgery

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Airway Management for Oral and

Maxillofacial Surgery

James F. Mayhew, MD, FAAP

Since the initial reports of Tessier,1 the area of craniofacial surgery hasincreased dramatically, with multiple centers reporting their experi-ences.25 The success of these surgeries depends on the close cooperationof the anesthesiologist and the surgeon.68 This discussion will focus onthe anesthetic care of these patients, with particular attention to airwaymanagement.

Preoperative Evaluation

The first step in the successful management of these complex patientsis the preoperative evaluation. It is during this preoperative visit that theanesthesiologist becomes familiar with the patient and the parents. Many

of these patients have behavioral problems related to poor self-image;9,10

however, following surgery, up to 87% have reported improvement inappearance, increased satisfaction with self-image, emotional improve-ment, and better school performance.11,12

Inquiry should be made about previous anesthetic and surgical expe-riences, and previous hospital records that include the anesthetic recordsshould be reviewed. It is particularly important to review x-rays and anynotes that pertain to the airway, since up to 37% of patients will haveairway problems.13 Patients with craniofacial dysostosis such as Apertssyndrome and Crouzon syndrome and those with mandibular dysostosessuch as Treacher Collins syndrome, Goldenhar syndrome, and hemifacialmicrosomia had a 53% incidence of airway difficulties.13

Physical Evaluation

Physical examination of the airway should include the size and shapeof the mandible. Mandibular hypoplasia and micrognathia are well-known

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causes for difficult laryngoscopy.14 Movement of the mandible and the

ability to open the mouth widely are also important to note. The size andshape of the tongue as well as the size and shape of the palate should benoted. Anomalies of the neck such as cervical fusion are common inchildren with Goldenhar, Apert, and Crouzon syndromes; therefore, neckmobility should be evaluated, since inability to extend or flex the neckmay interfere with airway management.15,16

In children with Goldenhar syndrome, particular attention shouldbe paid to the cardiovascular system, since 50% of these children havecongenital heart disease, tetralogy of Fallot being the most common le-sion.17

Preoperative Medication

Preparation for surgery in the pediatric patient with craniofacialanomalies should include, but is not limited to, the use of premedication,and psychological preparation should be an integral part of the process.The anxious child should benefit from some form of sedation. Oral mid-azolam has become the mainstay of pediatric premedication. The use of0.5 mg/kg orally 15 to 30 minutes prior to induction helps with separationfrom the parent and resulted in a smoother induction than a placebo.18,19

Anesthetic Management

The type of induction will depend on the anticipated problems with

the airway. This will depend on the patients craniofacial deformity orsyndrome and on any previous anesthetic management. In a retrospectivereview of the airway management from a major center for craniofacialsurgery, 20% of patients required a tracheostomy. In children with cra-niofacial synostosis (Crouzon, Pfeiffer, or Apert syndrome), 48% requireda tracheostomy, and 41% of children with mandibulofacial dysostoses(Treacher Collins or Nager syndrome) required a tracheostomy.20 In an-other report 18 of 100 patients received a tracheostomy, but 14 of these

were elective tracheostomies because of the extensive surgery planned.13

There were three emergency tracheostomies: one patient had maxillaryretrusion, and two were required in the postoperative period.13 However,in one review no mention was made of the need for a tracheostomy. 7Withthe advent of the laryngeal mask airway21 and the ultrathin broncho-scope,22 the incidence of tracheostomy should decrease dramatically.

Planning the induction for children with potential airway problemsmust include several alternative techniques. Several types and sizes oflaryngoscope blades and various sizes of endotracheal tubes should bereadily available. Specialty laryngoscopes such as the Bullard laryngoscope

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and the light wand should be readily available. Laryngeal mask airways

and fiberoptic scopes should be present for children with Goldenhar s,Treacher Collins, and Pfeiffer syndromes.23 The use of the anterior com-missure scope has been described in a child with mandibular hypoplasia.24

Although there are many reports in the literature about techniquesfor intubating children with difficult airways,25 the laryngeal mask airway21

and the ultrathin fiberoptic bronchoscope22 have been major advance-ments in the management of the difficult airway. Basic techniques havebeen described using an inhalation induction with halothane and morerecently with sevoflurane.26,27 The use of newer anesthesia masks that areclear and have soft, air-filled face cushions are a great aid in obtaining agood seal. Occasionally, in children with severe hypertelorism, invertingthe mask may be advantageous. After the child is safely under anesthesiaand an intravenous line is started, either atropine or glycopyrrolate is

administered. If the child has been easily intubated on previous occasions,direct laryngoscopy may be done and, following injection of 2% lidocainearound the arytenoid cartilage and vocal cords,28 an oral tracheal intuba-tion may be accomplished with or without use of a muscle relaxant. Mostoperations for major reconstruction of craniofacial defects can be man-aged with oral endotracheal tubes. The RAE endotracheal tube allows fora low-profile airway for procedures on the cranium and maxilla.29 Thesetubes may be secured with tape for less involved surgery, sutured to thetongue with heavy suture or wired to the lower teeth when more extensivesurgery is involved.

Use of the laryngeal mask airway21 in the pediatric patient has in-creased dramatically, particularly in the patient with a difficult airway.30,31

Many articles have been published describing techniques for intubating

the trachea through the laryngeal mask airway.3235Whether the patient is a small child, a teenager, or an adult, the

laryngeal mask airway may be placed after the induction of anesthesia.Once the laryngeal mask airway is in good position, determined by use ofclinical signs,36 a fiberoptic bronchoscope with a proper-size endotrachealtube37 is passed through the glottis until the carina is visualized. Theendotracheal tube is then advanced through the laryngeal mask airwayinto the trachea. The position of the endotracheal tube is then confirmedabove the carina and the fiberoptic scope is removed. Because the endo-tracheal tube is not long enough to remove the laryngeal mask airway

without dislodging the endotracheal tube, there have been techniquessuggested for safe removal of the laryngeal mask airway.37,38 I have modi-fied the technique suggested by Reynolds.39 An endotracheal tube one-half size smaller than the first endotracheal tube is inserted into the endafter the connector is removed. The anesthesia circuit is connected to thetubes and the patient is either ventilated or permitted to breathe sponta-neously while the end-tidal carbon dioxide is monitored continuously.The laryngeal mask airway is then slowly moved out of the pharynx until

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the first endotracheal tube can be grasped either with fingers or a clamp.

Once the tube is secured, the laryngeal mask airway is fully removed. Thesecond tube is then disconnected and the connector is reattached to thefirst tube, which is then reconnected to the anesthesia circuit.14,39 Theadvantage of this method is that it permits continuous ventilation andmonitoring of the end-tidal carbon dioxide during the removal of thelaryngeal mask airway. The endotracheal tube is then secured as previ-ously described.

For children with difficult airways or with a history of difficult intuba-tions, either awake fiberoptic intubation or fiberoptic intubation once asatisfactory level of anesthesia is reached is the first option. With olderchildren who can cooperate, judicious sedation with midazolam and fen-tanyl or ketamine40 are options. As sedation is achieved, the airway isanesthetized either with intermittent spraying of the posterior portion of

the tongue and oropharynx or with nebulization of lidocaine.41

Oral tra-cheal fiberoptic intubation under general anesthesia may be difficult inboth children42 and adults, with failure rates as high as 25%.4345 If one isfaced with a failed fiberoptic intubation, there is a recent report of thesuccessful use of the light wand for both oral and nasal intubation afterfailed fiberoptic bronchoscopy.46

If the nasal route is used, the nasal airway may be anesthetized usingcocaine-soaked pledgets or 4% lidocaine. The use of topical vasoconstric-tors, particularly phenylephrine, in the pediatric patient has been ques-tioned.47 Care must be taken, particularly in children who may have hadan uneventful anesthetic course, who have undergone cleft palate or pha-ryngeal procedures.4850 In children with congenital heart disease, pre-operative oral or intravenously administered antibiotics are given as

guided by the American Heart Association recommendations.51 The an-tibiotics must be given prior to the intubation sequence since bacteremiahas been reported with nasal intubations.52,53

For mandibular and maxillary surgery, which will require intraoralfixation, nasotracheal intubation is the preferred airway.54Although man-dibular surgery is usually done on healthy young adults and presents littledifficulty in airway management, maxillary surgery may be done on thepatient who has undergone procedures on the palate and may present aproblem with placement of the nasotracheal tube.50 In these patients asmall suction catheter may be passed as a guide and a larger endotrachealtube may be passed with little trauma to the pharyngeal flap.54 The use ofthe ultrathin fiberoptic bronchoscope can also help in this situation. Atechnique for atraumatic pediatric nasotracheal intubation is to place ared rubber catheter over the endotracheal tube. This is accomplished byplacing the flared end of the catheter over the end of the endotrachealtube, which then presents a noncutting surface to the nasal mucosa.55

Older patients may be induced using intravenous drugs. The nose canbe prepared with the use of phenylephrine nose drops47 and 4% lido-

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caine. The nares can be dilated using lidocaine-lubricated nasal airways,

increasing the size until one size larger than the endotracheal tube that isto be used. Following endotracheal intubation, the endotracheal tube maythen be secured with tape, if the procedure does not involve the maxilla,or sutured to the nares, if there is to be surgical movement of the maxilla.

If oral intubation must be used in cases involving Le Forte osteoto-mies, particularly in patients with cleft lip or palate, and the surgical planinvolves simultaneous procedures, the tube can be placed behind themaxillary tuberosity.54 An armored tube is best in this situation.

Complications With the Endotracheal Tube

Although major complications involving the endotracheal tube are

unusual, obstruction from dried secretions and blood can occur fre-quently. These problems may be prevented by good humidification of theanesthesia circuit and the use of cuffed endotracheal tubes; however,cuffed endotracheal tubes are not routinely used in children under age 8

years.6 A posterior pharyngeal pack can help seal the glottis when bleed-ing is expected or there is a leak around the endotracheal tube. Kinkingof the endotracheal tube may be prevented with the use of the armoredreinforced tube. More serious complications such as extubation and cut-ting of the endotracheal tube or the pilot tube have been described.56,57

The endotracheal tube may be moved higher in the trachea with possibleextubation with either extension of the head or maxillary advancement.6

Facial Trauma

Facial injuries can be as straightforward as multiple lacerations, afractured nose, or a fractured mandible, with little or no airway compro-mise, to the more serious panfacialinjuries involving the upper, middle,and lower face, in which endotracheal intubation may prove impossible.58

Bleeding and progressive swelling and edema may lead to total airwayobstruction. Even in severe facial trauma, the airway may be controlled

with endotracheal intubation if done at the scene of the accident beforeswelling and obstruction occur.58 Neck injuries must always be assumedand care must be taken not to hyperextend or hyperflex the neck duringendotracheal intubation. During the endotracheal intubation sequence,the head and neck must be maintained in the neutral position by anassistant. Because basilar skull fractures may also present in severe facialtrauma, nasotracheal intubation or the placement of a nasogastric tubeshould not be done. Penetration injuries may also present with airwaycompromise and a difficult endotracheal intubation.59,60 In these cases anawake fiberoptic endotracheal intubation appears to be the first choice to



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manage the airway,60 but the patient should not be placed at undue risk

simply to avoid a tracheostomy.59

Attempts to avoid the use of a trache-ostomy during surgical correction and reconstruction in patients withpanfacial trauma have led to suggestions for unique placement of theendotracheal tube.58 These authors suggest a submandibular placementof the endotracheal tube, thus avoiding a tracheostomy. However, I be-lieve that such a procedure as described appears to be more complicated,

with the potential for more airway difficulties, than a well-conducted tra-cheostomy.

Postoperative Care

Extubating the trachea at the completion of the surgery will depend

on a number of factors, which include the type of airway anatomy en-countered during induction, the type of surgery (such as intermaxillaryfixation after midface advancement), and the potential for bleeding orsevere airway edema.6 Usually the endotracheal tube is left in place for 24to 48 hours. In the occasional case, extubation may be done in the oper-ating room.6 If there is concern about airway edema, dexamethasone canbe given IV prior to extubation.61,62

The American Society of Anesthesiologists Task Force for the Man-agement of the Difficult Airway have set forth guidelines for extubatingpatients with a difficult airway.63 One of the suggestions is the use of adevice over which the endotracheal tube is removed, such as a fiberopticbronchoscope, a jet stylet, or a gum-elastic bougie.6466 Because thesedevices may not be suitable in the very small infant, the use of a guide wire

from the Cook airway exchange catheter (CAEC) (Cook, Inc., Blooming-ton, IN) has been described.62 This guide wire is 0.018 and permits theuse of the 8 Fr CAEC, over which a 3.0 endotracheal tube can be passed.This technique of leaving a device in the trachea in the patient with adifficult airway has proven useful in a number of reports.6668

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