The anaesthetic management of facial
trauma and fractures
Key points
All trauma patients
should be managed
according to the princi-
ples of ABC
Maxillofacial trauma is
associated with particular
airway problems
The airway in acute facial
trauma victims is usually
most safely secured with
rapid sequence induction
of anaesthesia and tra-
cheal intubation.
However, this may be
inappropriate in some
patients
Specialized airway skills
and equipment may be
required
The possibility of occult
haemorrhage due to
other injuries must never
be forgotten
Nicholas J Chesshire
Consultant Anaesthetist,
Department of Anaesthetics,
Derbyshire Royal Infirmary, London
Road, Derby DE1 2QY
David J W Knight
Specialist Registrar in Anaesthetics,
Department of Anaesthetics,
Queen’s Medical Centre,
Nottingham NG7 2UH
108
Nicholas J Chesshire
David J W Knight
In the field of maxillofacial trauma, the anaes-
thetist may be called upon to provide help in
the treatment of the acutely injured patient on
arrival to the accident and emergency depart-
ment or in the semi-elective repair of fractures
sustained previously. This article provides
advice on the best approaches to dealing with
these problems and the alternatives available.
The acutely injured patient
In the UK, the epidemiology of trauma has
changed dramatically since legislation on seat
belts and drinking and driving. These changes
have been most notable in the field of head injury
and maxillofacial trauma. The overall incidence
of complex pan-facial trauma may have
decreased, but an increase in violent crime and
associated facial injuries has easily compensated
for this. The management of any traumatized
patient is based on the principles of ABC, i.e. air-
way, breathing and circulation. When maxillofa-
cial trauma has occurred, particular problems
may be encountered in securing the airway and
oxygenation and these will be reviewed in detail.
Associated injuries frequently cause breathing
and circulation difficulties. Life-threatening
hypovolaemia is rarely seen in uncomplicated
maxillofacial trauma, but occurs in 1–4% of iso-
lated mid-face fractures.
Causes of airway difficulty
Airway obstruction
The mechanism of trauma itself may obstruct
the airway due to gross disruption of facial
anatomy or the presence of a foreign body such
as a knife or fence post. Blood, broken teeth and
generalized oedema may also compromise the
airway. Alternatively, the administration of opi-
ates, underlying cerebral trauma or drug and
alcohol intoxication can reduce the ability of the
British Journal of Anaesthesia | CEPD Reviews | Volume 1 Number 4 2001
© The Board of Management and Trustees of the British Journal of Anaesthesia 2001
trauma victim to maintain an adequate airway.
These factors often occur in combination.
Uncooperative/intoxicated patients
Many patients with maxillofacial trauma are
uncooperative, not only due to previous drug
and alcohol ingestion, but also to underlying
hypoxaemia, pain or cerebral trauma. This
often prevents utilisation of airway manage-
ment techniques that require patient co-opera-
tion, such as awake intubation.
Full stomach
A full stomach with concurrent risk of aspiration
should be assumed and precautions such as
rapid sequence induction with cricoid pressure
or, if appropriate, awake intubation before
induction of anaesthesia, are mandatory.
Disruption of normal anatomy
Even minor maxillofacial trauma can cause
enough anatomical distortion to prevent an
adequate mask seal and so make mask venti-
lation impossible. Basic airway adjuncts such
as oral or nasal airways may actually cause
further trauma or be contra-indicated and so
be lost as an aid to airway management.
Cervical spine protection
High velocity trauma, e.g. road traffic acci-
dents, has a relatively high incidence of asso-
ciated cervical spine injury. Thus, cervical
spine immobilisation should be achieved at all
times during management of the airway. This
may complicate matters further.
Management of the airway
Airway management should begin with an
assessment of the speed with which a definitive
airway needs to be secured, knowledge of airway
equipment that is readily available, and a plan of
action if primary airway manoeuvres fail.

Airway assessment in patients with facial injuries follows
the same principles as in any traumatized patient; the clinical
features of respiratory obstruction, hypoventilation, hypox-
aemia or coma indicate the need for urgent intervention.
Simple airway manoeuvres
Many routine airway manoeuvres may not be possible in maxillo-
facial trauma due to anatomical disruption or poor patient co-oper-
ation. It should be remembered that agitation is often due to hypox-
aemia and correction of this may convert a difficult patient to one
who co-operates fully with airway management. Fully conscious
patients will often present in the most favourable position to main-
tain their own airway and may fiercely resist attempts to lay them
supine. Obtunded patients may benefit greatly from a simple jaw
thrust and left lateral positioning to allow blood and secretions to
drain away from the oropharynx. A unique but life-saving manoeu-
vre in mid-face fracture is to grasp and pull forward a posteriorly
displaced and mobile fractured maxilla, in order to open a previ-
ously obstructed airway.
Oral/nasal intubation
Patients who are unable to maintain their own airway and/or
need the institution of positive pressure ventilation for other
reasons (such as suspected raised intracranial pressure or
impending respiratory failure) need a definitive airway
secured. The above factors may well make this difficult. The
techniques utilised will depend on the experience and exper-
tise of the anaesthetist and at all times a ‘plan B’ must be con-
sidered should failure be encountered. An experienced anaes-
thetist must be available, as it is often hard to assess how dif-
ficult intubation will be. The presence of a suspected basal
skull fracture will preclude the use of the nasal approach to
the trachea. Otherwise, either route can be chosen, depending
on the technique utilized and patient factors, e.g. site of
injuries. Battles sign (retroauricular haematoma) and perior-
bital haematoma (‘Racoon eyes’) are common clinical signs
of base of skull fracture.
General anaesthesia
Rapid sequence induction of anaesthesia with rigorous pre-
oxygenation and cricoid pressure remains the technique of
first choice in all trauma patients providing that there is no
obvious reason to suppose that direct laryngoscopy will be
impossible. Fortunately, most genuine grade IV Cormack and
Lehane laryngoscopies can be predicted and correspond to
those patients with gross anatomical disruption or foreign
body invasion. Bearing in mind that the intubation is likely to
British Journal of Anaesthesia | CEPD Reviews | Volume 1 Number 4 2001
Anaesthetic management of facial trauma and fractures
be difficult, rather than impossible, the most experienced
anaesthetist available should be present and all equipment
must be rigorously checked. Difficult intubation adjuncts
should be available such as a selection of different tubes and
laryngoscope blades and most importantly, a gum elastic
bougie. A plan of action involving a failed intubation drill
must be practised and agreed upon, and in the event of failure
to intubate and ventilate facilities for cricothyroid puncture
and oxygenation should be available.
There are many other useful aids now marketed which
should be considered for a difficult intubation trolley avail-
able in all accident departments. These include McCoy laryn-
goscopes, laryngeal mask airways, ventilating bougies and
specific cricothyrotomy cannulas. Simple facilities for jet
ventilation are not expensive and can be extremely useful if
oxygenation becomes difficult due to an airway problem.
Several case reports have demonstrated the use of the Bullard
laryngoscope in facial trauma. This is a rigid laryngoscope
with a fibre-optic viewing channel and guide wire which is
preloaded with an endotracheal tube. Unfortunately, most UK
anaesthetists are unfamiliar with these more specialized
equipment options. Intubation under general anaesthesia with
neuromuscular paralysis remains the technique most well
practised and is the first that should be considered in maxillo-
facial trauma. Clearly, if it is felt that intubation via direct
laryngoscopy is very likely to fail then another method of
securing the airway must be sought.
Some may advocate the use of inhalation induction of
anaesthesia in order to maintain spontaneous ventilation in the
face of a difficult airway. Theoretically, this avoids the possi-
bility of a ‘can’t intubate can’t ventilate’ scenario. In experi-
enced hands, this may be a useful technique, but is often prac-
tically difficult in uncooperative patients. The airway may
well obstruct during lighter planes of anaesthesia and hypox-
aemia often rapidly ensues in traumatized patients.
Regurgitation of gastric contents may occur and be aspirated
along with blood already in the airway. Once a deep plane of
anaesthesia is achieved, one is still faced with the problem of
how to intubate the trachea.
Awake intubation
If extreme difficulty in laryngoscopy is anticipated, awake intu-
bation must be considered. The major benefit is that the airway
is maintained reducing the chance of further catastrophic deteri-
oration in oxygenation and the aspiration of gastric contents. A
degree of patient co-operation is essential for awake intubation
109
Anaesthetic management of facial trauma and fractures
and this may preclude its use in aggressive or intoxicated
patients. However, those with progressing airway difficulties
will often tolerate a significant amount of discomfort to obtain
relief from their distressing symptoms.
Local anaesthesia is usually applied to the airway mucosa
by means of spray, injection, or nebulizer together with topi-
cal vasoconstrictors. Sedation is generally contra-indicated in
these patients due to respiratory compromise, full stomach
and/or reduced level of consciousness. Having achieved a rea-
sonable level of local anaesthesia, various methods of intuba-
tion can be employed. Gentle rigid laryngoscopy can be per-
formed but most practitioners would use a fibre-optic intubat-
ing laryngoscope as the method of first choice. However, after
trauma, the presence of blood and other matter in the airway
can make this extremely difficult.
Alternatively, blind nasal or oral intubation is often possible
and is helped in the awake patient by listening down the tube
for breath sounds emanating from the trachea. A laryngeal
mask airway can be placed under local anaesthesia and then
used as a port for the fibre-optically guided or blind passage
of a small endotracheal tube. The intubating laryngeal mask
airway can also be used. Various light wand and lighted stylets
have been marketed for difficult intubation and are useful in
the awake patient, as they require minimal mouth opening, but
few UK anaesthetists are experienced in their use. Retrograde
intubation may also be of value, in which a guide wire or
catheter is passed into the trachea through the cricothyroid
membrane and then up into the pharynx. The tube is then
passed downwards over the guide. Commercial kits are avail-
able to facilitate this. Whichever technique is chosen will
depend upon the expertise of the operator, the equipment
available and patient factors.
Surgical airway
This may be the only viable option if intubation is impossible
and ideally should consist of a tracheostomy performed awake
under local anaesthesia. This may present practical problems
if the patient is uncooperative of if there is gross swelling or
anatomical disruption of the cervical structures. It may have to
be performed in the sitting position if the patient cannot main-
tain an airway supine. Surgical access to the trachea may be
necessary urgently after induction of anaesthesia and a failure
to intubate or ventilate adequately. In these circumstances, the
quickest life-saving manoeuvre is to cannulate the trachea
through the cricothyroid membrane and oxygenate via this
route. Specific cannulas are designed for this purpose and
110 British Journal of Anaesthesia | CEPD Reviews | Volume 1 Number 4 2001
should be available as venous cannulas are extremely prone to
kinking and have no direct means of connection to a breathing
system. Jet ventilation is the ideal mode of ventilation through
a cannula due to the small bore of the tube ; extreme care must
be taken to watch for signs of barotrauma, particularly if exha-
lation is also obstructed. Conversion to a definitive tra-
cheostomy must proceed as soon as possible.
Haemorrhage
Persistent hypotension in a patient with apparently isolated
maxillofacial trauma should always prompt the resuscitation
team to look for an occult cause of haemorrhage. Profuse
bleeding from facial injuries can be very difficult to deal with
due to the complex vascular supply to the area involving
branches of both the internal and external carotid arteries.
Cerebral trauma
In a recent study, cerebral injury was the most common life-
threatening factor in cases of maxillofacial trauma (more com-
mon than airway compromise). It should, therefore, be remem-
bered that initial resuscitation in an agitated patient should be
aimed at preventing secondary brain injury and that computerised
tomography of the cranium should be performed early.
The semi-elective repair of maxillofacial
fractures
If surgical or anaesthetic intervention is not required for other
problems associated with the trauma, maxillofacial fracture
repair is often delayed until swelling has subsided, intoxica-
tion has passed and the effects of any head injury can be prop-
erly assessed. Also, repair can be scheduled for a time when
experienced medical and theatre staff are readily available
during daylight hours.
The treatment of facial fractures follows the principles of all
fracture management, i.e. debridement of open injuries, reduction
(open or closed), fixation (internal or external), immobilisation
and functional rehabilitation. Most commonly, fractures are fixed
internally using microplating instruments. External fixators and
long-term immobilisation are used less often. A simple under-
standing of the classification of the injuries and functional anato-
my is useful when planning anaesthesia.
Classification of facial fractures
Common facial injuries may involve fracture to one or more of
the bones of the facial skeleton. For example, mandibular frac-
tures often occur alone whereas orbital or midface fractures
 Anaesthetic management of facial trauma and fractures

commonly require fixation of multiple components of the

skull. The functional effect of the injury is most important to
the anaesthetist, but the fractures themselves can be classified
according to their anatomical position or displacement.
Mandibular fractures
These vary in site and relative incidence, i.e. condylar neck
35%, angle 20%, body 20%, parasymphysis 13%, symphysis
11% and coronoid 1%.
Midface fractures
The midface comprises the maxilla, zygoma, palatine, nasal,
lacrimal, inferior concha, pterygoid plate of sphenoid, vomer and
ethmoid. Rene Le Fort developed the following classification in
1901 after applying direct trauma to cadaveric heads:
Le Fort I: low level fractures
Le Fort II: pyramidal or sub-zygomatic fractures
Le Fort III: high level or supra-zygomatic fractures
Le Fort III fractures are often associated with base of the
skull fractures. Fig. 1 Classification of Le Fort fractures. I: low level fractures, II: pyramidal
or sub-zygomatic fractures, III: high level or supra-zygomatic fractures.
Other fractures
The classification of zygomatic fractures is shown in Table 1. securing the airway. A full pre-operative airway assessment
Others include naso-ethmoidal and orbital fractures. The lat- and knowledge of the anatomical disruption present will
ter may involve the rim, floor, roof or walls or the orbit. allow an estimate of ease of intubation to be made. Many
Isolated fractures or the medial wall or floor can occur and are patients with facial fractures find mouth opening difficult.
termed blow-out fractures. However, this is often due to pain or trismus and may not
cause difficulty in laryngoscopy once anaesthesia is induced.
Principles of anaesthesia for facial fracture repair If difficult intubation is anticipated, the options are a careful
General anaesthesia is almost invariably required for the inhalational induction of anaesthesia with laryngoscopy under
repair of facial fractures and all the usual general principles of deep anaesthesia, or to secure the airway awake. With the
anaesthetic management are employed. increasing dissemination of fibre-optic endoscopy skills,
The security of the airway is of particular relevance in view many would now advocate awake fibre-optic intubation.
of the following points: (i) intubation may be difficult due to Other difficult airway adjuncts must be available as described
anatomical distortion of the facial structures and residual above. In the rare event of a total loss of the airway, then a
swelling; (ii) the airway is shared between surgeon and anaes- surgical airway may be necessary.
thetist; and (iii) endotracheal tube placement may interfere Intermaxillary fixation (IMF) is frequently employed intra-
with surgical management. operatively for midface and mandibular fractures to produce a
Good communication is vital between surgeon and anaes- template for the fracture reduction and may remain in place
thetist prior to deciding on the appropriate technique for for some time postoperatively. This is becoming less common
as modern microplating techniques provide good immobiliza-
Table 1 Classification of zygomatic fractures tion of the fracture site. IMF precludes the use of an oral tube
Type 1 Undisplaced fracture unless there is a large gap between the teeth. Therefore, naso-
Type 2 Arch fracture only
Type 3 Tripod malar fracture (frontozygomatic suture intact) tracheal intubation is commonly required for mandibular and
Type 4 Tripod malar fracture (frontozygomatic suture distracted) midface fractures. However, this route may not be available if
Type 5 Pure blowout fracture
Type 6 Orbital rim fracture involving zygoma only basal skull fracture is present (common in Le Fort III injuries)
Type 7 Comminuted and other fractures or if fractures of the naso-ethmoidal complex are to be plated.

British Journal of Anaesthesia | CEPD Reviews | Volume 1 Number 4 2001 111

Anaesthetic management of facial trauma and fractures
In these circumstances, either a tracheostomy must be formed or
the technique of sub-mental intubation must be employed. This
technique, first described in 1986, involves the surgeon making a
submental skin incision adjacent to the lower border of the
mandible and blunt dissecting into the floor of the mouth. A tube
may then be passed through the tissues and into the larynx if
direct laryngoscopy is straight-forward. Alternatively, a tracheal
tube already in situ can be exteriorised through the hole if the uni-
versal connector is removed. After extubation, the submental
incision is simply repaired. This technique may be associated
with less morbidity than tracheostomy.
The surgical fixation of multiple facial fractures may be
prolonged and the usual steps should be taken to keep the
patient warm and well monitored. Moderate controlled
hypotension is useful to improve operative conditions but care
must be taken to restore the blood pressure prior to closure to
ensure haemostasis.
Extubation must be planned carefully. A generally safe tech-
nique is to allow the patient to regain consciousness and air-
way reflexes prior to extubation and to ensure that the airway
112 British Journal of Anaesthesia | CEPD Reviews | Volume 1 Number 4 2001
is clear. If IMF is in place, then a nasopharyngeal airway can
be useful to maintain a clear airway. Tools for releasing the
IMF must be immediately available in the event of loss of the
airway or severe vomiting. Patients with IMF should be
recovered and nursed in a high dependency area.
Key references
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Ghouri A, Bernstein C. Use of Bullard laryngoscope blade in patients
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See multiple choice questions 65–68.