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PERIOPERATIVE ANESTHETIC
MANAGEMENT OF
MAXILLOFACIAL TRAUMA
INCLUDING OPHTHALMIC
INJURIES
Vance E. Shearer, MD, Jess Gardner, MD, DMD,
and Mark T. Murphy, MD

ANESTHETIC MANAGEMENT OF PATIENTS WITH

MAXILLOFACIAL TRAUMA

Traumatic injuries to the maxillofacial region are of utmost concern to

anesthesiologists, considering their intimate association with the airway, The
complex anatomy of the cervicomaxillofacial region and the plethora of-injuries
that can occur, each with its own impact on anesthetic management, necessitate
that anesthesiologists have a working knowledge of the anatomy, types of
injuries, and their impact on care.

Maxillofacial Anatomy

Classically, the facial skeleton has anatomically been divided into thirds:
lower, middle, and upper. The lower third corresponds with the mandible and
associated structures; the middle third consists of the maxilla, zygomatic, orbital,
and nasal complexes; and the upper third encompasses the frontal bone and cra-
nium.

From the Department of Anesthesiology and Pain Management (VES, MTM) and the
Division of Oral and Maxillofacial Surgery, Department of Surgery (JG), The Univer-
sity of Texas Southwestern Medical Center at Dallas, Dallas, Texas

~~

ANESTHESIOLOGY CLINICS OF NORTH AMERICA

VOLUME 17 NUMBER 1 * MARCH 1999 141

142 SHEARER et a1

Lower Third
The mandible is commonly injured in facial trauma, with studies demonstra-
ting involvement in as many as 66% of cases.3 It is made up of six regions:
symphyseal, body, angle, ramus, condylar, and coronoid process. A study of
facial trauma by a large urban hospital showed that fractures of the body of the
mandibula are the most common (30%), followed by the angle and condyle,
sustaining injury in 21% and 19% of cases, respe~tive1y.l~

Middle Third and Upper Third

The middle third of the facial region is composed of nine bones, chief
among which are the maxilla, zygoma, and the bones that comprise the orbital
and nasal complexes. Fractures of the middle third were classically described by
LeForte in his experiments with cadaver skulls.'* Three major fracture patterns
were identified (Fig. 1);however, most such patients present with various combi-
nations of these patterns. The upper third consists of the frontal bone and
the cranium.

COEXISTING COMPLICATIONS

Airway Compromise

A patent airway should be immediately ensured or established. Fractured

teeth, foreign bodies, and blood should be cleared from the oral cavity (Table 1).
All fractured teeth should be accounted for because tooth fragments may have
been aspirated. Secondly, attempts to inhibit bleeding should be undertaken.
Intraoral lacerations of the floor of the mouth and the tongue, severely displaced
open mandibular fractures, and epistaxis from midface trauma are common
sources of hemorrhage. Attempts at control of the bleeding include direct pres-
sure, acute reduction of fractures, and placement of nasal packs or nasal airways.
Although they may bleed profusely, tongue injuries can also result in significant
edema that may completely obstruct the oropharynx, making ventilation and
intubation difficult or impossible.
Certain fractures of the facial skeleton have been associated with airway
compromise. Bilateral condylar fractures with a symphyseal fracture or a bilat-
eral body fracture of the mandible may cause loss of support of the glossal and
suprahyoid musculature, thereby allowing the soft tissues to fall posteriorly,
obstructing the oropharynx. This may be relieved by pulling the mandible
anteriorly. Significant LeForte fractures displaced in a posteroinferior direction
may cause airway obstruction. Finally, nasal fractures with deviation of the nasal
septum may prohibit nasal intubation.

Laryngeal Injuries

Laryngeal injuries are associated with hoarseness, stridor, laryngeal crepitus,

radiographic evidence of subcutaneous air, and the inability to make high-
pitched sounds. Extreme caution must be used if intubation is performed be-
cause an exacerbation of the injury may occur. Therefore, blind techniques at
intubation are not indicated. A surgical intubation technique must be strongly
considered in these instances and at least on ready standby with a high probabil-
 PERIOPERATIVE ANESTHETIC MANAGEMENT OF MAXILLOFACIAL TRAUMA 143

Figure 1. The classic facial fractures as described by LeForte.”

ity for activation of this contingency plan.8 If the laryngeal fracture is displaced,
then a surgical airway with the patient under local anesthesia is indicated. In
the event of a coexistent tracheal injury, the endotracheal tube (ETT) cuff must
be distal to the site of injury to avoid barotrauma. This is best accomplished by
direct vision with the aid of a fiberoptic bronchoscope.
Table 1. COEXISTING COMPLICATIONS
Fracture Malocclusion Oral Bleeding Airway Compromise Trismus Pneumocephalus Cervical Spine Injury
Mandible + f f + - f
LeForte I + f * * - f
LeForte I1 + f f -r- f f
LeForte 111 + f f f f f
Zygomatic - - - f - f
Frontal - - - - f -c
Laryngeal - f + - - *
+ ,Common; f ,possible; - ,unlikely.
 PERIOPERATIVE ANESTHETIC MANAGEMENT OF MAXILLOFACIAL TRAUMA 145

Trismus

Trismus, or difficulty in opening the mouth, is associated with several

injuries to the maxillofacial region. Injuries to the mandible may cause trismus
and in acutely injured patients is usually secondary to muscle spasm and pain
on opening. Once the patient is sedated or anesthetized, the mouth can usually
be opened with minimal difficulty. After several days, oral opening may be
restricted secondary to edema, scarring, or infection, necessitating an awake
intubation technique. Injuries to the temporomandibular joints and intracranial
displacement of the condyle, although not common, may also restrict opening.
Finally, zygomatic arch fractures that are significantly depressed may cause
mechanical interference with the coronoid process of the mandible.

Cervical Spine Injuries

It must be assumed that all patients with maxillofacial injuries also have
cervical spine injuries. The incidence ranges from 10% to 15% in patients with
traumatic facial injuries. Lewis et all3 found that 19.3% of patients with cervical
spine injuries also had facial injuries. They also found a relationship between
mandibular fractures and fractures of the upper cervical spine and facial soft
tissue injuries with fractures of the lower cervical spine. Therefore, all necessary
cervical spine precautions should be taken in patients who have not had clinical
or radiographic clearance of their cervical spines.

Pneumocephalus

Fractures through the posterior table of the frontal sinus with dural tears
and LeForte I1 and 111 fractures are all associated with pneumocephalus. There-
fore, the use of nitrous oxide is best avoided.

PERIOPERATIVE MANAGEMENT

Preoperative Evaluation

A thorough preoperative evaluation requires the luxury of time, which is

usually not available in severely traumatized patients. An effective method of
evaluating severely injured patients is to follow the "ABCs" of the primary
survey of Advanced Trauma Life Support protocolzof the American College of
Surgeons. Once the ABCs are evaluated and managed, then the secondary
survey, which includes the history and physical examination, laboratory results,
and radiologic findings, can be completed. Because some patients with maxillo-
facial trauma present with distracting, grotesque deformities and tenuous air-
ways, this method d o w s for rapid systematic evaluation and treatment. An
understanding of common coexisting injuries (see Table l),mechanisms of injury,
causes of airway obstruction, and communication with the surgeon complete
this plan. Causes of airway obstruction include:
Foreign material, vomit, bone, teeth
L=Y%-P-
Biman- fracture
146 SHEARERetal

Edema
Laryngeal fracture
Tracheal deviation
Hemorrhage
Loss of structural support

INTRAOPERATIVE MANAGEMENT

Airway Management

Airway obstruction is the leading cause of death in patients with craniocer-

vicofacial traumalo (see also article by Thierbach and Lipp, this issue). Patients
with maxillofacial or airway trauma admitted to level 1 trauma centers have
been reported to have a 24% to 35% incidence of difficulty with airway manage-
ment requiring emergent trache~stomy.~,Kelly et alBreported that 21% of
patients with airway injuries died within the first 2 hours of admission. There-
fore, signs and symptoms of airway obstruction should be immediately and
continuously evaluated. The trachea should be carefully palpated for midline
position and crepitus and auscultated for subtle stridor with a stethoscope.
When successful intubation of the trachea is questionable, it is wise to have
a qualified surgeon at bedside and worth remembering that many surgeons
actually have little practical experience in establishing a ”rescue surgical airway”
under emergency conditions. It is equally as prudent to have emergency airway
equipment immediately available, and the authors strongly suggest that an
emergency airway cart be kept stocked and available. The equipment on the
cart should include:
Tracheostomy tray
Percutaneous cricothyroidectomy kit (Cook Critical Care)
Retrograde intubation kit (Cook Critical Care)
Tracheal tube introducer, Eschmann stylet “gum elastic bougie
ETT changer with jet ventilation capability
Sanders jet ventilator
Laryngeal mask airways
Combitubes
Fasttrach (intubating laryngeal mask airway)
Key concepts for managing the airways of trauma patients are: (1) protect
the airway from the full stomach, (2) do not create a situation from which retreat
is impossible, and (3) have a valid backup plan. Some patients with maxillofacial
trauma cannot be ventilated by bag-valve-mask either because of displacement
of the bony framework of the face, edema, or the risk of forcing infectious
material into a basilar skull fracture.9 If such patients are administered neuro-
muscular blocking agents or excessive sedation, options are limited if tracheal
intubation fails. Overconfidence in one’s ability to intubate the trachea is espe-
cially hazardous in this patient population.

Orotracheal lntubation

Orotracheal intubation is usually the technique of choice with isolated

midface fractures. If hemorrhage is excessive, distortion is significant, or a
 PERIOPERATIVE ANESTHETIC MANAGEMENT OF MAXILLOFACIAL TRAUMA 147

mandibular fracture is impinging on the coronoid process, then an awake surgi-

cal airway with the patient under local anesthesia is a good alternative. If in
doubt, a sound approach before the induction of general anesthesia is to attempt
an awake visualization via direct laryngoscopy after topicalization of the airway;
however, this technique can be difficult or impossible in uncooperative or intoxi-
cated patients. When time permits, the authors also recommend premedication
with metaclopramide, 10 mg intravenously (IV); sodium citrate dihydrate, 30
mL orally; glycopyrrolate, 0.2 mg IV; and an H,-blocker, such as ranitidine, 50
mg IV. Adequate preoxygenation is essential and can buy valuable time if
intubation proves difficult. Acutely traumatized patients require a rapid se-
quence induction with cricoid pressure and usually manual inline axial stabiliza-
tion. It is equally as important to have adequate suction to clear blood and
secretion from the airway for visualization. If the airway is difficult and is clear
of blood and secretions, then an oral fiberoptic technique may be a good
alternative when time permits.

Nasotracheal lntubation

Nasotracheal intubation is usually the technique of choice for stable, less

emergent patients with mandibular fractures or immobility of the jaw either
from trismus or mechanical impairment of the temporomandibular joint. Unless
no other method of establishing an emergency airway exists, nasotracheal intu-
bation is contraindicated for patients with a basilar skull fracture because of the
possibility of placing the ETT or contaminated material into the subarachnoid
space.9,l7 The authors also do not recommend blind nasotracheal techniques for
patients with penetrating neck or laryngeal trauma because stimulation by the
ETT may result in significant hematoma formation and loss of the airway or the
creation of a false tissue passage.'8
Nasotracheal intubation can be performed either blindly or over a fiberoptic
bronchoscope in awake or anesthetized patients. With adult patients in the acute
setting, awake techniques are strongly recommended. For patient comfort and
to improve the success rate, the airway should be adequately anesthetized.
Anesthetizing the lower airway in patients with a full stomach is best avoided;
however, anesthesia of the trachea may be desirable in such patients with
concomitant cervical spine injuries who require a neurologic examination after
intubation. For this purpose, the authors have found that the administration of
2 mL or 3 mL of nebulized lidocaine 4% over approximately 10 minutes allows
patients to comfortably accept passage of the ETT into the trachea. Most patients
also require some modest sedation, which must be administered with great
caution, considering the full stomach and tenuous airway. Patients should re-
main awake and cooperative throughout the intubation process, which can be
accomplished by administering incremental doses of fentanyl, 10 p,g IV; midazo-
lam, 0.5 mg IV; or droperidol, 0.625 p,g IV.
Because nasotracheal intubation is well described elsewhere (see article by
Thierbach and Lipp, this issue), the authors offer only a few suggested tech-
niques that apply to hemodynamically stable patients not in need of an immedi-
ate airway:
1. Before intubation, determine the path of least resistance by having the
patient breathe through each nostril.
2. Ensure that the nasal passage is well prepared with a vasoconstrictor
and a topical anesthetic, which requires approximately 10 to 20 minutes
to accomplish.
148 SHEARERetal

3. To minimize trauma, the tip of the ETT can be softened in warm, sterile
water.
4. A suction catheter through the ETT helps to guide the tube through the
turbinates and reduce trauma. A fiberoptic bronchoscope is also suitable
for this purpose.
5. A BAAM whistle (Beck Airway Airflow Monitor, Great Plains Ballistics,
Inc., Lubbock, TX)is helpful to guide the ETT in proximity to the glottic
opening during blind or fiberoptic intubation.
6. Inflating the ETT cuff may help lift the tube anteriorly into the airway.
7. Before the induction of general anesthesia, the ETT must be secured and
placement confirmed by capnography and auscultation.

Retrograde lntubation

Because of its apparent invasiveness, retrograde intubation techniques have

not gained wide acceptance. Anesthesiologists should, however, be familiar with
this technique because it can be useful in several clinical situations, including
maxillofacial trauma, spinal cord injury, ankylosing spondylitis, and other diffi-
cult airways. Barriot and Rioul described 13 patients with severe maxillofacial
trauma in the prehospital setting who could not be intubated with direct laryn-
goscopy after multiple attempts but were subsequently intubated on the first
attempt with the retrograde technique. Although the necessary equipment to
perform retrograde intubation can be found in a standard epidural tray, the
authors recommend the commercially prepared kits by Cook Critical Care (El-
lettsville, IN). This technique is well described in the book Aivulay Munugement.16
An added advantage of this technique is that a retrograde wire passed through
the suction port of the fiberoptic bronchoscope may guide the scope into the
trachea if flexible fiberoptic bronchoscopy is not possible either because of
anatomy, blood, or secretions. If the ETT hangs up at the glottic opening, the
tube is rotated 90" or the guide wire is threaded through the Murphy eye instead
of the end of the tube. The authors have used this technique successfully;
however, two failures have occurred, both in patients with significantly deviated
tracheas and greatly distorted edematous airways. Although this technique
is relatively safe, complications, such as bleeding, subcutaneous emphysema,
pneumomediastinum, and pneumothorax, have been reported. With this tech-
nique, if the catheter used to introduce the J-wire is left in place, one can convert
to transtracheal jet ventilation (TI'JV) or use the J-wire for a percutaneous
cricothyroidotomy.

Transtracheal Jet Ventilation

The fear of every anesthesiologist is the inability to intubate and ventilate

an hypoxic patient, even with a laryngeal mask airway or combitube. When a
properly experienced surgeon is not immediately available and the anesthesiolo-
gist is either inexperienced, untrained, or uncomfortable with performing a
surgical airway technique, then lTJV can be a life-saving alternative. Because
this technique is well described elsewhere)6 the authors offer only a few sugges-
tions:
1. when administering W, have oral and nasal airways in place to main-
tain a patent upper airway. lTJVof patients with completely obstructed
upper airways results in significant bamtrauma.
 PERIOPERATIVE ANESTHETIC MANAGEMENT OF MAMLLOFACIAL T R A M 149

2. Take the time to locate the cricothyroid membrane or the trachea and, if
time permits, confirm proper placement of the needle by aspirating air
through a fluid-filled syringe.
3. Once the catheter is in place, strictly maintain its position manually
because a misplaced catheter can result in barotrauma or subcutaneous
emphysema, thus making a subsequent surgical airway technique diffi-
cult or impossible to obtain.
4. Continuously watch the chest rise with each inspiration and listen for
exhalation.
5. After each second of inspiration, allow 2 seconds for expiration.
6. Do not cease ventilation until a more definitive airway is established.

Surgical Techniques

Occasionally, some patients with maxillofacial injuries require tracheostomy

for airway management. These indications include:
Laryngeal fractures
Extensive gunshot and shotgun injuries to the face
Extensive injury to the tongue of the floor of the mouth
Combined LeForte and mandibular fractures
Massive facial injuries
Massive hemorrhage
Concomitant cervical spine injuries with laryngeal edema (stridor)
Airway burns
Inability for timely translaryngeal intubation for any reason (e.g., mechanical
obstruction, or inability to visualize)
If an immediate surgical airway is necessary in an adult, then a cricothy-
roidotomy is the technique of choice. For less emergent indications, tracheos-
tomy with the patient under local anesthesia is usually well tolerated. Although
anesthesiologists do not routinely perform cricothyroidotomies, they should
be familiar with this technique if the need arises. This is especially true for
anesthesiologists working routinely with seriously injured patients, particularly
in nonteaching facilities. As experience indicates, anesthesiologists often find
themselves alone at night, without a surgeon, during much of the "golden
hour." Percutaneous cricothyroidotomy kits are available (e.g., Cook Critical
Care), and the authors recommend that they be included in the emergency
airway cart and that practitioners become familiar with their use.
Because multitrauma patients have little ventilatory reserve, they experience
rapid decreases in oxygen saturation if their airways become obstructed. Once
it is apparent that such a patient cannot be intubated or ventilated by standard
means, including an LMA or combitubes, then a cricothyroidotomy should be
attempted sooner rather than later. Risks of emergency surgical cricothyroido-
tomy include:
Unsuccessful attempt
Hemorrhage
Pneumothotax
Esophageal injury
Laryngeal injury
Vocal cord injury
Passage of ETT into false passage
150 SHEARER et a1

Subcutaneous emphysema
Tracheal stenosis
Dysphonia
Aspiration
McGill et all5 reported a 33% complication rate for emergency surgical
cricothyroidotomiesperformed in the emergency department. The benefit of this
procedure is a life-saving airway.
Because this technique is described in standard surgical texts in detail, the
authors offer only a few suggestions:
1. Keep calm.
2. Take a few seconds to properly locate the cricothyroid membrane; often,
the operator does not correctly identify the space, and this is the “begin-
ning of the end.”
3. With the nonoperative hand, place the thumb and index finger 1 cm
apart, affix the skin over the cricoid membrane, and do not move it until
the trachea is secure.
4. Make the initial skin incision vertically to separate the tissue at the
operative site and substantially minimize bleeding. Then make a hori-
zontal incision through the cricothyroid membrane.
5. Be careful with this incision to avoid perforating the posterior tracheal
wall or the esophagus.
6. Once the trachea is located, have an assistant hold a hemostat, tracheal
hook, or other instrument in the airway to secure it until the trachea is
intubated.
7. A size 6.0 ETT is suitable for intubation. Caution is necessary to avoid a
mainstem intubation.

Special Considerations

Self-Inflicted Shotgun Injuries

Some patients will have attempted suicide by firing shotguns under their
chins (Fig. 2). These injuries cause devastating trauma by removing the mandible
and maxilla and totally destroying the upper airway. Because of hemorrhage
and loss of structural support, these patients often cannot lie supine and should
be positioned either upright or in the lateral position. Although an immediate
surgical airway is a good option, using direct visualization without a laryngo-
scope, one can usually see air bubbles or spraying blood and identify the
trachea. It should be secured with a hemostat or a finger and successfully
intubated.

Ophthalmic Trauma
Another important special consideration is the management of patients with
penetrating ophthalmic trauma. If surgical repair is necessary, then these patients
usually require a rapid sequence induction even after an 8-hour fast because the
pain of injury and the opioids given for that pain may delay gastric emptying.
The chief concern is a potential increase in intraocular pressure (IOP) during
induction and intubation. The use of succinylcholine remains controversial be-
cause of the potential increase in IOP primarily from contraction of the extraocu-
lar muscles with fasciculation. A defasciculating dose of a nondepolarizing
 PERIOPERATIVE ANESTHETIC MANAGEMENT OF MAxnLOFACIAL TRAUMA 151

Figure 2. A typical shotgun wound to the face.

relaxant administered 3 to 5 minutes before induction tends to blunt this increase

in IOP. No cases of expelling aqueous humor have been reported with this
technique.14If the airway is not difficult, then a good alternative to succinylcho-
line is rocuronium.Using the priming technique, rocuronium, 0.06 mg/kg IV, is
administered before induction then followed during induction with a dose of
0.6 mg/kg IV. This allows for good or excellent intubating conditions within 60
seconds? Alternatively, using higher doses of rocuronium, 0.9 to 1.2 mg/kg IV,
in adequately anesthetized patients permits good to excellent intubating condi-
tions in approximately 1minute and avoids complications associated with prim-
ing.

lntraoperative Management

Most patients with isolated maxillofacial trauma do not require emergent

surgery unless signlflcant hemorrhage or airway compromise is present; there-
fore, most techniques and drugs for induction and maintenance of anesthesia
are acceptable as long as the airway is easily secured. Nitrous oxide is best
avoided when the potential for a pneumothorax or pneumocephalus is present,
as with a midface fracture, or if sulphur hexaflouride has been injected to repair
a retinal detachment. Etomidate, which may cause myoclonus, and ketamine,
which can cause increased IOP, are also best avoided with isolated open-globe in-
juries.
Intraoperative fluid management should be titrated to have adequately
hydrated patients with stable vital signs and urine outputs of 1 mL/kg/h.
Overhydration should be avoided, however, to minimize excessive edema. A
hypotensive technique may be considered in adequately hydrated, hemodynami-
152 SHEARER et a1

cally stable patients to minimize blood loss during surgical repair of extensive
maxillofacial injuries. Appropriate invasive monitoring should be used for the
type of injury and medical status of the patient.

Emergence and Extubation

Patients with maxillofacial or ophthalmic injuries require a smooth emer-

gence and the ability to maintain their open airways at extubation. The decision
to extubate the trachea is always a clinical judgment; “when in doubt, don‘t
take it out.” Many patients have extensive injuries, long surgical procedures,
and significant airway edema. In these situations, the ETT should be left in place
postoperatively until patients are awake with return of airway reflexes, and the
degree of tissue swelling can be evaluated.
When intermaxillary fixation is applied, a wire cutter should be taped to
the patient’s chest in the event of airway obstruction. Before extubation, the
patient should be well oxygenated, the airway and stomach cleared of blood
and secretions, and a nasopharyngeal airway placed in the patient’s nostril. It is
the authors’ practice to then pass a suction catheter or ETT changer several
centimeters beyond the tip of the ETT and insufflate oxygen 1 or 2 L/min. Then,
the ETT is withdrawn into the pharynx while the catheter insufflating oxygen
remains in the trachea. The patient’s respiration is observed for a few minutes,
and if respiratory difficulties occur, reintubation is usually simple using the
existing catheter or tube changer as a guide. If no respiratory difficulties arise,
the airway is suctioned and the patient is extubated.

SUMMARY

Anesthetic management of patients with maxillofacial trauma can stress the

abilities of the most seasoned trauma anesthesiologists. These injuries are all in
proximity to, and often directly affect, the airway. Teamwork with the surgeons
and emergency room physicians, a sound plan, and a backup plan are essential.
There are no “best ways” to manage these patients; the authors have only
suggested some techniques that have proven successful in their practice. A wise
approach when managing these cases is to exercise extreme caution and to have
adequate materials and manpower to maximize care.

References

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Address reprint requests to

Vance E. Shearer, MD
Department of Anesthesiology and Pain Management
The University of Texas Southwestern Medical Center at Dallas
5323 Harry Hines Blvd.
Dallas, TX 75235-9068