Airway Management for Oral and Maxillofacial Surgery

James F. Mayhew, MD, FAAP

Since the initial reports of Tessier,1 the area of craniofacial surgery has increased dramatically, with multiple centers reporting their experiences.25 The success of these surgeries depends on the close cooperation of the anesthesiologist and the surgeon.68 This discussion will focus on the anesthetic care of these patients, with particular attention to airway management.

Preoperative Evaluation
The first step in the successful management of these complex patients is the preoperative evaluation. It is during this preoperative visit that the anesthesiologist 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 in appearance, increased satisfaction with self-image, emotional improvement, and better school performance.11,12 Inquiry should be made about previous anesthetic and surgical experiences, and previous hospital records that include the anesthetic records should be reviewed. It is particularly important to review x-rays and any notes that pertain to the airway, since up to 37% of patients will have airway problems.13 Patients with craniofacial dysostosis such as Aperts syndrome and Crouzon syndrome and those with mandibular dysostoses such as Treacher Collins syndrome, Goldenhar syndrome, and hemifacial microsomia had a 53% incidence of airway difficulties.13

Physical Evaluation
Physical examination of the airway should include the size and shape of 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 and shape of the tongue as well as the size and shape of the palate should be noted. Anomalies of the neck such as cervical fusion are common in children with Goldenhar, Apert, and Crouzon syndromes; therefore, neck mobility should be evaluated, since inability to extend or flex the neck may interfere with airway management.15,16 In children with Goldenhar syndrome, particular attention should be paid to the cardiovascular system, since 50% of these children have congenital heart disease, tetralogy of Fallot being the most common lesion.17

Preoperative Medication
Preparation for surgery in the pediatric patient with craniofacial anomalies 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 midazolam has become the mainstay of pediatric premedication. The use of 0.5 mg/kg orally 15 to 30 minutes prior to induction helps with separation from 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 or syndrome and on any previous anesthetic management. In a retrospective review of the airway management from a major center for craniofacial surgery, 20% of patients required a tracheostomy. In children with craniofacial synostosis (Crouzon, Pfeiffer, or Apert syndrome), 48% required a tracheostomy, and 41% of children with mandibulofacial dysostoses (Treacher Collins or Nager syndrome) required a tracheostomy.20 In another 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 maxillary retrusion, and two were required in the postoperative period.13 However, in one review no mention was made of the need for a tracheostomy.7 With the advent of the laryngeal mask airway21 and the ultrathin bronchoscope,22 the incidence of tracheostomy should decrease dramatically. Planning the induction for children with potential airway problems must include several alternative techniques. Several types and sizes of laryngoscope blades and various sizes of endotracheal tubes should be readily 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 Goldenhars, Treacher Collins, and Pfeiffer syndromes.23 The use of the anterior commissure scope has been described in a child with mandibular hypoplasia.24 Although there are many reports in the literature about techniques for intubating children with difficult airways,25 the laryngeal mask airway21 and the ultrathin fiberoptic bronchoscope22 have been major advancements in the management of the difficult airway. Basic techniques have been described using an inhalation induction with halothane and more recently with sevoflurane.26,27 The use of newer anesthesia masks that are clear and have soft, air-filled face cushions are a great aid in obtaining a good seal. Occasionally, in children with severe hypertelorism, inverting the mask may be advantageous. After the child is safely under anesthesia and 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% lidocaine around the arytenoid cartilage and vocal cords,28 an oral tracheal intubation may be accomplished with or without use of a muscle relaxant. Most operations for major reconstruction of craniofacial defects can be managed with oral endotracheal tubes. The RAE endotracheal tube allows for a low-profile airway for procedures on the cranium and maxilla.29 These tubes may be secured with tape for less involved surgery, sutured to the tongue with heavy suture or wired to the lower teeth when more extensive surgery is involved. Use of the laryngeal mask airway21 in the pediatric patient has increased 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.3235 Whether 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 of clinical signs,36 a fiberoptic bronchoscope with a proper-size endotracheal tube37 is passed through the glottis until the carina is visualized. The endotracheal tube is then advanced through the laryngeal mask airway into the trachea. The position of the endotracheal tube is then confirmed above the carina and the fiberoptic scope is removed. Because the endotracheal tube is not long enough to remove the laryngeal mask airway without dislodging the endotracheal tube, there have been techniques suggested for safe removal of the laryngeal mask airway.37,38 I have modified the technique suggested by Reynolds.39 An endotracheal tube onehalf size smaller than the first endotracheal tube is inserted into the end after the connector is removed. The anesthesia circuit is connected to the tubes and the patient is either ventilated or permitted to breathe spontaneously 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. The second tube is then disconnected and the connector is reattached to the first tube, which is then reconnected to the anesthesia circuit.14,39 The advantage of this method is that it permits continuous ventilation and monitoring of the end-tidal carbon dioxide during the removal of the laryngeal mask airway. The endotracheal tube is then secured as previously described. For children with difficult airways or with a history of difficult intubations, either awake fiberoptic intubation or fiberoptic intubation once a satisfactory level of anesthesia is reached is the first option. With older children who can cooperate, judicious sedation with midazolam and fentanyl or ketamine40 are options. As sedation is achieved, the airway is anesthetized either with intermittent spraying of the posterior portion of the tongue and oropharynx or with nebulization of lidocaine.41 Oral tracheal fiberoptic intubation under general anesthesia may be difficult in both children42 and adults, with failure rates as high as 25%.4345 If one is faced with a failed fiberoptic intubation, there is a recent report of the successful use of the light wand for both oral and nasal intubation after failed fiberoptic bronchoscopy.46 If the nasal route is used, the nasal airway may be anesthetized using cocaine-soaked pledgets or 4% lidocaine. The use of topical vasoconstrictors, particularly phenylephrine, in the pediatric patient has been questioned.47 Care must be taken, particularly in children who may have had an uneventful anesthetic course, who have undergone cleft palate or pharyngeal procedures.4850 In children with congenital heart disease, preoperative oral or intravenously administered antibiotics are given as guided by the American Heart Association recommendations.51 The antibiotics must be given prior to the intubation sequence since bacteremia has been reported with nasal intubations.52,53 For mandibular and maxillary surgery, which will require intraoral fixation, nasotracheal intubation is the preferred airway.54 Although mandibular surgery is usually done on healthy young adults and presents little difficulty in airway management, maxillary surgery may be done on the patient who has undergone procedures on the palate and may present a problem with placement of the nasotracheal tube.50 In these patients a small suction catheter may be passed as a guide and a larger endotracheal tube may be passed with little trauma to the pharyngeal flap.54 The use of the ultrathin fiberoptic bronchoscope can also help in this situation. A technique for atraumatic pediatric nasotracheal intubation is to place a red rubber catheter over the endotracheal tube. This is accomplished by placing the flared end of the catheter over the end of the endotracheal tube, which then presents a noncutting surface to the nasal mucosa.55 Older patients may be induced using intravenous drugs. The nose can be 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 is to be used. Following endotracheal intubation, the endotracheal tube may then 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 osteotomies, particularly in patients with cleft lip or palate, and the surgical plan involves simultaneous procedures, the tube can be placed behind the maxillary 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 frequently. These problems may be prevented by good humidification of the anesthesia 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 bleeding is expected or there is a leak around the endotracheal tube. Kinking of the endotracheal tube may be prevented with the use of the armored reinforced tube. More serious complications such as extubation and cutting of the endotracheal tube or the pilot tube have been described.56,57 The endotracheal tube may be moved higher in the trachea with possible extubation with either extension of the head or maxillary advancement.6

Facial Trauma
Facial injuries can be as straightforward as multiple lacerations, a fractured nose, or a fractured mandible, with little or no airway compromise, to the more serious panfacial injuries 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 airway obstruction. Even in severe facial trauma, the airway may be controlled with endotracheal intubation if done at the scene of the accident before swelling and obstruction occur.58 Neck injuries must always be assumed and care must be taken not to hyperextend or hyperflex the neck during endotracheal intubation. During the endotracheal intubation sequence, the head and neck must be maintained in the neutral position by an assistant. Because basilar skull fractures may also present in severe facial trauma, nasotracheal intubation or the placement of a nasogastric tube should not be done. Penetration injuries may also present with airway compromise and a difficult endotracheal intubation.59,60 In these cases an awake 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 tracheostomy during surgical correction and reconstruction in patients with panfacial trauma have led to suggestions for unique placement of the endotracheal tube.58 These authors suggest a submandibular placement of the endotracheal tube, thus avoiding a tracheostomy. However, I believe that such a procedure as described appears to be more complicated, with the potential for more airway difficulties, than a well-conducted tracheostomy.

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 encountered during induction, the type of surgery (such as intermaxillary fixation after midface advancement), and the potential for bleeding or severe airway edema.6 Usually the endotracheal tube is left in place for 24 to 48 hours. In the occasional case, extubation may be done in the operating room.6 If there is concern about airway edema, dexamethasone can be given IV prior to extubation.61,62 The American Society of Anesthesiologists Task Force for the Management of the Difficult Airway have set forth guidelines for extubating patients with a difficult airway.63 One of the suggestions is the use of a device over which the endotracheal tube is removed, such as a fiberoptic bronchoscope, a jet stylet, or a gum-elastic bougie.6466 Because these devices may not be suitable in the very small infant, the use of a guide wire from the Cook airway exchange catheter (CAEC) (Cook, Inc., Bloomington, IN) has been described.62 This guide wire is 0.018 and permits the use 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 a difficult airway has proven useful in a number of reports.6668

References
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57. Patel C, Cotton S, Trundorf H. Letter to the editor. Partial severance of an oronasotracheal tube during LeFort I procedure. Anesthesiology 1980;53:357 58. Stoll P, Galli, Wachter R, Bahr W. Letter to the editor. Submandibular endotracheal intubation in panfacial fractures. J Clin Anesth 1994;6:8386 59. Melillo EP, Hawkins DJ, Lynch L, Macnamara A. Difficult airway management of a child impaled through the neck. Paediatr Anaesth 2001;11:615617 60. Bullingham A, Hampson-Evans D, Palazzo M. An impaled neckmanagement of difficult airway access. Anaesthesia 1994;49:866869 61. Darmon JY, Rauss A, Dreyfuss D, et al. Evaluation of risk factors for laryngeal edema after tracheal extubation in adults and its prevention by dexamethasone. Anesthesiology 1992;77:245251 62. Hammer GB, Funck N, Rosenthal DN, Feinstein A. A technique for maintenance of airway access in infants with a difficult airway following tracheal extubation. Paediatr Anaesth 2001;11:622625 63. Caplan RA, Benumorf JL, Berry FA, et al. Practice guidelines for management of the difficult airway. A report by the American Society of Anesthesiologists Task Force for the Management of the Difficult Airway. Anesthesiology 1993;78:597602 64. Dellinger RP. Fiberoptic bronchoscopy in adult airway management. Crit Care Med 1990;18:882887 65. Bedger RC, Chang JL. A jet-stylet endotracheal catheter for difficult airway management. Anesthesiology 1987;66:221223 66. Robles B, Hester J, Brock-Utne JG. Remember the gum-elastic bougie at extubation. J Clin Anesth 1999;5:329331 67. Cooper RM. The use of an endotracheal ventilation catheter in the management of difficult extubations. Can J Anaesth 1996;43:9093 68. Loudermilk EP, Hartmannsgruber M, Stoltzfus DP, et al. A prospective study of the safety of tracheal extubation using a pediatric airway exchange catheter or patients with a known difficult airway. Chest 1997;111:16601665