Airway considerations

Establishment and maintenance of airway has the highest priority through all phases of prehospital and hospital care. Its management includes the assessment, establishment and protection of the airway along with appropriate oxygenation and ventilation.

Need for emergency management may arise at any time during patient care.

Foreign body
Unstable teeth, artificial implants, or dentures need to be addressed. Preoperative treatment has to be performed in order to remove any objects obstructing the airway.

X-ray examination (neck/chest/abdomen) must be performed when there is doubt regarding the integrity of the dentition or suspicion that other objects are missing.

Procedures to consider during primary care of CMF trauma patients:

• Suction
• Clearing of airway or foreign debris (denture, loose teeth, etc.)
• Tongue position/retraction
• Patient positioning
• Appropriate temporary airway devices
• Temporary stabilization of fractures
• Tracheotomy

The type of airway maintenance during surgery has to be appropriate for the patient and to allow the surgeon adequate operative access. Intubation may be compromised by a severe fracture pattern or inability to open the mouth, in which cases endoscopically guided nasoendotracheal intubation may be the best choice.

The choice of airway during the procedure may also depend on the need for prolonged postoperative stabilization, such as the presence of severe swelling or a compromised level of consciousness. Controlled airway with an endotracheal or tracheotomy tube is required. In the case of an endotracheal tube, several approaches can be considered, such as nasoendotracheal or oral endotracheal or submental/submandibular.

During surgery it is recommended to place a throat pack which must be removed at the end of the procedure.

Consider gastric decompression by placement of a nasogastric tube which may be left in place for postoperative care.

Procedures to consider during postoperative care of CMF trauma patients:

• Suction
• Consider supplemental oxygenation (nasal prongs, masks, etc.)
• Patient positioning
• Appropriate airway devices
• Methods to reduce swelling
  - Nasal decongestants
  - Possible use of steroids
  - Cold packs

Several devices are available to facilitate an adequate airway.

The airway can be compromised from bleeding, swelling, foreign bodies or altered mental state.

Various devices are available to help establish the airway on a temporary or permanent basis. These include:

• Nasopharyngeal airway device

• Oropharyngeal airway device (Guedel airway)

• Cuffed nasoendotracheal tube

• Cuffed tracheostomy tube

After a midface injury and surgery, particularly Le Fort fractures, there is significant mucosal swelling. Postoperatively, the use of antihistamine medication, vasoconstrictor nasal drops, and/or general steroid medication may be helpful as is head elevation following surgery.

The nasoendotracheal tube may be left in place after surgery and/or during intensive care as required until edema and level of consciousness has improved.

Severe edema of the tongue may obstruct the airway.

In moderate cases, a nasopharyngeal airway device will be sufficient. In severe cases, intubation or tracheotomy may be indicated.

Severe facial injury often results in pharyngeal swelling. Edema may result in swallowing dysfunction. Airway narrowing is the result of mucosal, tongue, and pharyngeal swelling.

In moderate cases, a postoperative nasopharyngeal airway device may be beneficial. In severe cases, tracheotomy may be indicated, especially if the patient needs to remain in MMF.

In some cases, the surgeon may choose to leave the arch bars on, and remove the MMF (elastics or MMF wires) for the first few days postoperatively until the facial edema has improved, the patient is more awake, and the airway is better established. In these cases one option may be to place the patient back into MMF for a period of time if as necessary.

Bleeding presents a severe risk to the airway. It may compromise the airway or fill the stomach causing risk of vomiting and aspiration. Increased risk of aspiration exists in patients with altered level of consciousness.

It is important to diagnose the cause of bleeding and control it. A gastric tube may be used to decompress the stomach and reduce the risk of vomiting and aspiration.

If massive bleeding continues, it may be necessary to place an endotracheal airway.

Hemostasis may be obtained with:

• Control of blood pressure
• Vasoconstrictor based nasal decongestants
• Injection of vasoconstrictors
• Anterior and/or posterior nasal packing
• Cauterization
• Selective embolization

In a nontrauma patient a common location for nasal bleeding is from Kiesselbach’s plexus. The surgeon must be aware that nasal bleeding following trauma may be from many other locations including the skull base.

Massive bleeding (not controlled) can be treated by head elevation, ice packs, tamponade using nasal packing, or a balloon device. If massive bleeding is uncontrolled, treatment begins with tamponade. If bleeding persists after removal of the tamponade, electrocoagulation might be helpful. Sometimes, massive bleeding is controlled using anterior and posterior packing (eg, Belloque tamponade, the balloon of a Foley catheter, or other balloon devices specifically designed for nasal tamponade). Proper positioning of packing is essential.

Adequate positioning of the patient has to be maintained.

Laryngeal trauma is often overlooked, and should be considered in any patient who has sustained severe facial trauma.

Laryngeal trauma should be suspected in any patient who has pain, swelling, ecchymosis, and/or subcutaneous emphysema over the laryngeal area. It is seldom the main complaint, and is often a subtle physical finding relative to the other obvious injuries to the face. Air within the tissues may be noticed on CT examination.

Laryngeal trauma commonly occurs from blunt trauma to the larynx. It can also be seen in patients following an event of strangulation or attempted hanging.

It may or may not be associated with a laryngeal fracture.

This case example shows a laryngeal fracture on the right side.

The patient may present with an inadequate airway. The injury may be associated with a laryngeal hematoma, making intubation difficult or impossible. An emergency cricothyroidotomy/coniotomy is possible in some circumstances. One risk of cricothyroidotomy/coniotomy is that the procedure is often performed through the zone of injury and of severe swelling and hematoma, resulting in significant bleeding and complete loss of the airway. Most surgeons would therefore recommend a tracheotomy (establishing the airway inferior to the zone of injury and swelling) rather than an emergency cricothyroidotomy/coniotomy if a significant laryngeal fracture is suspected.

Airway may be compromised in patients in (mandibulomaxillary fixation) MMF. In addition to this, vomiting or a low Glasgow coma score (GCS) can result in further airway problems. To solve this problem, should it occur, the MMF must be released. For patients at risk, adequate internal fixation may obviate the need for MMF.

Note: care must be taken to be prepared for emergency release of MMF if airway problems arise.

There are two modes of nasal intubation:

1) During operation

The tube is inserted into the trachea and, once it is in place, the cuff is adequately pressurized to seal the trachea. The tube needs to be fixed in place. This can be done by suturing to the nasal septum (recommended in fracture repair) or by taping it to the nose and cheek area.

2) Postoperatively

If this tube is used postoperatively the cuff is released and pressurized again every 2–3 hours.
In this mode, saliva suction is necessary from time to time.

In some cases, a tracheotomy may be necessary.

A cannula is inserted into the trachea and stabilized with a tracheotomy tie and suture.

It is necessary that the secretions are suctioned frequently. Proper skin care is also essential.