Overview
Definition:
Airway control in maxillofacial trauma refers to the immediate management and maintenance of a patent airway in patients with injuries to the face, jaw, and surrounding structures, which can compromise breathing.
Epidemiology:
Maxillofacial trauma is a significant cause of morbidity and mortality, with airway compromise occurring in a notable percentage of severe cases, particularly those involving the midface or mandible
Road traffic accidents are the leading cause, followed by assaults and falls.
Clinical Significance:
Failure to secure and maintain an airway in maxillofacial trauma can lead to rapid hypoxia, brain damage, and death
Prompt and appropriate airway management is paramount for patient survival and minimizing long-term neurological sequelae, making it a critical skill for surgeons preparing for DNB and NEET SS examinations.
Clinical Presentation
Symptoms:
Difficulty breathing
Noisy breathing (stridor, gurgling)
Cyanosis
Inability to speak
Feeling of suffocation
Gagging or choking sensation.
Signs:
Retractions of accessory muscles of respiration
Nasal flaring
Tracheal deviation
Presence of blood or foreign bodies in the airway
Soft tissue swelling of the face and neck
Oral or nasal bleeding
Inability to manage secretions
Palpable facial or mandibular fractures.
Diagnostic Criteria:
There are no formal diagnostic criteria
diagnosis is primarily clinical based on signs of airway obstruction and the presence of maxillofacial injuries
The primary assessment follows the ABCDE approach (Airway, Breathing, Circulation, Disability, Exposure).
Diagnostic Approach
History Taking:
Mechanism of injury (blunt vs
penetrating, forces involved)
Speed of onset of symptoms
Previous airway issues or surgeries
Co-existing injuries (e.g., cervical spine)
Allergies
Medications.
Physical Examination:
Assess for patency and listen for breath sounds
Look for facial deformities, swelling, ecchymosis, lacerations, and bleeding
Palpate for crepitus or instability of facial bones
Inspect the oral cavity for blood, foreign bodies, and tongue position
Assess for nasal obstruction
Note any blood or vomitus in the airway
Examine for cervical spine stability.
Investigations:
Initial assessment is clinical
Imaging is secondary to airway management: X-rays (lateral neck, facial bones, mandible) may be used if stable
CT scan of the facial bones and head is crucial for definitive fracture assessment once the airway is secured
Arterial blood gas (ABG) analysis to assess oxygenation and ventilation
Direct laryngoscopy or bronchoscopy under controlled conditions if intubation is difficult or visualization is needed.
Differential Diagnosis:
Non-trauma related airway obstruction (e.g., anaphylaxis, foreign body aspiration)
Cervical spine injury causing airway compromise
Intracranial hemorrhage affecting respiratory drive
Pulmonary contusion or hemothorax.
Management
Initial Management:
The primary goal is rapid assessment and securing of the airway using the least invasive method necessary
ABCDE approach is critical
Positioning the patient to facilitate breathing (e.g., head-tilt/chin-lift if no cervical spine injury suspected)
Suctioning of blood, secretions, or foreign bodies
Jaw thrust maneuver for suspected cervical spine injury.
Airway Securing Techniques:
1
Nasopharyngeal airway: Useful for partial obstruction when patient is awake or lightly sedated
Contraindicated with suspected basal skull fractures
2
Oropharyngeal airway: Useful for unconscious patients with airway collapse due to tongue
Contraindicated in conscious patients due to gag reflex
3
Bag-valve-mask (BVM) ventilation: Provides temporary ventilation and oxygenation
4
Nasal intubation: Often preferred in awake or semiconscious patients with facial trauma as it avoids manipulation of potential midface fractures and gag reflex
Requires lubrication and adequate patient cooperation
5
Oral intubation: Standard method but may be challenging with severe facial edema, trismus, or midface instability
Can be difficult with posterior displacement of tongue
6
Surgical airway (Cricothyroidotomy or Tracheostomy): Indicated when endotracheal intubation is impossible or contraindicated
Cricothyroidotomy is faster but temporary
tracheostomy is more definitive for prolonged ventilation.
Medical Management:
Sedation and analgesia to facilitate airway manipulation and patient comfort (e.g., midazolam, fentanyl)
Local anesthetics for topicalization during intubation
Antibiotics may be initiated if there are open fractures or significant contamination.
Surgical Management:
Definitive surgical management of fractures is typically delayed until the patient is stabilized and the airway is secured
However, emergent procedures like freeing an entrapped tongue or removing a foreign body may be part of initial airway management
Surgical airway is a definitive step if non-invasive methods fail.
Supportive Care:
Continuous monitoring of vital signs, oxygen saturation, and end-tidal CO2
Management of associated injuries (e.g., hemorrhage control, fluid resuscitation)
Nutritional support once oral intake is possible or via enteral feeding.
Complications
Early Complications:
Airway obstruction due to edema, hematoma, or displaced fractures
Aspiration pneumonitis
Hypoxia and its sequelae (brain injury, cardiac arrest)
Damage to dental structures or nasolacrimal duct during intubation
Failure to achieve intubation leading to delay in securing airway.
Late Complications:
Chronic airway compromise due to scarring or malunion of fractures
Dysphagia
Dysphonia
Malocclusion
Infection (osteomyelitis)
Delayed union or non-union of fractures
Aesthetic deformities.
Prevention Strategies:
Early recognition of airway compromise
Prompt and appropriate airway intervention
Careful technique during intubation to avoid iatrogenic injury
Thorough suctioning and management of secretions
Timely surgical intervention for definitive fracture repair
Prophylactic antibiotics for open fractures.
Prognosis
Factors Affecting Prognosis:
Severity of trauma and associated injuries (especially head and cervical spine injuries)
Timeliness and efficacy of airway management
Promptness and success of definitive surgical treatment
Patient’s overall health status and comorbidities.
Outcomes:
With timely and appropriate airway management, the prognosis for survival is good
Long-term outcomes depend on the extent of facial and associated injuries, the success of reconstructive surgery, and the absence of complications such as infection or neurological deficits.
Follow Up:
Long-term follow-up is essential to monitor for complications, assess functional recovery (mastication, speech, breathing), and address aesthetic concerns
This includes regular clinic visits, imaging as needed, and potential revision surgeries.
Key Points
Exam Focus:
The "cannot intubate, cannot ventilate" scenario is a critical exam topic
Cricothyroidotomy vs
Tracheostomy indications and techniques are frequently tested
Airway assessment in the context of specific fractures (e.g., Le Fort III, mandibular fractures).
Clinical Pearls:
Always consider airway first in any patient with maxillofacial trauma, even if initial breathing appears normal
A small amount of bleeding can rapidly obstruct an airway in the supine position
If you suspect cervical spine injury, use jaw thrust and avoid head tilt
Be prepared to perform a surgical airway if intubation fails.
Common Mistakes:
Delaying airway intervention due to focus on other injuries
Attempting intubation in a severely compromised airway without a backup plan for surgical airway
Inadequate suctioning of blood or secretions
Forgetting to consider associated cervical spine injury.