Airway Management in a Patient with Extensive Maxillofacial Trauma: A Case Report

INTRODUCTION

Airway management in patients with maxillofacial trauma presents significant challenges for anesthesiologists. Inadequate or improper management can result in a compromised airway, leading to life-threatening conditions such as hypoxia or airway obstruction. Therefore, meticulous planning of airway management is crucial, accounting for both patient-specific and surgical factors. Although tracheostomy is generally considered a last resort due to its invasive nature and potential for serious complications, there are situations in which it is the most effective and safest airway management strategy. We report a case of severe maxillofacial trauma and its airway management, in which surgical tracheostomy was chosen as the primary approach. The authors obtained written informed consent from the patient for publication of the case details and prepared the case report in accordance with the CARE guidelines.

CASE REPORT

A 23-year-old male patient weighing 50 kg presented to our hospital after a road-traffic accident in which a truck struck his motorcycle, resulting in severe maxillofacial trauma. Clinical evaluation revealed multiple facial lacerations involving injuries to the upper lip and philtrum, a degloving injury of the nose, and a laceration of the tongue [Figure 1a]. Non-contrast computed tomography (NCCT) of the face revealed a paramedian mandibular split fracture, an anterior maxillary fracture with associated bone loss, and a nasal bone fracture with soft tissue loss consistent with a Le Fort II fracture pattern. The NCCT of the brain and contrast-enhanced computed tomography of the thorax showed no abnormalities. Radiograph of the lower limb revealed a fracture of the right femoral shaft. However, the patient was hemodynamically stable with a Glasgow Coma Scale score of 15/15 and had no comorbidities. In the emergency department, he was administered oxygen via facemask at 10 L/min during the primary and secondary surveys and preoperative stabilization. Preoperative laboratory investigations, including complete blood count, serum electrolytes, urea, and creatinine, were within normal limits. The surgical team scheduled the patient for open reduction and internal fixation of the mandibular fracture, along with debridement and soft tissue closure, under general anesthesia approximately 4 h after the accident.

Close

Figure 1: (a) Extensive maxillofacial injury. (b) Paraoxygenation technique.

Export to PPT

Because of the severity of his facial injuries, including nasal degloving, significant soft tissue edema, lacerations of the lip and tongue, and restricted mouth opening difficult. We classified classified the airway as difficult. The team anticipated challenges at multiple levels, including mask ventilation, laryngoscopy, and supraglottic airway placement.

After careful consideration of both patient-related and surgery-related factors, a decision was taken to perform a surgical tracheostomy under local anesthesia before induction of general anesthesia, as this was deemed the safest approach for airway management. In the operating theater, supplemental oxygen (15L/min) was administered via a catheter mount connected to the breathing circuit, positioned close to the patient’s nose and mouth [Figure 1b]. The tracheostomy was performed under local anesthesia by the otorhinolaryngology team [Figure 2]. After confirming that the tracheostomy tube was correctly positioned within the trachea, general anesthesia was induced, followed by administration of a muscle relaxant. Anesthesia was maintained with isoflurane in a nitrous oxide-oxygen mixture. Intraoperative analgesia was provided with intravenous morphine (7.5 mg), fentanyl (100 mcg), paracetamol (1 g), and ketorolac (30 mg). Dexamethasone (8 mg) and ondansetron (4 mg) were given as antiemetic prophylaxis. The patient remained hemodynamically stable throughout the perioperative period. After surgery, following confirmation of adequate spontaneous respiratory efforts, neuromuscular blockade was reversed with intravenous neostigmine (2.5 mg) and glycopyrrolate (0.5 mg). After adequate breathing efforts were established, the patient was shifted to the recovery room for postoperative monitoring.

Close

Figure 2: Airway secured with tracheostomy.

Export to PPT

DISCUSSION

Maxillofacial trauma presents significant challenges for anesthesiologists in securing the airway. Distortion of normal anatomy may result in restricted mouth opening, upper airway edema, active hemorrhage, or partial or complete airway obstruction. In addition, the possibility of concomitant cervical spine injuries further complicates airway management decisions.¹ When formulating an airway management strategy, anesthesiologists must carefully evaluate multiple critical factors, including the extent and nature of the trauma, the anticipated difficulty with mask ventilation or endotracheal intubation, risk of regurgitation and aspiration of gastric contents, presence of significant bleeding, and the specific maxillofacial procedure planned.² A variety of alternative airway techniques, such as awake fiberoptic bronchoscopy, retromolar intubation, and submental intubation, are available and may facilitate safe airway control while avoiding surgical airway interventions and their associated risks, including pneumothorax, false tract formation, and bleeding.

In contemporary practice, particularly with the frequent use of rigid internal fixation techniques that reduce the need for maxillomandibular fixation, surgical airway interventions are often considered as a last resort.³ However, it is imperative to recognize that in selected clinical scenarios, surgical airway management may remain the safest and most definitive option.

The patient had mandibular fracture accompanied by lip and tongue lacerations causing significant upper airway edema. Any attempt at oral manipulation in the presence of lip and tongue lacerations would have increased the risk of further mucosal injury. In addition, nasal injury ruled out nasal intubation. Owing to the extensive nature of the injuries, mask ventilation was not possible. The use of nasal prongs or high-flow nasal cannula (HFNC) was also deemed infeasible.⁴ Extensive disruption of the nasal passages may prevent proper placement of the HFNC prongs, while mid-facial fractures increase the risk of false passage creation or device misplacement. Furthermore, lacerations involving the oronasal cavity would cause significant leakage of high-flow oxygen through defects, resulting in ineffective oxygenation. Insertion of nasal prongs or cannula into a fractured nasal cavity may also displace bony fragments or result in intracranial placement, particularly in Le Fort II/III fractures, where cribriform plate injury is suspected. HFNC relies on relatively preserved upper airway patency; however, in this patient, airway edema, bleeding, secretions, and debris could have caused partial or complete obstruction, rendering HFNC both unsafe and ineffective.

The patient had severe trismus, with an interincisor mouth opening of approximately 1 cm, primarily due to severe pain causing reflex spasm of the masseter and temporalis muscles, compounded by soft-tissue swelling and hematoma. Additionally, mandibular fracture-related maxillomandibular instability can result in malocclusion and restrict mandibular movement. Direct laryngoscopy was therefore not feasible due to limited mouth opening and multiple intraoral lacerations. Although awake fiberoptic-guided intubation could have been considered, it was deemed impractical in this scenario due to raw intraoral surfaces and a blood-tinged field. Advancing an endotracheal tube over the bronchoscope could have caused further injury, thereby exacerbating bleeding or dislodging clots, which could precipitate a “Cannot Intubate Cannot Oxygenate” scenario.

Following multidisciplinary discussions involving otolaryngology, oral and maxillofacial surgery, and anesthesiology teams, the following key points were addressed. It was anticipated that the patient may require additional surgical interventions postoperatively and possibly prolonged mechanical ventilation. Given these factors, a decision was made to perform surgical tracheostomy under local anesthesia. This approach ensured a secure airway outside the surgical field, allowing unrestricted manipulation of the head during repositioning, drilling, and reconstructive procedures.⁵ Severe edema, bleeding, and soft tissue swelling involving the face, pharynx, and larynx can worsen over the first 24–48 hours, making early extubation unsafe. In the absence of a tracheostomy, post-extubation airway obstruction would have posed a significant risk. Multi-stage reconstructive surgeries necessitate repeated anesthetic exposure; therefore, maintaining a definitive secured airway via tracheostomy was considered prudent until surgical correction was complete and airway edema had subsided.

An oxygen hood was attempted but was poorly tolerated due to the patient’s claustrophobia. Para-oxygenation was achieved by holding the anaesthesia delivering 100% oxygen close to the patient’s face before and during the tracheostomy procedure, under local anesthesia with continuous vital-sign monitoring. The procedure was completed uneventfully.

CONCLUSION

Maxillofacial trauma presents a high-risk airway scenario that demands meticulous preoperative planning, advanced airway management skills, and preparedness for an emergency surgical airway. Close coordination between the anaesthesiology and surgical teams is essential. Although awake fiberoptic intubation is traditionally regarded as the gold standard, its utility may be limited in the presence of bleeding, excessive secretions, or distorted anatomy that obscures visualization. Therefore, while surgical tracheostomy is generally considered a last-resort intervention, in selected situations it may be the safest and most definitive airway option available. Early decision-making in favour of a surgical airway can be lifesaving and may prevent catastrophic airway loss.