Airway Management

The possibility of cervical spine injury makes airway management more complex in the facial trauma patient. Spinal injuries are increased fourfold if there is a clinically significant head injury (Glasgow coma scale [GCS] score ≤8). A cervical spine injury should be suspected in all patients involving forced blunt trauma. Cervical spine injury may be occult, in which case secondary injury to the spinal cord must be avoided. Immobilization of the cervical spine must be instituted immediately until a complete clinical and radiologic evaluation has excluded injury (16,17).

A fully conscious, coherent patient will maintain his/her airway; as overall status may deteriorate at any time, the ABCs must constantly be reassessed. The following subsets of patients require that the airway be immediately secured to prevent respiratory failure: (a) patients with GCS scores of 8 or less; (b) patients with sustained seizure activity; (c) patients with unstable midface trauma; (d) patients with direct injuries to the airway; (e) patients with aspiration risk or unable to maintain an airway; and (f) patients with oxygenation problems.

Hutchison et al. (18) identified six specific maxillofacial trauma situations, which could have adverse effects on the airway:

1. Posteroinferior displacement of a fractured maxilla blocking the nasopharyngeal airway. This is managed by pulling maxilla forward with index and middle fingers to disimpact;
   
2. A bilateral fracture of the anterior mandible may cause the fractured symphysis and the tongue to slide posteriorly and block the oropharynx in the supine patient. This is managed by placing a 0-silk suture transversely through dorsum of tongue and pulling the tongue forward using a towel clip/pulling mandible forward;
   
3. Obstruction of oropharynx, larynx and trachea/bronchi by teeth, bone fragments vomitus, hematoma, or other foreign bodies. This is managed by manual clearing of debris with a hooked gloved finger/using large bore suction with adequate illumination (e.g., laryngoscope) to examine and clear oropharynx and larynx;
   
4. Hemorrhage from distinct vessels in open wounds or severe nasal bleeding from anterior/posterior ethmoidal vessels or terminal portion of maxillary artery. This is managed by packing or putting occlusive pressure on the area, with definitive treatment to follow;
   
5. Soft tissue swelling and edema resulting from trauma of the oral cavity leading to delayed airway compromise. This is managed by being cognizant of potential for delayed airway compromise and early airway securement;
   
6. Trauma of the larynx and trachea causing swelling and displacement of structures, such as the epiglottis, arytenoid cartilages, and vocal cords, thereby increasing the risk of airway obstruction. This is managed by having high index of suspicion especially if mechanism of injury suggests trauma to the aforesaid areas, monitoring for alarm features such as surgical emphysema, tenderness, or tracheal or laryngeal crepitus. Bronchoscopy can be performed to seek the site of injury.

In an emergent situation, the clinical situation may dictate that the quickest way to secure the airway, rather than the safest and most appropriate way, be used.

The airway should be cleared of debris, foreign bodies (teeth), blood, and secretions. The classic “chin lift” or “jaw thrust” maneuvers are commonly employed for assessment of airway patency and to remove obstruction of the tongue base. However, jaw thrust and chin lift may cause distraction of at least 5 mm in a cadaver with C5–6 instability, unaffected by the use of a rigid collar (16). Manual in-line axial stabilization must therefore be maintained throughout. Bag-mask ventilation may also produce significant degrees of cervical spine movement at zones of instability. The “sniffing” position for standard endotracheal intubation should, similarly, be avoided as it flexes the lower cervical spine and extends the occiput on the atlas. As atlanto-occipital extension is necessary to visualize the vocal cords, patients with unstable C1 or C2 injuries might be at more risk from this technique. Although the hard C-collar may interfere with intubation efforts, the front part of the collar may be removed to facilitate intubation as long as manual stabilization remains in effect.

In this situation, the safest method of securing an endotracheal tube remains debatable. Advanced Trauma Life Support (ATLS) recommends a nasotracheal tube in the spontaneously breathing patient, and orotracheal intubation in the apneic patient. Orotracheal intubation is the fastest and surest method of intubating the trachea and therefore the more commonly used method. At the University of Maryland–Shock Trauma in Baltimore, Maryland, more than 3,000 patients were intubated orally with a modified rapid sequence induction technique with preoxygenation (actually denitrogenation of the alveoli) and cricoid pressure. Ten percent of these patients were found to have cervical spine injury and none deteriorated neurologically following intubation (19). Blind nasal intubation is ultimately successful in 90% of patients, but requires multiple attempts in up to 90% of these. Nasotracheal intubation is (relatively) contraindicated in patients with potential skull base fractures or unstable midface injuries that typically involve the naso-orbito-ethmoid (NOE) complex. The same holds true for the use of nasogastric tube placement. Any paranasal manipulation may notoriously produce or recreate local hemorrhage, making airway manipulations difficult or impossible. Inadvertent placement and contamination/violation of the cranial space is a theoretical possibility. Submental orotracheal/endotracheal intubation is a possibility for patients whom may need maxillomandibular repair or with NOE injury (19–21).

Nasotracheal intubation in nontrauma patients is often accomplished by rotating or flexing the neck to align the tube correctly; in the trauma patient, this requires prior cervical spine clearance. Local anesthetic preparation of the airway is also time consuming and might increase the risk of aspiration. Laryngeal mask airway (LMA) does not protect the airway from aspiration, and by acting as a bolus in the pharynx, may increase esophageal reflux. The need for a surgical airway should be recognized and obtained without delay. A percutaneous needle cricothyroidotomy with high-flow oxygen is indicated in emergency situations when standard tracheotomy is not feasible or advisable. The potential for carbon dioxide retention with this technique must be remembered and the levels in arterial samples monitored. Studies on movement of the neck during cricothyroidotomy, ease of cricothyroidotomy with neck immobilization, or neurologic deterioration following cricothyroidotomy are lacking. If identification of anatomic landmarks is ambiguous, one should proceed with standard tracheotomy or the needle cricothyroidotomy, especially if time is of the essence. Cricothyroidotomy is contraindicated in laryngeal or tracheal trauma, cervical infection, and young children, but unfortunately is necessary if unable to intubate. A standard tracheotomy is essential in unstable patients who require prolonged maxillomandibular fixation (MMF) for fracture stabilization and management.

Life-Threatening Hemorrhage and Bleeding from Facial Fractures

In the multisystem-injured patient, hemorrhage is the most common cause of hypovolemia. Hemorrhage can be external or internal, into body cavities. Because the face and neck have a rich vascular supply, injuries in these areas can lead to substantial blood loss leading to hemorrhagic shock. Major hemorrhage can result from large scalp wounds, nasal or midface fractures, and penetrating wounds. As opposed to bleeding into body cavities, hemorrhage in the head and neck area is almost always immediately detectable in the trauma bay on clinical examination and is most often external in nature. Direct pressure to wounds or to major arteries proximal to wounds often is effective in staunching the flow of blood. Scalp wounds are notorious for large amounts of blood loss in a short time if the galea is involved. Scalp wounds can be rapidly approximated with 2-0 nonabsorbable sutures (nylon, Prolene) or staples, if available. Sutures should be placed away from the wound edge to ensure hemostasis, as the galea tends to retract. The patient should be stabilized prior to continuing with further diagnostic studies.

Nasal and midface fractures can result in tearing of the ethmoidal arteries. Most of these can be controlled with direct pressure or packing. Nasal packing can be made of gauze, foam, or cotton. It may be commercial, preformed specifically for the purpose, or adapted to the task. Packings may be made by cutting the fingers of a sterile examination glove and stuffing with gauze. Nasal packing may be coated with petrolatum, antibiotic ointment, or agents such as lidocaine and thrombin that aid in hemostasis and clot formation. Preformed foam nasal packs may have small tubes in the center of the pack to allow nasal breathing while the packing is in place, as nasal packing usually prevents air exchange through the nose. Nonintubated patients with nasal packing in place should have the head of the bed elevated 30 degrees and be observed for respiratory distress. Continued bleeding may not be apparent on the nasal side of the packing. Nasal packing easily slips posteriorly with swallowing or out with movement or sneezing. The posterior oropharynx should be checked regularly.

Fractures of the posterior maxillary wall, as in LeFort I and II fractures, may be associated with profuse bleeding from the internal maxillary artery. Bleeding from this artery can be very difficult to control by gauze packing. Epinephrine and liquid thrombin can be added to the packing and the head elevated to help achieve hemostasis. However, a postnasal pack has to be used to treat the bleeding in the postnasal area; this is a difficult area to pack. A balloon catheter can be passed through the nose and pulled out through the mouth. The safety and length of nasal packing is not evidence based. In rhinoplasty surgery, nasal stents and packs are routinely left in place for 7 to 10 days. The role of systemic antibiotics routinely in patients with nasal packing is still controversial, but current evidence seems to suggest topical, rather than systemic, antimicrobials should be used in epistaxis, with preoperative antibiotics sufficing for maxillofacial trauma, as infections are quite rare in maxilla, condylar and zygoma fractures, and seen in less than 10% in those of the mandible (22–24).

Complications can be packing related. The most common complication of nasal packing is that removal of the packing dislodges healing tissue and causes recurrent hemorrhage. Hypoxemia and hypercarbia can cause respiratory and cardiac complications. Airway obstruction and asphyxiation can occur if the nasal packing slips back into the airway, particularly during sleep. Complications may occur if a pack compresses the eustachian tube. Rarely, infections can develop in the nose, sinus, or middle ear after nasal packing and lead to toxic shock syndrome (TSS). Risk factors for TSS include any wound and respiratory infections, such as sinusitis, sore throat (pharyngitis), laryngitis, tonsillitis, or pneumonia. Foul odor is alarming as the nasal pack ages over 48 hours from insertion. Bruising or swelling of the eyelids secondary to nasal packing may develop. Therefore, packing is best removed within 24 to 48 hours following placement, provided the patient’s clinical condition has stabilized.

When tight nasal/oral packing fails in unstable patients, supraselective arteriography and embolization is the treatment of choice, if this modality is available (25). Ligation of the external carotid artery is a last resort in the unstable multitrauma patient who cannot be transported. However, due to collateral circulation of the face, ligation is seldom truly effective. The best control of hemorrhage is obtained by exploratory surgery and fracture fixation. In patients with isolated LeFort fractures, open reduction/internal fixation (ORIF) is the first line of treatment (26).

Wound Management

The management of facial soft tissue injuries depends on the area of injury. However, there are some basic rules that apply in treating these injuries. Soft tissue injuries are only properly evaluated after the wound is cleaned of dirt, foreign bodies, debris, and dry blood. A local anesthetic is usually necessary to properly clean the wound and perform a thorough examination. In the awake patient, most local infiltrative anesthetics cause great discomfort, which may compromise spinal precautions. Very slow injection using a fine needle (30 gauge) as well as adding bicarbonate in a 1:10 ratio may help. Facial nerve function should be assessed in all patients with facial lacerations and nerve function should be documented prior to anesthetic use. Anatomic landmarks are of great importance: if facial nerve paralysis results from a laceration anterior to a line perpendicular to the lateral canthus of the eye, the terminal nerve branches are involved. If facial nerve paralysis results from a laceration posterior to this imaginary line, the facial nerve should be explored. Ideally, repair of the facial nerve should occur as soon as possible, but no later than 72 hours, unless the wound is heavily contaminated. In this case, the nerve endings are tagged with a permanent suture and repair is performed when the wound is clean. In patients with deep lacerations of the cheek, the wound should also be explored for injury to the parotid (Stensen) duct. One may see saliva in the wound if the duct is lacerated. The parotid duct is repaired over a stent to prevent stenosis. Lacerations and contusions of specialized three-dimensional structures such as the eyelid, nasal alae, and ear are often best referred to a specialist, especially if flaps show signs of devascularization.

Optimum timing of facial laceration repair is a topic of some debate. After tetanus prophylaxis, soft tissue repair can be performed within 12 to 24 hours, provided the wounds are irrigated, cleaned, and kept moist. Because of the abundant blood supply, definite wound closure can be delayed and, in general, requires minimal debridement. “Traumatic tattooing” is a greater problem in the face than skin loss. A perfect repair is difficult to obtain in the acute setting as areas of contusion have to declare themselves and often leave irregularities later on. As long as important anatomic landmarks are aligned (e.g., vermillion border of the lip, gray line of the eyelid) and like tissues are approximated (mucosa to mucosa, muscle to muscle, cartilage to cartilage, and skin to skin), revisions can be done later. Deep sutures are used to close dead space to avoid hematomas and to remove tension from the skin closure, preventing an unsightly scar. Good esthetic results depend less on suture technique than on proper redraping of tissues. Scars are noticeable as a result of reflection of light and creation of shadow. For cosmesis, it is of importance to create an “even” closure and, if possible, to place scars in areas of shadow and along lines perpendicular to facial muscle pull. Photographic documentation is important so that the patient may later realize the extent of the original injury, to follow healing, to document subsequent revisions, and for medical-legal reasons.

Cranial Nerve Examination

Nasal Bones

The clinical features of an isolated nasal fracture are noted in Table 67.2. Because of the prominence of the nose, nasal injuries are fairly common and the nose is the most commonly fractured bone in the facial skeleton. Nasal fracture diagnosis is often a clinical, and not a radiologic, diagnosis. External nasal deformities are usually obvious during examination. Crepitus will distinguish recent trauma from a nasal deformity due to a previous injury. Septal hematoma must be ruled out in every patient. A septal hematoma forms between the septal cartilage and perichondrium from which it gets its blood supply. It appears as edema and ecchymosis of the septum with narrowing of the nasal airway on speculum examination. Septal hematoma is treated with incision and drainage. Failure to treat can lead to a septal abscess, intracranial complications, or delayed saddle nose deformity due to cartilage loss.

TABLE 67.2 Clinical Features of an Isolated Nasal Fracture

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