Anaesthesia and common oral and

maxillo-facial emergencies
Monica Morosan FRCA
Alan Parbhoo MRCS BSc BDS
Nicola Curry FRCA
Maxillo-facial cases frequently present for
emergency surgery and are commonly infective
or traumatic in nature. These are usually rst
assessed by junior members of the anaesthetic
and surgical teams. A thorough understanding
of the potential for complications and the need
for a whole strategy
1
approach in airway man-
agement is essential in achieving a successful
outcome.
Head and neck infections
Despite advances in microbiology and antibiot-
ic therapy, the treatment of head and neck in-
fection often requires surgery. It can present
with life-threatening complications such as
airway obstruction, mediastinal spread, and
cavernous sinus thrombosis, all of which have
increased morbidity and mortality.
Pathophysiology
Odontogenic- or dental-related infections begin
with decay and progress to pulpitis, which is in-
ammation of the nerve chamber in the centre
of the tooth. Infection then spreads into the
bone and causes perforation of the bone cortex
into the subperiosteal region. Fascial planes of
the head and neck are virtual spaces, bounded
by muscle attachments and bone. The muscle
attachments and fascial planes will govern in
which direction the infection spreads to the soft
tissue spaces. Knowledge of the orofacial mus-
culature is needed to predict the path of infec-
tion. The commonly affected fascial spaces are
illustrated in Figures 1 and 2. Infection can
spread from these into the infra-temporal fossa,
sub-temporalis, and parapharyngeal spaces.
This describes the local or direct spread.
The spread from the pre-maxillary region
(soft tissue anterior to the maxilla containing
the canine and part of the buccal space) can
progress to orbital cellulitis. If left unchecked,
this can lead to cavernous sinus thrombosis. A
parapharyngeal abscess often has little clinical
signs until the airway is compromised, as the
swelling is intra-oral or parapharyngeal. A fre-
quent culprit is a wisdom tooth which also
causes submasseteric inammation and trismus.
Examination of the pharynx is almost impos-
sible in the presence of severe trismus and
patients are often falsely downgraded in prior-
ity, due to lack of visible swelling.
Complications of spread to cervical fascial
planes include airway obstruction, mediastinitis,
and pulmonary aspiration of pus either through
spontaneous rupture or iatrogenic rupture
during attempts at intubation.
The haematogenous spread can lead to
thrombophlebitis, bacteraemia, prosthetic valve,
or joint involvement and systemic sepsis. The
spread of infection is affected by compromised
host defences such as diabetes mellitus, malig-
nancy, or immunosuppression.
Preoperative considerations
for dental abscess surgery
All patients require an appropriate and adequate
preoperative assessment to dene the extent of
disease progression, in particular, looking for
indicators of potential airway compromise,
anticipated difculties in airway management,
and signicant comorbidities. A history of
altered speech, odynophagia, rapidly worsening
swelling, and severe trismus can signify partial
airway obstruction. Stridor and dysphagia are
often late signs and stridor may be absent when
at rest.
Careful assessment of the airway is needed
using routine bedside techniques such as
Mallampati score, interdental distance, and pro-
tusion of the mandible and should include a
detailed examination of the neck. The lack of
tongue protrusion is a very sensitive indicator
of sublingual involvement and a good indicator
Key points
Oral and maxillo-facial cases
present frequently on the
emergency operating list
and can pose signicant
challenges for the
anaesthetic team.
Forty per cent of cases
reported to the recent
NAP 4 audit were head and
neck pathology.
Correct management
requires early recognition and
knowledge of anatomy and
path of spread of infections.
Facial and neck trauma can
present specic challenges for
the anaesthetist.
Careful assessment and
planning, effective
communication, early senior
involvement and appropriate
back up plans are paramount
for a successful outcome.
Monica Morosan FRCA
ST5 in Anaesthesia
Luton and Dunstable Hospital NHS Trust
Lewsey Road, Luton LU4 0DZ
UK
Alan Parbhoo MRCS BSc BDS
ST4 in Oral & Maxillofacial Surgery
Luton and Dunstable Hospital NHS Trust
Lewsey Road, Luton LU4 0DZ
UK
Nicola Curry FRCA
Consultant Anaesthetist
Luton and Dunstable Hospital NHS Trust
Lewsey Road, Luton LU4 0DZ
UK
Tel: 44 1582 497 230
Fax: 44 1582 497 230
E-mail: nicky.curry@ldh.nhs.uk
(for correspondence)
Page 1 of 6
Matrix reference 2A07, 3A02
doi:10.1093/bjaceaccp/mks031
Continuing Education in Anaesthesia, Critical Care & Pain | 2012
& The Author [2012]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia.
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Continuing Education in Anaesthesia, Critical Care & Pain Advance Access published May 24, 2012

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of impending airway compromise. Mouth opening can be limited
by trismus. Application of the assessment ndings, to help antici-
pate where difculties might be encountered, for example face-
mask ventilation, direct tracheal access, insertion of supraglottic
airway devices, or emergency surgical airway access, will assist
the planning and decision-making processes (see Table 1). Senior
anaesthetist and surgeon involvement should start early.
Preoperative imaging may have facilitated surgical diagnosis and
operative strategy and should be reviewed by the anaesthetist for
further evaluation of the airway. Flexible nasendoscopy should
also be considered.
Anaesthetic technique
The choice of anaesthetic technique will be inuenced by the
airway evaluation, the skills of the anaesthetist and surgeon, and
the available equipment. Conventional i.v. induction of general an-
aesthesia with muscle relaxation, inhalation route without muscle
relaxation, insertion of trans-tracheal catheter under local anaesthe-
sia before induction, awake breoptic intubation or tracheostomy
under local anaesthesia have been techniques described in the lit-
erature.
2
Adequate pre-oxygenation, i.v. access, and monitoring are
paramount irrespective of the technique used.
Trismus secondary to infection might not improve with in-
duction of anaesthesia.
3
In cases where mouth opening is limited
and swelling is conned to the oral cavity, there should be a
low threshold for the use of awake nasal breoptic intubation. In
the recently published NAP 4 report, failure to consider awake
breoptic intubation as the primary airway technique led to
direct harm in a proportion of reported patients. The avoidance
of muscle relaxation when a difcult laryngoscopy is also antici-
pated, by using either a gaseous induction or a TIVA technique
led to a feeling of false reassurance and contributed to adverse
outcome in some cases.
2
This, however, should be balanced
against those cases where these techniques were used successful-
ly and so, were not included in the project. It should be recog-
nized that all primary techniques may fail and that clear rescue
plans are in place before commencing anaesthesia. The location
of anaesthetic management also needs consideration. The NAP 4
report recommends the anaesthetic management of any case
which may involve surgical tracheostomy as a rescue technique
should start in the operating theatre.
2
Once a secure airway is established, anaesthesia can be main-
tained by either gaseous or i.v. routes. A saline-soaked throat pack
is placed in the oropharynx, if possible, to absorb pus, secretions,
and blood. Antibiotics are given according to local microbiology
guidance. I.v. dexamethasone may also be required.
The operating table may need to be rotated to 908 or 1808 with
regards to the anaesthetic machine. Pain relief can be provided by
paracetamol, non-steroidal anti-inammatory drugs, intra- oral
local anaesthesia, and long acting opioids.
Postoperative management
The decision to extubate post-surgery should be taken on a
case-by-case basis and after discussion with the surgeon. For
patients with signicant swelling and stridor at presentation, it may
be necessary to keep them sedated and ventilated until extubation
becomes safe to do so. Some patients are likely to develop further
postoperative swelling, particularly those with Ludwigs angina or
parapharyngeal involvement.
Fig 1 Axial section of right mandible showing potential paths of spread of
infection from a carious wisdom tooth.
Fig 2 Coronal section of right mandible showing potential paths of spread
of infection from a carious wisdom tooth.
Anaesthesia and common oral and maxillo-facial emergencies
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The Difcult Airway Society is currently drafting guidelines
for extubation. Anticipating, planning, and preparing for what
could be an equally dangerous time of anaesthesia should include
checking for a cuff down leak, having airway equipment for
re-intubation on standby, appropriate anaesthetic drugs drawn up in
the required doses, and a management strategy in case extubation
fails. The surgical team should remain in the operating theatre
until successful extubation has been established. A period of obser-
vation in theatre should follow before transfer to recovery.
Special considerations
Ludwigs angina
Ludwigs angina is a life-threatening cellulitis of the oor of the
mouth involving both submandibular and sublingual spaces, bilat-
erally. It was rst described in 1836 by Wilhelm Friedrich von
Ludwig. A good predictor of sublingual involvement is the inabil-
ity of the patient to protrude the tongue. This is related to the ana-
tomical shape of the genioglossus muscle which is c-shaped. The
concavity of the c produces the sublingual space. When this is
full (oedema or pus), the muscle cannot fold over itself, as
happens in tongue protrusion.
Surgical tracheostomy is often difcult and occasionally life
threatening due to the involvement of the neck and pre-tracheal
tissues. Incising through the pre-tracheal fascia and exposing the
pre-vertebral tissues to pathogens risks the spread of infection into
the mediastinum. Mediastinitis, despite modern healthcare, still
carries signicant mortality.
4
Facial trauma
The face is a complex apparatus, giving us the ability to eat, speak,
smell, hear, see, and interact socially. Facial injuries can be life
threatening, by compromising the airway and causing signicant
blood loss.
Epidemiology
The most common causes of facial injuries in the UK are
5
:
interpersonal violence (52%),
road trafc accidents (16%),
sports injuries (19%),
falls (11%),
industrial accidents (2%).
In a BAOMS survey of the UK facial injuries in 1997, the
male-to-female ratio was 2:1 overall. The mean age was 25.3
years.
6
Facial fractures have associated soft tissue injuries and
dental injuries. Traumatic brain injury occurs in 1548% of
patients with maxillo-facial trauma.
7
The incidence of cranio
maxillofacial injuries initially decreased after basic road safety
measures (seat belts, motor cycle helmets), but has increased again
due to interpersonal violence.
5
Anatomical considerations
The facial skeleton is composed of many bones inter-digitating
with each other at suture lines. It is designed to perform several
Table 1 Key considerations to assist in decision-making in the choice of the anaesthetic technique
These cases can be challenging and each one should be taken on its own evaluation and often requires experienced help
Preoperative
ndings
Techniques Considerations Caution Outcome
Assessment of
airway
Conventional induction of
anaesthesia then establish
an airway
I.v. muscle
relaxation
Do I anticipate any difculty with
facemask ventilation?
If difculty is not anticipated and
airway adjuncts can be used,
proceed with caution.
Patient asleep
with denitive
airway Does the mouth open adequately for
me to use adjuncts? You may require:
Oral/nasal airways, LM airway
Rapid sequence induction if
aspiration risk
Do I anticipate any difculty with
intubation?
Alternative laryngoscopes
Intubating laryngeal mask
Have I assessed all the swelling? Asleep breoptic
Could this be subtle airway
obstruction?
Always plan for unanticipated
difculty, failed intubation, and
CICV situations
Inhalation Children May take longer in obstructed airway.
Aspiration risk, agitation,
laryngospasm
Uncooperative adults
Awake breoptic intubation +Local
anaesthesia
Difcult airway management
anticipated (either face mask
ventilation or intubation)
May be difcult if moderate blood in
airway. Beware advanced airway
obstruction +Sedation
Poor mouth opening Plan for tracheostomy in case of
failure
Tracheostomy under local
anaesthesia
Are there already signs of airway
obstruction?
May be difcult if swelling
signicant in anterior neck
Failed awake FOI Does the benet outweigh the risk of
alternative techniques?
Anaesthesia and common oral and maxillo-facial emergencies
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functions but in the context of trauma, they act as a crumple zone
to evenly distribute energy transferred to the face whilst minimiz-
ing damage occurring to the skull and brain. There are natural
points of weakness in the facial skeleton as well as areas of very
strong dense bone called buttresses (Fig. 3). Facial fractures occur
in characteristic points where the bones are weakest, and when the
buttresses break, it is less usual for the break to be comminuted.
Comminution implies greater energy transfer. There are further
points of weakness where the facial bones are penetrated by vital
structures forming holes in the bony cortex. An example of this
is the infra-orbital foramen carrying branches of maxillary nerve
(second branch of trigeminal nerve, V
2
) and infra-orbital vessels.
The tongue is tethered forward to the mandible by the paired
genioglossi muscles that insert into the genial tubercles on the
lingual aspect of the anterior mandible (symphysis). Bilateral an-
terior fractures of the mandible may cause the tongue to fall back
into the oropharynx and a conscious patient with this injury will
sit up and forwards to protect his own airway. In an unconscious
supine patient without airway protection, this fracture is fatal.
The face has an extremely good blood supply and facial frac-
tures, particularly of the mid-face, can cause catastrophic haemor-
rhage. A signicant portion of this may go unnoticed in an
unconscious supine patient as it can accumulate in the airway,
pharynx, and stomach.
Basics of energy transfer
Energy transfer is an important concept to explain when dealing
with any form of trauma. It is now understood that the total force
is not as important as the amount of energy transferred into the
tissues, which is directly proportional to the level of tissue damage
that will occur. This is most easily exemplied in ballistic trauma.
A snipers bullet travelling greater than the speed of sound will hit
the face and pass through it causing a minimal damage. A
handgun res a bullet at much lower speed but the bullet often
does not exit the tissues. All of the kinetic energy in the handgun
bullet is therefore transmitted to the tissues, leading to more exten-
sive damage.
Classication
Fractures of the lower third
The lower third of the face is made of the mandible and its teeth.
The mandible forms a ring with the temporo-mandibular joint and
the base of skull. A ring is difcult to break in only one place and
therefore the mandible often fractures in two or more places.
Frequently, these are in different places on each side and this has
generally little impact on the airway, unless there is gross displace-
ment or bilateral anterior fractures (Fig. 4). Gross displacement
causes bleeding that can cause a large sublingual haematoma in
effect reproducing the airway compromise of Ludwigs angina. As
the roots of teeth act as a natural weak point in the mandible, teeth
are often in the fracture line and can become displaced, loosened,
or avulsed.
Fractures of the middle third
The mid-face is made up of the maxilla, zygoma, and lower half
of the nasoorbitoethmoidal complex. This part of the face
houses the eyes, the nasal airway, maxillary sinuses, and maxillary
teeth. The mid-face acts as the crumple zone to protect the brain
from injury and is frequently involved in facial injuries. As
complex mandibular injuries can result in airway compromise, so
can middle third fractures. Importantly, these can result in signi-
cant haemorrhage and immediate life-saving measures may involve
placement of Epistats, Rapid Rhinos
TM
, Foley catheters, or equiva-
lents and bite blocks such as McKessons to splint the maxilla and
tamponade bleeding points.
Le Fort fractures (Fig. 5) are common patterns of injury. It
must be borne in mind that these patterns were produced on cada-
vers and do not occur so precisely in vivo.
Fig 3 Facial buttresses (with kind permission from Springer
ScienceBusiness Media).
10
Fig 4 CTof mid-face trauma showing right Le Fort I and III with palatal
split and comminute mandibular fractures.
Anaesthesia and common oral and maxillo-facial emergencies
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In Le Fort I, the maxilla is fractured from the rest of the face
and is often not as freely mobile as one might expect. Only in high
energy transfer does the maxilla become loose and at risk to
the airway. Le Fort II involves the maxilla and nasal complex
fracturing from the facial bones and mobility is often more than Le
Fort I. Le Fort III injuries are more signicant and involve the
whole mid-face dissociating from the base of the skull and facial
bones. Frequently Le Fort injuries will occur in combination and
involve the mandible.
Fractures of the upper third
The upper third is made of the frontal bone, sphenoid and upper
half of the nasoorbitoethmoidal complex. It contains the eyes
and more of the paranasal sinuses (frontal, anterior and posterior
ethmoids, and sphenoids). The frontal bones weakness is the
frontal sinus and the extent of pneumatization varies considerably
between individuals. When the sinuses are large, the frontal bone
may fracture and involve the anterior skull base. These fractures
may be associated with dural tears, cerebrospinal uid leak and,
therefore, the risk of ascending infection.
Upper third fractures are of consequence to the anaesthetist
because it is commonly necessary for tubes to be placed into the
nose (Foley catheters, nasogastric tubes, and temperature probes).
Due to fracture displacement and difcult clinical circumstances,
they can end up in the frontal lobe. There is no absolute contra-
indication for placement of these tubes in anterior skull base
trauma, but adequate anatomical understanding that the nasal oor
is horizontal when upright and caution is needed.
Assessment and management in Accident
and Emergency department
When assessing any trauma patient, it is fundamental to consider
the mechanism of injury and the amount of energy transfer. This
will give the surgeon and anaesthetist an idea of the likely severity
of injury and potential for impending airway embarrassment.
Although injuries to the face can be distracting, the team must
follow the ATLS protocol when it comes to severe trauma. During
the primary survey, denitive airway control may be necessary
before complete evaluation of facial injuries. A proportion of
patients with facial trauma may require early intubation before
bleeding and swelling impede ventilation. There may be associated
cerebral and cervical spine injury.
Airway compromise is suggested by signs associated with
impaired air ow such as dyspnoea and stridor. Other signs may
include drooling, odynophagia, tracheal deviation, and trismus, es-
pecially if associated with bleeding, subcutaneous emphysema of
neck and chest, voice changes, burns, and unstable fractures of the
face.
8
Subtle changes should not be ignored.
Preoperative considerations for
maxillofacial trauma surgery
This article excludes those patients who have already been intu-
bated for denitive airway control as part of the ATLS primary
survey. It assumes an adequate general preoperative assessment
and should follow similar principles as outlined in the previous
section for dental abscess surgery.
For the ward patient with isolated facial trauma, airway assess-
ment should include the inspection of swelling, nasal patency,
mouth opening, and Mallampati scoring. Trismus is often caused
by pain and can disappear on induction of anaesthesia. However, it
may persist for mechanical reasons and this needs to be discussed
with the surgical team. Preoperative imaging should be reviewed.
The route of repair also needs consideration, as it can be intraoral,
subconjunctival or via a scalp ap. Different tracheal tubes (TTs)
may be used: south facing oral R.A.E
TM
for zygomatic or orbital
fractures, nasal for other fractures including mandibular, Le Fort
fractures or any that involve malocclusion. Alternatives to oral in-
tubation include tracheostomy or submental intubation. The need
for a throat pack, postoperative intermaxillary xation, and facial
nerve monitoring should also be discussed.
Fig 5 Le Fort classication of facial fractures.
Anaesthesia and common oral and maxillo-facial emergencies
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Anaesthetic technique
The choice of anaesthetic technique will again be inuenced by
the airway evaluation and the difculties anticipated. Blood in the
airway can make some techniques more challenging and therefore
vigilant planning and decision-making is necessary (see Table 1).
Senior involvement is recommended.
Pain can decrease after xation of fractures. The surgeons inl-
trate local anaesthetic with vasoconstrictors during the procedure
and paracetamol, non-steroidal anti-inammatory drugs and long-
acting opioids can be used in combination. I.v. dexamethasone is
administered to decrease swelling, followed by subsequent doses
for the rst 48 h. Antibiotic prophylaxis is indicated in wounds
with gross contamination, orally penetrating wounds, exposed car-
tilage, and devascularized wounds.
8
The anaesthetist needs to be aware of and prepare for potential
intra-operative complications. Reex bradycardia during levering
of a zygomatic fracture or manipulation of the mid-face can occur.
This can be treated with anticholinergics such as atropine. Blood
loss from facial fractures can be extensive and a large bore
cannula, uid replacement, and a recent group and save sample is
a basic requirement. Other complications include TT damage,
oculo-cardiac reex, and wiring of the TT to the maxilla.
9
Postoperative considerations
Extubation should be planned as prudently as intubation, bearing
in mind that the degree of oedema can worsen in the rst 48 h
after the injury. This is especially true in the case of Le Fort II and
III fractures. Throat packs should be removed at the end of the op-
eration and the oropharynx suctioned for debris and clots. Wire
cutters or scissors for elastic band xation should be immediately
available. Extubation should occur when the patient is fully awake,
and emergency intubation drugs and airway equipment are instant-
ly to hand. The surgical team should be in attendance until suc-
cessful extubation has occurred.
Due to residual swelling, some patients may be admitted to a
high dependency unit for close observation. Those that remain
intubated and ventilated are sent to the intensive care unit.
Postoperative haematoma
Haematoma formation in the early postoperative period is an un-
common, but potentially airway-threatening complication of some
maxillofacial operations, notably neck surgery, thyroid resections,
and oor of mouth surgery.
The rate at which airway compromise occurs is variable.
Emergency decompression of the haematoma by removing the
clips/sutures and manually evacuating the haematoma with a
Yankaur sucker may not alleviate the airway obstruction adequate-
ly due to oedema that results from venous congestion. The method
of securing the airway should take into consideration information
from the initial operation but it is expected to be more challenging
and warrant expert participation.
Conclusions
Anaesthesia for common oral and maxillofacial emergency cases
can present signicant challenges to the anaesthetist. They can
often be patients who are previously t and well but who now
have temporarily difcult or compromised airways. No one size
ts all method is possible and careful assessment and planning,
effective communication, and early senior involvement are para-
mount to a successful outcome. The NAP 4 project highlights that
Plan As can and do fail. Well thought through back up plans are
essential to the airway management strategy, in these cases.
Declaration of interest
None declared.
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4.2.1
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