Maxillofacial surgery

Anesthetic Issues
HOSSAM M ATEF;MD
Department of Anesthesia
SUEZ CANAL UNIVERSITY
 Maxillofacial surgery
• Diseases, injuries and defects in the head, neck, face, jaws and the
hard and soft tissues of the oral and Cranio-maxillofacial region
• Indications
Correction of congenital deformities
Acquired injuries
Neoplasms
Cosmetic (dental malocclusions)
ANESTHETIC IMPLICATIONS
PRE-OPERATIVE PROBLEMS

• Neonate, Elderly, Chronically Debilitated Patients

• Malnourished, under weight

• COPD ,chest infection, aspiration

• Alcoholism

• Co-existing disease such as HTN,D.M, IHD, etc.

PRE-OPERATIVE

MANAGEMENT

Adequate pre-operative work-up of Cardiac Status & Pulmonary

Functions should be carried out using various diagnostic modalities with
the objective of optimizing patient’s condition
RECONSTRUCTIVE MAXILLOFACIAL SURGERY

Problems:
 Major problem: Airway Management
 Extensive, long operation
 Significant blood loss
 Poor nutritional status
 Micro-vascular surgery
• Caution with Vasoconstrictors
• Caution with Transfusion
• Caution with Diurresis
• Blood Rheology (Hct:25-27)
INTRA-OPERATIVE MANAGEMENT
SPECIAL CONSIDERATIONS
• Two large bore canulae
• Invasive blood pressure monitoring
• Central venous pressure monitoring
• Use of muscle relaxants
• Induced hypotension
• Blood loss & transfusion
• Haemodynamic changes
• Venous air embolism
INTRA-OPERATIVE MANAGEMENT

Invasive Blood Pressure Monitoring

• is indicated due to following reasons :

• Blood loss may be rapid secondary to

• Neck dissection
• Pre operative radiotherapy
• Surgery close to big vessels of neck

• Frequent fluctuations in the blood pressure due to manipulation in the area

of carotid body and sinus.
INTRA-OPERATIVE MANAGEMENT

Central Venous Pressure Monitoring

• Risk of venous air embolism during neck dissection

• As a guide to the management of fluid therapy

• The site of insertion is either:

• Antecubital vein
• Femoral vein
INTRAOPERATIVE MANAGEMENT

Use of Muscle Relaxants

During surgery IPPV is carried out without muscle relaxant as

surgeons need to identify the nerves during surgery
 Issues
• Associated defects/injuries
• Shared airway
• Anticipated/Unanticipated Difficult intubation
• Bleeding & Induced hypotension
• Emergence/Extubation
• Post-operative complications & PONV

hossam
 Issues
• Associated defects/injuries
• Shared airway
• Difficult intubation
• Bleeding & Induced hypotension
• Emergence/Extubation
• PONV
 Associated Injuries/Complications
• Airway compromise
• Cervical spine injury/fracture ribs
• Head trauma/Pneumocephalus /hemopneumothorax
• Subcutaneous emphysema and pneumomediastinum
• Trismus
• Hemorrhage
 Issues
• Associated defects/injuries
• Shared airway
• Difficult intubation
• Bleeding & Induced hypotension
• Emergence/Extubation
• PONV
 Airway sharing
• Common site of Work
• Pre-op discussion & planning helpful
• Intraop assesssment of facial symmetry, mouth opening & teeth
occlusion
• Extra vigilance for tube dislodgement,kinking
 Issues
• Associated defects/injuries
• Shared airway
• Difficult intubation
• Bleeding & Induced hypotension
• Emergence/Extubation
• PONV
 Documented History of Difficulties with general anesthesia or,
more specifically, mask ventilation or endotracheal intubation

 Congenital Syndromes Associated With Difficult Endotracheal

Intubation

 Pathologic States That Influence Airway Management

Congenital Syndromes Associated With Difficult Endotracheal Intubation

• SYNDROME
• Down
• Large tongue, small mouth ; small subglottic diameter possible Laryngospasm frequent
• Goldenhar
• Mandibular hypoplasia and cervical spine abnormality
• Klippel-Feil
• Neck rigidity because of cervical vertebral fusion
• Pierre Robin
• Small mouth, large tongue, mandibular anomaly; awake intubation essential in neonate
• Treacher Collins (mandibulofacial dysostosis) Laryngoscopy difficult
• Turner
• High likelihood of difficult intubation
Pathologic States That Influence Airway Management

• Infectious epiglottitis,Laryngoscopy may worsen obstruction

• Abscess (submandibular, retropharyngeal, Ludwig‘s angina)
• Distortion of airway renders mask ventilation or intubation extremely
difficult
• Croup, bronchitis, pneumonia (current or recent)
• Airway irritability with tendency for cough, laryngospasm, bronchospasm
• Maxillary/mandibular injury
• Airway obstruction, difficult mask ventilation, and intubation;
cricothyroidotomy may be necessary with combined injuries
• Laryngeal fracture ,Airway obstruction may worsen during
instrumentation
• Cervical spine injury ,Neck manipulation may traumatize spinal cord
• Selected Pathologic States That Influence Airway Management
• Upper airway tumors Inspiratory obstruction with spontaneous ventilation

• Lower airway tumors Airway obstruction not relieved by tracheal intubation

• Radiation therapy Fibrosis may distort airway or make manipulations difficult

• Inflammatory rheumatoid arthritis

• Mandibular hypoplasia, temporomandibular joint arthritis, immobile cervical spine,

laryngeal rotation, cricoarytenoid arthritis all make intubation difficult and hazardous

• Ankylosing spondylitis Direct laryngoscopy maybe impossible

• Soft tissue, neck injury (edema, bleeding, emphysema) Anatomic distortion of airway

• Laryngeal edema (postintubation) Irritable airway, narrowed laryngeal inlet

Selected Pathologic States That Influence Airway Management

• Angioedema Obstructive swelling renders ventilation and intubation difficult

• Endocrine/metabolic acromegaly Large tongue, bony overgrowths

• Diabetes mellitus Reduced mobility of atlanto-occipital joint

• Hypothyroidism Large tongue, abnormal soft tissue (myxedema) make

ventilation and intubation difficult

• Thyromegaly Extrinsic airway compression or deviation

• Obesity Upper airway obstruction with loss of consciousness, Tissue mass

makes successful mask ventilation unlikely
Further Evaluation
PRE-OPERATIVE ASSESSMENT OF THE AIRWAY

• Indirect or Fiberoptic Laryngoscopy

• X ray: Chest , Cervical Spine
• CT or MRI
• Flow- Volume Loops
• Pulmonary Function Tests
Difficult Airway
 Difficult airway
The clinical situation in which a conventionally trained anesthesiologist
experiences difficulty with mask ventilation, difficulty with tracheal
intubation, or both

 Difficult mask ventilation

1) inability of unassisted anesthesiologist to maintain SpO2 > 90%
using 100% oxygen and positive pressure mask ventilation in a patient
whose SpO2 was 90% before anesthetic intervention;
Difficult Airway
 Difficult Laryngoscopy
Not being able to see any part of the vocal cords with conventional
laryngoscopy

 Difficult Intubation
Proper insertion with conventional laryngoscopy requires either :
a) > 3 attempts
b) > 10min
 Difficult Airway

Under
Awake
GA/Sedation

Different
Awake
,Laryngoscopes
Laryngoscopy
Stylets

Awake Fiberoptic LMA/ I LMA/FO

Tracheostomy Fiberoptic

Retrograde
Tracheostomy
Intubation

Blind Nasal
Intubation
 Difficult Airway

Awake

Awake
Laryngoscopy

Awake
Fiberoptic

Tracheostomy

Retrograde
Intubation
AWAKE TECHNIQUES
Glosso-Pharyngeal Nerve IX Nerve

Posterior pharyngeal fold at its midpoint, 1 cm deep to the mucosa of the lateral
pharyngeal wall
AWAKE TECHNIQUES

Superior Laryngeal Nerve

Pyriform Fossa
External :1 cm medial to the superior cornu of the Hyoid Bone to pierce the thyrohyoid
membrane
AWAKE TECHNIQUES
 C h i d r e n / U n c o a p e r a ti v e A d u l ts / S e p s is A s s e s s / A n ti c h o l in e r g i c / A n x i o l y tic ( i f a n y )

1 ) I n h a la ti o n a l / a s s e s : V e n ti l a tio n / V e iw

2 ) S ti l le te / D i ffe r e n t L a r y n g e o s c o p e s

(= /- s h o rt a c tin g M R)

3 ) L M A / L M A + F .O .

F a c e M a sk + F .O . + M o d i fi e d O r a l A W

4 ) F .O u s i n g S e d a ti o n O r li g h t G A

5 ) T r a c h e o s y o m y u n d e r li g h t G A

6 ) B l in d N a s a l T e c h n i q u e
Anticipated problems
• 1.Anticipated difficult airway
• 2.Restricted ability to open the mouth
• 3.Possibility of cervical spine fracture
• 4.Possibility of concurrent base skull fracture
• 5. Full stomach (emergency cases)
 Methods available
• Awake vs Anesthetized patient
• Orotracheal vs nasotracheal intubation
• Fiberoptic laryngoscopy/intubation
• Anterograde vs retrograde
• Cricothyroidotomy, tracheostomy
DIFFICULT AIRWAY
ALGORITHM
 Intubation

• Retromolar intubation, TT behind the most posterior

molars, allows teeth to be brought into occlusion.

• Submental intubation, TT is passed (without connector)

through the floor of the mouth and out percutaneously.
The Internet Journal of Anesthesiology Volume 12. 2013
Faciomaxillary Surgery - Our Experience: Anaesthesiologist's
Perspective
M Sarkar, V Puri, D Kumar, Dewoolkar, C Shastri, M Shakeel

• Abstract
• Retrospective study
• 241 patients who underwent elective surgeries for maxillofacial
injuries (2002-2005)
• Choice of airway management is directed by thorough preoperative
evaluation including radiological study, surgical requirement of
maxillomandibular fixation and experience of anaesthesiologist.
• Wherever possible Submental intubation should be considered over
tracheostomy to reduce morbidity.
 Induction of anesthesia
• Regular induction vs Rapid Sequence Induction
• Opioids
IV inducing agents
+/- Muscle relaxants
 Maintenance of anesthesia
• Volatile agents or total i.v. anesthesia (TIVA).
• analgesia may be provided with Morphine or shorter acting opioids
such as Fentanyl or Alfentanil.
• Remifentanil becoming popular, rapidly titratable, accelerated Wake
up and recovery
• Mandibular and maxillary nerve blocks performed by surgeons can aid
intra/post-op analgesia
 Issues
• Associated defects/injuries
• Shared airway
• Difficult intubation
• Bleeding & Induced hypotension
• Emergence/Extubation
• PONV
 Bleeding & Control measures
• Extensive blood supply to mid-face
(maxillary artery/Pterygoid venous plexus)
• Head-up positioning
• Infiltration of large quantities of Epinephrine
containing LA
• Induced hypotension
 Induced hypotension
• Induced-hypotension can reduce blood loss, transfusion rate, and
operating time. Not without risks !!
• No more than 30% reduction with an absolute lower limit of 55 mm
Hg (in ASA I patients)*
• Caution in CAD,uncontrolled HTN,CVD,hepatic/renal impairment
• Clonidine/Magnesium may contribute to postoperative analgesia.
• Mg should be titrated and caution exercised, may prolong
neuromuscular blockade
INTRAOPERATIVE MANAGEMENT

Induced Hypotension

Mild degree of hypotension is required during surgery to reduce the

blood loss. This can be achieved by following:

• 15-30 degree head up tilt

• Increasing the conc. of volatile anesthetics
• Use of peripheral vasodilators
• Use of beta blockers
 INTRAOPERATIVE MANAGEMENT

Blood Transfusion
Before the decision of blood transfusion the following points should be
considered

• Patient’s underlying medical condition

• Possibility of risks of transfusion hazards
• Increased risk of post-transfusion cancer recurrence as a result of immune suppression
INTRAOPERATIVE MANAGEMENT

Haemodynamic Changes
During radical neck dissection, the traction or pressure on the carotid
sinus and / or stellate ganglion can cause following:-

• Brady-dysrhythmias
• Sinus arrest leading to asystole
• Wide swings in blood pressure
• Prolonged QT Interval
INTRAOPERATIVE MANAGEMENT

Haemodynamic Changes “Treatment”

• Immediate cessation of the stimulus

• Blockage of the sinus with local anesthetic by the surgeon

• Vagolysis by atropine
INTRAOPERATIVE MANAGEMENT

Venous Air Embolism

• When CVP is low

• Veins are open to atmosphere, air is sucked in causing air embolism.

• Diagnosis
• Early Detection
• Hypoxia
• Hypotension
• Hypocarbia
INTRAOPERATIVE MANAGEMENT

Venous Air Embolism

Treatment

• Compression of neck veins

• Positive pressure ventilation
• Left lateral position
• Aspiration of air through the central venous catheter
• Ionotropes
POST-OPERATIVE CARE

ROUTINE CARE

SPECIAL CONSIDRATIONS

• ICU care & Possible mechanical Ventilation

• Hemodynamic Instability
• Analgesia
• Tracheostomy
POST-OPERATIVE CARE
ICU Care & Possible Mechanical Ventilation

• Patient should be kept in the intensive care unit for 24-48 hours
• Prolonged Surgery
• Airway Oedema
• Co-existing diseases
• Risk of bleeding and/or neck hematoma
 POST-OPERATIVE CARE

Haemodynamic Instability

• Bilateral neck dissection may result in

• Post-operative hypertension and hypoxic drive

• Denervation of the carotid sinus and carotid body

POST-OPERATIVE CARE

Analgesia

• Non Steroidal Anti-inflammatory Agents as opioids cause respiratory

depression in spontaneously breathing patients

• When patient is on ventilator opioid analgesia can be given

POST-OPERATIVE CARE

Tracheostomy Care

• Humidified Oxygen
• Intermittent Suction
• Sterile Precautions
• Adjustment of cuff pressure to15-20 mmHg
• Complications
Hypotensive Anesthesia versus Normotensive Anesthesia during Major
Maxillofacial Surgery: A Review of the Literature The Scientific World Journal August:
2014
Michal Barak MD 1 Leiser Yoav DMD, PhD2, Imad Abu el-Naaj DDS 3
1Department of Anesthesiology, Rambam Health Care Campus, and the Bruce Rappaport Faculty of Medicine,
Technion-Israel Institute of Technology, Haifa, Israel

• Conclusions
• Patients who undergo major maxillofacial surgery are at risk of
considerable intra-operative bleeding, and the outcome of the
surgical procedure depends on the quality of the surgical field
conditions. Since hypotensive anesthesia can reduce the extent of
intraoperative bleeding and can potentially improve the quality of the
surgical field conditions, hypotensive anesthesia is considered to be
beneficial during these procedures.
• However, hypotension carries the risk of hypoperfusion in vital organs
and is unsafe in certain patients.
• Thus, the magnitude of the blood pressure reduction should be
adjusted to the patient's general condition, age, and existing diseases.
• Normotensive or modified hypotensive anesthesia should be used for
patients with ischemic heart disease, carotid artery stenosis, a
disseminated vascular disease, kidney dysfunction, or severe
hypertension who are scheduled to undergo a major maxillofacial
operation.
• Appropriate patient selection, careful monitoring, and adequate
intraoperative volume replacement are mandatory in hypotensive
anesthesia for its safe implementation in patients who are scheduled
to undergo a major
 Issues
• Associated defects/injuries
• Shared airway
• Difficult intubation
• Bleeding & Induced hypotension
• Emergence/Extubation
• PONV
 Emergence and Extubation
• Discontinue Induced hypotension
• ?Airway cleared with suction
• Ensure hemostasis before jaw wiring is carried out (esp if
intermaxillary fixation)
• Deep smooth Vs Safer Awake extubation
• Pharyngeal Pack removed
 Issues
• Associated defects/injuries
• Shared airway
• Difficult intubation
• Bleeding & Induced hypotension
• Emergence/Extubation
• Post-operative complications
 Postoperative complications
• Vigilance for soft tissue swelling/hematoma which can
result in airway obstruction
• Management of pain and PONV are paramount.
Vomiting in patients in IMF is dangerous
• With IMF, wire cutters must always be kept next pt.
for emergency (vomiting, airway obstruction,
bleeding)

IMF= intermaxillary fixation

 PONV
• Orthognathic surgery associated with a high incidence of PONV 7-40%
• Intra-operative steroids (usu dexamethasone) administered also
efficacious anti-emetics and contribute to analgesia.
• The use of additional anti-emetics should be considered
 Post op Analgesia
• Postoperative pain after orthognathic surgery often not severe,
probable contribution by intra-op use of LA
• Usu managed by Opioids with PCM and NSAIDs
 Conclusion

• Close communication & detailed understanding of the surgical plan to

be followed
• Specific considerations
airway management
techniques to assist surgical hemostasis and reduce blood loss
effective anti-emesis and
vigilance for postoperative airway complications