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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4510_Библиотеки_им_академика_М_И_Перельмана.pdf
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R.L. da Cruz et al.
Craniomaxillofacial Trauma andTracheostomy
Indications forUse ofTracheostomy inCraniomaxillofacial Trauma
Although tracheostomy is a common procedure, the decision to perform it in craniomaxillofacial trauma patients can be complex [1]. Not a lot has been researched or
written regarding the objectives of tracheostomy in the management of these fractures [2].
Airway management in trauma patients should take multiple factors into consideration, such as trauma etiology, extent of the injuries, existence of comorbidities,
and surgeon experience and preference. Tracheostomy is usually performed in multisystem trauma and is considered a safe method for airway stabilization in craniomaxillofacial trauma patients (Fig.1) [2–4].
During the Second World War, the roles of hemostatic control and airway maintenance became widely recognized, and these procedures were established as immediate screening in campaign hospitals. At the time, most patients had a need for
prolonged intermaxillary xation, and tracheostomy was seen as a way to protect
airway function as well as facilitating a surgical approach. Subsequent technological advances at the end of the twentieth century imposed changes on the routine use
of tracheostomy for airway maintenance during trauma surgery [5, 6]. Monitoring
Fig. 1 Panfacial trauma before and after tracheostomy and treatment
Tracheostomy inOrthognathic Surgery andFacial Trauma Surgery: Is There aPlace?
243
techniques and equipment allowed more accurate assessment of vital functions,
diagnostic resources became more precise, and the use of internal rigid xation
(Figs.2 and 3) eliminated the need for long periods of intermaxillary xation. As a
result of these innovations, many surgeons oppose routine use of tracheostomy in
complex facial trauma [4, 7].
Tracheostomy is one of the most common procedures performed in intensive
care units, having many benets for patients under mechanical ventilation, such as
maintaining unobstructed upper airways, achieving better control of mechanical
support ventilation, protection of direct laryngeal lesions, facilitating basic nursing
care, enabling aspiration of tracheobronchial mucus, and making it more
Fig. 2 Panfacial fractures
Fig. 3 The same patient from Fig.2 after rigid internal xation of the fractures
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R.L. da Cruz et al.
ab
Fig. 4 (a) Computed tomography (CT) scan of facial trauma. (b) Chest CT scan of the same
patient, showing chest trauma. (Courtesy of Roger Lanes, MD, DDS, PhD, FHEMIG)
comfortable for the patients [8, 9]. In general, the best indications for performing
tracheostomy are upper airway obstruction, facial swelling, whenever oral or nasotracheal intubation are deemed unsafe, airway deviation during or after facial fracture repair, frequent need for tracheobronchial hygiene, prolonged mechanical
ventilation, and associated trauma (Fig.4) [10–12].
Some specic patient variables are predictive of long-term need for mechanical
ventilation, including cranial lesions, a low Glasgow Coma Scale score, the mechanism of injury, and patient comorbidities [13]. For instance, oral or nasotracheal
intubation that lasts longer than 2–3weeks increases the risk of complications for
the patient, including tracheal stenosis, vocal cord dysfunction, gastric hemorrhage,
vascular lesions, pneumothorax, and tracheoesophageal stula [14]. However, some
studies have suggested that glottic and subglottic stenosis, pneumonia, and death are
no more frequent in patients who remain intubated for over 2weeks than in those
who have early tracheostomy performed (Fig.5) [15].
Other studies have demonstrated a decrease in the amount of time spent in the
intensive care unit, a lower incidence of pneumonia, decreased mortality rates, and
facilitation of basic nursing care when tracheostomy is performed at the beginning
of the hospital stay [16].
Aside from the indications for tracheostomy intended for better clinical stabilization of the craniomaxillofacial trauma patient, one must consider airway maintenance during the surgical procedure for the treatment of the fractures. In cases of
simultaneous inferior and medial third facial fractures, oral and nasotracheal intubation may incur limitations for performing the necessary surgical procedures. In this
context, tracheostomy may be useful. With regard solely to the surgical procedure,
submental intubation is also possible, providing satisfactory airway access [8]. It
consists of orotracheal intubation, followed by submental access to the buccal cavity and transposition of the extremity of the intubation tube through this access, with
its exteriorization through the skin incision in the submental region. The benets of
this technique are discussed below (Fig.6).
Tracheostomy inOrthognathic Surgery andFacial Trauma Surgery: Is There aPlace?
245
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Fig. 5 (a) Multiple-trauma patient with severe facial airway-compromising trauma and tracheos-
tomy. (b) Computed tomography (CT) scan of the same patient’s facial fractures. (Courtesy of
Davidson Rodarte, DDS, MSc, FHEMIG)
Fig. 6 Sagittal view of submental intubation on a cadaver specimen
246
Submental Intubation
Fig. 7 Submental intubation [8]
R.L. da Cruz et al.
Submental intubation is regarded as a less invasive technique than tracheostomy,
although it has a more limited set of indications. The technique was rst described
in 1986 (Fig.7) for acute airway management of craniomaxillofacial trauma patients
where nasotracheal intubation was not a viable choice due to the need for maxillomandibular blockage during the surgical procedure [8].
More frequently used in trauma patients, submental intubation can also be indicated during orthognathic surgery and cranial base surgical procedures [17, 18].
Maxillofacial trauma remains its primary indication [19, 20]. It is described as a
safe and efcient technique, requiring participation of both anesthesiologists and
maxillofacial surgeons for its performance [1].
Submental intubation can be utilized when there is a need for maxillomandibular
xation in cases where a nasotracheal tube cannot be used, such as in nasal fractures
and naso-orbital-ethmoidal complex fractures. It also avoids tracheostomy when
long-term intubation is not mandatory. It can be indicated when orthognathic surgery is associated with rhinoplasty and in patients undergoing orthognathic surgery
who have anatomical anomalies that make use of a nasal tube impossible. Submental
intubation can be used in cranial base procedures, such as transmaxillary access
with oLe FortI osteotomy [2]. This approach allows better maxillary exposure than
orotracheal intubation.
Submental intubation is not indicated when a long period of intubation is likely.
In any patient with severe brain lesions—a condition frequently seen in facial
trauma patients—this procedure should not be chosen.
Tracheostomy inOrthognathic Surgery andFacial Trauma Surgery: Is There aPlace?
247
The advantages of submental intubation, as compared with tracheostomy, are
avoidance of morbidity such as infection, hemorrhage, laryngeal nerve lesions, tracheal stenosis, pneumothorax, pneumomediastinum, subcutaneous emphysema,
and tracheoesophageal stula. Simplicity of postoperative care and ease of reversibility are also benets to be considered [19].
One of the few described disadvantages of submental intubation is the skin scar;
this can be minimized with a small incision and meticulous suturing (Fig.8). There
have been cases of supercial wound infections due to the passage of the tube from
orotracheal to submental placement. Less frequent are orocutaneous stulae, temporary lingual nerve palsy, venous bleeding, and mucocele formation [1, 3].
Fig. 8 Submental intubation scar
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R.L. da Cruz et al.
Airway Management inPediatric Patients
Severe craniofacial and laryngeal traumas are not common in pediatric patients.
When they do happen, these lesions present specic challenges in airway management because of the smaller size of the oropharynx, laryngeal swelling, displacement of soft tissue, and excessive bleeding. These can rapidly compromise
airway permeability in children. Also seen, though less frequently, are foreign
bodies in the aerodigestive tract and laryngotracheal rupture. Both can lead to
devastating consequences in pediatric patients. Brain hypoxia can quickly ensue,
and death is imminent if proper ventilation and oxygenation are not promptly
re-established [4].
The anatomy and location of the tongue, larynx, and trachea are different in children compared with adults. In children, the tongue’s size is bigger compared with
the size of the oral cavity and oropharynx. The same applies to the epiglottis, which
occupies more space in the laryngeal segment of the airways, impairing a proper
view of the glottis during orotracheal intubation. On top of that, the pediatric larynx
is more cephalically placed (at the C3–C4 level, compared with the C4–C5 level in
adults), with subsequent superior placement of the tongue [5].
Craniomaxillofacial trauma in pediatric patients requires rapid assessment and
management of the airways. The small lumen and unique development characteristics of the aerodigestive tract in children make it difcult to ensure the safety of
airway permeability, even in a nonemergency setting. There are options for managing the airways in children affected by craniofacial trauma, but the best approach
depends on evaluation of each individual patient [6].
In general, orotracheal intubation is a fast and efcient way to stabilize the airways
in children, though it can lead to hoarseness, coughing, and a sore throat, which resolve
spontaneously 2–3days after extubation. Rarely seen are complications such as massive barotrauma and misguided esophageal intubation [18]. Nasotracheal intubation is
an alternative and can be useful in repairing craniofacial fractures with maxillomandibular xation. But there are drawbacks in its use. In patients with extensive nasoethmoidal frontal trauma, it may result in intracranial misguided intubation through a
basilar cranial fracture, especially if done by inexperienced professionals [7].
Cricothyroidostomy is not an option in pediatric patients, as mentioned in
Chap.15. This procedure has a high level of complications in this group of patients.
In cases of laryngeal trauma, tracheostomy can be used to surpass the injured site,
thus avoiding potential complications of orotracheal intubation [6].
Other than the specic conditions mentioned above, the indications for tracheostomy in pediatric patients follow the same principles as those for adult patients.
Orthognathic Surgery andTracheostomy
Orthognathic surgery consists of maxilla and/or mandible osteotomies in order to
correct dentofacial discrepancies (Figs.9 and 10). The indications to perform this
surgery are for treatment of dentofacial deformities (DFD), and the etiology can be
Tracheostomy inOrthognathic Surgery andFacial Trauma Surgery: Is There aPlace?
Fig. 9 Patient with dentofacial discrepancy on preoperative view
249
Fig. 10 The same patient from Fig.9, 1 year postoperatively (orthodontist: Bernardo Quiroga,
DDS, PhD)
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R.L. da Cruz et al.
Fig. 11 Severe dentofacial discrepancy with probable difcult airway
facial development derangements, craniofacial congenital anomalies, facial fracture
sequelae, inheritance deformities, and others. Other types of surgery in the head and
neck area and considerations regarding the upper airway are also important for
orthognathic patients, especially because of some etiologic factors, the surgery
itself, and/or the anesthesiological procedure (Fig.11).
Despite these rst considerations, ventilatory complications due to orthognathic
surgery are uncommon, although not impossible. Some of them have been experienced during the practice of the authors, and certainly by some other surgeons.
Posnick states that a patient with DFD should be considered to have difculties in
the upper airway, unless proved otherwise [8].
The purpose of this chapter is to present the indications to perform tracheostomy
(after previous cricothyroidostomy or not), as well as submental intubation, establishing the relationships with the biotype or physical characteristics of the patient,
the type of DFD, and treatment planning [10, 11]. Considerations regarding preoperative, perioperative, and postoperative evaluation and care are also presented.
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251
Biotype or Physical Characteristics ofthePatient
Orthognathic surgery is applied to a great number of patients and to treat a large
variety of facial diseases. In some cases, due to some physical characteristics of the
patient, a tracheostomy may become a necessity.
Obese patients with DFD, mainly where a mandibular setback is to be done, may
have respiratory difculties during the postoperative period, which might require a
tracheostomy.
For those with craniofacial syndromes that require orthognathic surgery as
part of the treatment—such as hemifacial microsomia, Treacher Collins syndrome (Fig. 12), cleft palate, or craniosynostosis (Fig. 13)—a preoperatively
dened tracheostomy may be a standard procedure in order to make the orthognathic surgery possible and also to promote better postoperative care and safety,
especially when external appliances such as external distracters (Fig.14) are
used.
Fig. 12 Lateral view after orthognathic surgery and rhinoplasty for Treacher Collins syndrome
(rhinoplasty: Paulo Henrique Rodrigues, MD; orthodontist: Silvia Reis, DDS, PhD)