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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4510_Библиотеки_им_академика_М_И_Перельмана.pdf
252
Fig. 13 Child with Crouzon syndrome electively tracheostomized before facial middle third distraction (neurosurgeon: Sandro Lemos, MD)
R.L. da Cruz et al.
Fig. 14 The same patient from Fig.13 with a facial middle third distractor
Tracheostomy inOrthognathic Surgery andFacial Trauma Surgery: Is There aPlace?
Fig. 15 Macroglossia in a patient with mandibular prognathism
253
Whenever macroglossia is presented and a glossectomy is to be performed
(Fig.15), tongue swelling may pose a risk of upper air way obstruction and/or dysphagia and a higher risk of aspiration. Special care should be taken in patients with
a wide and short neck who are to have a mandible setback, and for those who—even
when they do not present with sleep obstructive apnea syndrome (SOAS)—complain of snoring. In these cases, tracheostomy may be necessary to prevent airway
collapse during the postoperative period. An intensive care unit stay is recommended for these patients during the initial postoperative period due to the risk of
respiratory obstruction when tracheostomy is not the rst option.
Finally, some comments are needed on the choice of the tracheostomy cannula.
Since it is common to have some blood coming from the nose and mouth, together
with saliva, after orthognathic surgery, and considering some dysphagia on the rst
days, the cannula must have a cuff. In patients who require a long period of tracheostomy, a cannula with a cuff and an inner cannula is the best choice.
Dentofacial Deformity Characteristics andTheir Relationship
withtheAirway
Normally, patients who are to be treated by orthognathic surgery are classied
according to the deformity presented. As an example, deformities such as a long or
short face, asymmetries, anterior/posterior excess or deciency, or transverse deciencies of the maxilla or the mandible can present in isolation or together in a
patient (Fig.16).
Deformities with a deciency, such as retrognathia or maxillary atresia, can be
associated with a narrow upper airway, and the best method to maintain it during
and after the surgery should be dened preoperatively. For some cases, bronchobroscopy may be indicated for the intubation procedure (Fig.17).
254
Fig. 16 Examples of dentofacial discrepancies
R.L. da Cruz et al.
Fig. 17 Orotracheal
intubation with a
brobronchoscope in a
patient with Treacher
Collins syndrome (chest
surgeon: Agnaldo
Eisenberg, MD)
Tracheostomy inOrthognathic Surgery andFacial Trauma Surgery: Is There aPlace?
255
In cases in which a narrow nasal cavity is presented, the choice of submental
intubation should be considered [8, 21]. The necessity for maintaining maxillomandibular immobilization during orthognathic surgery prevents the possibility of performing oral intubation. For these cases, oral intubation followed by submental
intubation, as previously described in this chapter, are highly recommended [13].
In order to surgically treat these patients, tracheostomy is rarely employed, since
the main concern is to provide an airway for surgical and anesthesiological purposes. In case of a restricted bone anatomy and constricted airway, the outcome of
the surgical treatment normally improves the airway volume, leading to a better
breathing pattern, even during the immediate postoperative period.
In contrast to this, DFD with excess in the sagittal, coronal, and/or axial planes
may acquire a more constricted condition postoperatively. It may also imply a more
constricted airway. Naturally, the treatment planning must consider these possibilities, and the patient might need a longer period of intubation or a tracheostomy. In
fact, only in very rare situations will an orthognathic patient undergo these
procedures.
Although unlikely to happen, some special conditions should be mentioned due
to the high risk of complications arising from them. Whenever it is necessary to
employ any kind of positive pressure ventilator system, such as continuous positive
airway pressure (CPAP) or bilevel positive airway pressure (BiPAP), during the
postoperative period (especially in the rst month), an elective tracheostomy is indicated as the rst step of the surgery. This avoids the risk of subcutaneous emphysema or further complications such as pneumomediastinum [14, 15]. These are
conditions that would probable compromise the airway, and under these circumstances, a tracheostomy or even a cricothyroidostomy would be very difcult to
perform.
As a clinical example, a case of DFD and myasthenia gravis depending on BiPAP
is presented (Fig.18). An elective tracheostomy was performed and orthognathic
surgery, together with rhinoplasty, was done. Ventilatory assistance was applied
and, after a couple of months, the patient was decannulated without any concern.
Dentofacial Deformity Treatment Planning
Orthognathic treatment planning involves measurement of dentofacial discrepancies and makes a prediction regarding the surgical movements of the maxilla and/or
the mandible. With the possibility of doing this procedure virtually, with computeraided design and manufacturing (CAD/CAM) resources, additional information
concerning the airway evaluation can be obtained. However, some bias can be noted
when this planning is based on a computed tomography (CT) scan and not on a
dynamic evaluation of the upper airways. These methods can partially predict the
airway volume after surgery, acting as a warning about the risk of airway compromise. Nevertheless, they cannot be taken as a secure predictable method for this
purpose (Fig.19).
256
R.L. da Cruz et al.
a
b
Fig. 18 (a) Patient with myasthenia gravis and dentofacial discrepancy using bilevel positive
airway pressure (BiPAP). Elective tracheostomy was performed. (b) Pre- and immediate postoperative views after tracheostomy, orthognathic surgery, and rhinoplasty (rhinoplasty: Paulo
Henrique Rodrigues, MD)
Tracheostomy inOrthognathic Surgery andFacial Trauma Surgery: Is There aPlace?
257
Fig. 19 Airway evaluation with a cone beam computed tomography (CT) scan. (Courtesy of
Eduardo Januzzi, DDS, PhD)
Still, treatment planning can consider the necessity of surgical procedures for the
osteotomies, such as glossectomy, rhinoplasty, septoplasty, or turbinectomy [16, 22].
With the increasing indication of orthognathic surgery as a treatment method for
SOAS, uvulopalatoplasty and other pharyngeal procedures can be put together with
the previously described surgeries [17, 18]. Although these are procedures normally
performed separately from orthognathic surgery, elective tracheostomy should be
an available choice if they are done together.
Endonasal surgeries, such as septoplasty and/or turbinectomy, are often done
together with orthognathic surgery without worsening the risk of airway obstruction. When performed, glossectomy of the anterior two thirds of the tongue can
compromise the airway and cause an obstruction [16, 19]. In cases such as this,
effort in breathing can be the etiology of subcutaneous emphysema and pneumothorax. There are literature data presenting cases of pneumothorax and pneumomediastinum due to the effort to breathe after orthognathic surgery [14, 15, 20]. A
tracheostomy may be indicated in these cases, but not electively.
258
Fig. 20 Screen view of uvulopalatoplasty and posterior glossectomy. Note the nasotracheal tube
in the oropharynx (Surgeon: Arturo Carpes, MD, PhD)
R.L. da Cruz et al.
Uvulopalatoplasty and/or glossectomy of the base of the tongue are presented as
possible treatments for SOAS (Fig.20). Whenever they are planned to be performed
together with orthognathic surgery, special care should be taken related to the risk
of postoperative airway obstruction due to the increased swelling expected with
these procedures, although smaller soft tissue pharyngeal surgeries may be done
along with the orthognathic surgery with minor risk [8]. Elective tracheostomy may
also be considered in these cases.
Rhinoplasty can be done together with orthognathic surgery whenever it appears
to be necessary, or according to the wishes of the patient [22]. Since the orthognathic surgery is performed rst, nasotracheal intubation is used because it is mandatory to immobilize the maxilla and the mandible together while establishing and
xing them. To perform rhinoplasty, a change from naso- to orotracheal intubation
is needed. Care should be taken for this procedure; the anesthesiologist must be
condent in doing it, and the use of a bronchoberscope or a bougie may be necessary. When changing the endotracheal tube is not an option, submental intubation is
the best choice (Figs.21 and 22). A tracheostomy would be indicated only if a complication is presented.
Finally, an accurate preoperative evaluation related to the upper airways such
as maximum mouth opening, temporomandibular joint (TMJ) mobility, a
Mallampati test, and other data can classify the degree of difculty in accessing
the airway [32].
Tracheostomy inOrthognathic Surgery andFacial Trauma Surgery: Is There aPlace?
Fig. 21 Sequence for submental intubation in a patient with dentofacial discrepancy and brous
dysplasia of the right maxilla, undergoing orthognathic surgery with ostectomy to treat the brous
dysplasia, and rhinoplasty (rhinoplasty: Paulo Henrique Rodrigues, MD; orthodontist: Heloísio
Leite, DDS, MSc)
259
Fig. 22 View of the submental intubation of the patient from Fig.19
260
R.L. da Cruz et al.
Final Considerations
Tracheostomy has a relevant role in cranial and maxillofacial surgery, and its use
should be considered whenever any procedures of this surgical modality are being
planned [2, 6, 15, 23–26]. Although it is rare, patients undergoing orthognathic surgery, patients with trauma or trauma sequelae, patients with craniomaxillofacial
congenital anomalies, and those about to undergo reconstruction procedures in this
eld may need a tracheostomy in order to make an airway viable, in either an emergency or elective manner. All of these clinical conditions have received attention
from the authors concerning whether to perform a tracheostomy or not. The literature also presents data on this subject.
Nasotracheal intubation is the rst option for orthognathic surgery, such as mandible fractures and fractures of the lower middle third of the facial skeleton. Upper
middle third and superior facial third fractures will require orotracheal intubation.
In cases of combined fractures, such as panfacial fractures, submental intubation or
tracheostomy should be chosen, unless it is feasible not to do it. If necessary, perioperative maxillomandibular immobilization, nasotracheal intubation, or submental
intubation is the rst choice.
Whenever a long period of intubation is expected—for instance, in a patient with
facial fractures, brain injuries, and chest trauma—there is an indication to perform
a tracheostomy, if it has not yet been done [27].
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