Faciomaxillary anesthesia

1. Maxillofacialsurgery
AnestheticIssues
HOSSAM M ATEF;MD
Department of Anesthesia
SUEZ CANAL UNIVERSITY

2. 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)

4. 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.

5. 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

6. 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)

7. 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

8. 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.

9. 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

10. INTRAOPERATIVE MANAGEMENT
Use of Muscle Relaxants
During surgery IPPV is carried out without muscle relaxant as
surgeons need to identify the nerves during surgery

11. Issues
• Associated defects/injuries
• Shared airway
• Anticipated/Unanticipated Difficult intubation
• Bleeding & Induced hypotension
• Emergence/Extubation
• Post-operative complications & PONV
hossam

12. Issues
• Associated defects/injuries
• Shared airway
• Difficult intubation
• Bleeding & Induced hypotension
• Emergence/Extubation
• PONV

13. Associated Injuries/Complications
• Airway compromise
• Cervical spine injury/fracture ribs
• Head trauma/Pneumocephalus /hemopneumothorax
• Subcutaneous emphysema and pneumomediastinum
• Trismus
• Hemorrhage

14. Issues
• Associated defects/injuries
• Shared airway
• Difficult intubation
• Bleeding & Induced hypotension
• Emergence/Extubation
• PONV

15. 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

16. Issues
• Associated defects/injuries
• Shared airway
• Difficult intubation
• Bleeding & Induced hypotension
• Emergence/Extubation
• PONV

17.  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

18. 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

19. 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

20. • 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

21. 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

22. 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

23. 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;

24. 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

25. Difficult Airway
Awake
Awake
Laryngoscopy
Awake Fiberoptic
Tracheostomy
Retrograde
Intubation
Under
GA/Sedation
Different
Laryngoscopes,
Stylets
LMA/ I LMA/FO
Fiberoptic
Tracheostomy
Blind Nasal
Intubation

26. Difficult Airway
Awake
Awake
Laryngoscopy
Awake
Fiberoptic
Tracheostomy
Retrograde
Intubation

27. AWAKE TECHNIQUES
Glosso-Pharyngeal Nerve IX Nerve
Posterior pharyngeal fold at its midpoint, 1 cm deep to the mucosa of the lateral
pharyngeal wall

28. AWAKE TECHNIQUES
Superior Laryngeal Nerve
Pyriform Fossa
External :1 cm medial to the superior cornu of the Hyoid Bone to pierce the thyrohyoid
membrane

29. AWAKE TECHNIQUES

30. Chidren / Uncoaperative Adults / Sepsis Assess / Anticholinergic / Anxiolytic ( if any)
1) Inhalational / asses: Ventilation / Veiw
(=/- short acting MR)
2) Stillete / Different Laryngeoscopes
Face Mask + F.O. + Modified Oral AW
3) LMA / LMA + F.O.
4) F.O using Sedation Or light GA
5) Tracheosyomy under light GA
6) Blind Nasal Technique

31. 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)

32. Methods available
• Awake vs Anesthetized patient
• Orotracheal vs nasotracheal intubation
• Fiberoptic laryngoscopy/intubation
• Anterograde vs retrograde
• Cricothyroidotomy, tracheostomy

33. DIFFICULT AIRWAY
ALGORITHM

34. 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.

35. 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.

36. Induction of anesthesia
• Regular induction vs Rapid Sequence Induction
• Opioids
IV inducing agents
+/- Muscle relaxants

37. 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

38. Issues
• Associated defects/injuries
• Shared airway
• Difficult intubation
• Bleeding & Induced hypotension
• Emergence/Extubation
• PONV

39. 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

40. 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

41. 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

42. 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

43. 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

44. INTRAOPERATIVE MANAGEMENT
Haemodynamic Changes “Treatment”
• Immediate cessation of the stimulus
• Blockage of the sinus with local anesthetic by the surgeon
• Vagolysis by atropine

45. 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

46. Venous Air Embolism
Treatment
• Compression of neck veins
• Positive pressure ventilation
• Left lateral position
• Aspiration of air through the central venous catheter
• Ionotropes
INTRAOPERATIVE MANAGEMENT

47. POST-OPERATIVE CARE
ROUTINE CARE
SPECIAL CONSIDRATIONS
• ICU care & Possible mechanical Ventilation
• Hemodynamic Instability
• Analgesia
• Tracheostomy

48. 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

49. 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

50. 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

51. POST-OPERATIVE CARE
Tracheostomy Care
• Humidified Oxygen
• Intermittent Suction
• Sterile Precautions
• Adjustment of cuff pressure to15-20 mmHg
• Complications

52. 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.

53. • 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.

54. • 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

55. Issues
• Associated defects/injuries
• Shared airway
• Difficult intubation
• Bleeding & Induced hypotension
• Emergence/Extubation
• PONV

56. 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

57. Issues
• Associated defects/injuries
• Shared airway
• Difficult intubation
• Bleeding & Induced hypotension
• Emergence/Extubation
• Post-operative complications

58. 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

59. 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

60. 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

61. 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