maxillofacial surgery

2.  Dentoalveolar surgery
 Maxillofacial trauma
 Orthognathic surgery
 Temporomandibular Joint disorders
 Salivary gland surgery
 Head and Neck tumours
 Reconstructive surgery

3. Trauma

6. Tumours

7. SYNDROME DESCRIPTION
Down Large tongue, small mouth make laryngoscopy difficult;
small subglottic diameter possible
Laryngospasm frequent
Goldenhar Mandibular hypoplasia and cervical spine abnormality
make laryngoscopy difficult
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

8. Congenital
Deformities

11.  Major cases have a heavy reliance on
GA
 Shared operative site between the
anesthesiologist and the surgeons
 More challenging airways than any
other specialty
 Major cases require a precise and
delicate anesthetic management

12.  ABCDE of ATLS protocol
 Does not come in isolation
 Airway complicated by loose teeth, oral
/ pharyngeal bleeding, foreign bodies,
collapsed bones and anterior neck
injuries
 Associated C spine injuries very
common; further complicate airway
management

13.  Things to look for
› Mandibular mobility
› Tongue mobility and size
› Status and fragility of dentition
› Amount of oral secretions
› Hemorrhage, foreign body or a mass in oral
cavity / pharynx

14. 1. Recognize airway obstruction
2. Clear airway
3. Reposition patient
4. Utilize artificial airways
a. Oral airway
b. Nasopharyngeal airway
c. Other airway adjuncts
5. Perform endotracheal intubation
6. Cricothyrotomy
7. Tracheostomy

18. Laryngeal Mask
Airway (LMA)

21.  Rapid sequence intubation
• Sellick maneuver
• Pre oxygenation
• No ventilation
• Never nasal intubation
 ? Fiberoptic intubation Expertise required
in emergency situation

22.  Preferably nasal intubation; except
• Nasal & BOS #
 Be cautious about posterior pharyngeal
lacerations
 Intra op Nasal  Oral  Nasal shift (panfacial #)
 Other possible routes; esp when post op IMF and
nasal packing planned
• Submental
• Retromolar
• Buccal (cheek laceration)

23. PATHOLOGIC STATE DIFFICULTY
Laryngeal fracture Airway obstruction may worsen during
instrumentation
Cervical spine injury Neck manipulation may traumatize spinal cord
Maxillary/mandibular
injury
Airway obstruction, difficult mask ventilation,
and intubation; cricothyroidotomy may be
necessary with combined injuries
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

24. PATHOLOGIC STATE DIFFICULTY
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
Endocrine/metabolic
acromegaly
Large tongue, bony overgrowths

27.  Cricothyrotomy
 Tracheostomy
 Retrograde intubation
 Transtracheal jet insufflation

29.  Topical
 Nerve blocks
 Ganglion block
 Field block

31.  Reassurance & confidence building
 Venous access
 Monitoring
 Warm fluids and
 Ensure availability of blood products

32.  Thermal control
 Eye protection
› Keep them in surgical field  Protective
lubricant or tape
› If covered  Thick padding
 Urinary catheterization
› > 4 hours
› Urinary output monitoring
 NG tube insertion

33.  Pre medication
• ‘Localized neurogenic shock’  Lesser pain after facial
trauma
• Sedation with Midazolam
• Anti emetics
• Anti cholinergic; Atropine or Glycopyrrolate
 Induction
• ? Barbiturates  Hypotension
• Ketamine  increases catecholamine levels & maintain
BP and cardiac output
• Etomidate (0.3 – 0.5 mg/kg)
• Propofol
• 20-30 % decrease in BP
• Decreases heart rate

34.  Surgical position
• Ideal
 Longer circuit
 RAE (Ring-Adair-Elwyn) tube
 Machine away from head; ? Foot end
 Secure tube and connections
 Suture tube  columellar suture
 Intra operative
• LA delivery; Surgeon informs anaesthetist
• Adequate muscle relaxation
• Orbital #  Forced duction test  Oculocardiac reflex  Vagally
mediated bradycardia
• Panfacial #; nasal  oral  nasal (Bottom – top approach)
 Previously trachys or other routes
 IMF + nasal packing  Trachy
• Current ORIF techniques  Post op IMF not common

35.  Pre requisites
• Good health
• Hematocrit at least 34 %
• Hb at least 11 g / dL
 Fe sulphate 150 mg OD; 2/52 before donation
• Continue till day of surgery
• After hospital discharge

36.  Careful estimate of blood loss
 Autologous blood transfusion
 Hemodilution
 Aprotinin
• Serine protease inhibitor
• Inhibits plasmin, and plasminogen
• Anti fibrinolytic  No evidence of thrombosis
• 200 mL stat (2,000,000 KIU)
• Continuous infusion. 50 mL (500,000 KIU)

37.  Deeper anaesthesia
• Narcotics, e.g. morphine, pethidine, nalbuphine, fentanyl,
sufentanyl
• Inhalational agents, e.g. Isoflurane, Sevoflurane
• Relaxants
 Pharmacological
• Adrenergic blockers, e.g. Labetolol, Esmolol, Atenolol
• Ganglion blockers, e.g. guinethidine, Trimethaphan
• Direct acting vasodilators, e.g. Nitroprusside,
Nitroglycerine,
• Calcium channel blockers, e.g. Nicardipine

38.  Head-up posture
 Minor degree of reverse Trendelenburg
tilt (10 – 15 degrees)
 1 cm rise in surgical area  0.77 mm Hg
fall in BP
 10 degrees tilt = 6 inches = 15 cm =
Decrease of 11.5 mm Hg

39.  Colloids
 Crystalloids
 Whole blood
 Red cell concentrate
 FFP

40.  Rewarming
 Post op transfusion
› Haemorrhage
› Hb <9 g/dl
 ICU / HDU essential
 Accurate physiologic monitoring
 Elective post op ventilation
 Analgesia & Sedation
› Nalbuphine / Ketorolac
› PCA

41. Prolonged surgery
Intensive monitoring
Exhaustive vigilance
Concealed patient
Blood loss
Difficult airways
Anesthetic choiceRecovery problems
Surgeon’s
expertise
Financial issues