Maxillofacial surgery involves the head, neck, face and jaws and can be done for congenital deformities, injuries, or tumors. Anesthesia for these procedures presents several challenges including a shared airway, potential for difficult intubation, blood loss requiring induced hypotension, and risks during emergence like airway obstruction. Careful pre-operative planning is important to choose the best airway management strategy and prevent complications. Induced hypotension can improve surgical conditions but risks need to be weighed. Emergence and extubation also require vigilance to address swelling and ensure hemostasis and a secure airway.

1. Maxillofacial surgery
Anesthetic Issues
Dr Bikash Subedi
2nd yr resident
Moderator: Dr Sushila Tabdar
Assoc. Professor
Department of Anesthesia & IC,KMCTH

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

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

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

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

8. 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

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

10. 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)

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

12. DIFFICULT AIRWAY
ALGORITHM

13. 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.

14. 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.

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

16. 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

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

18. 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

19. 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
• *Choi WS, Samman N
• . Risks and benefits of deliberate hypotension in anaesthesia: a systematic review. Int J Oral Maxillofac Surg 2008;37:687-
703. doi:10.1016/j.ijom.2008.03.011.

20. 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

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

22. Emergence and Extubation
• Discontinue Induced hypotension
• Removal of the throat pack
• ?Airway cleared with suction
• Ensure hemostasis before jaw wiring is carried out (esp if
intermaxillary fixation)
• Deep smooth Vs Safer Awake extubation

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

24. 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

25. 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

26. 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

27. 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