Anaesthesia For OMF Surgery

DENTAL AND MAXILLOFACIAL ANAESTHESIA

Anaesthesia for Learning objectives

maxillofacial surgery After reading this article, you should be able to
C identify symptoms and signs that indicate impending airway
Luay Kersan compromise
Urmila Ratnasabapathy C discuss choice of airway technique for a range of oral maxillo-
facial procedures including rationale behind your choice
C outline the important factors in optimizing vascular perfusion
Abstract for free flap tissue transfer reconstructive surgery
Airway management is central to anaesthesia for maxillofacial surgery.
Not only is there a shared airway to contend with, difficult airways are Nasendoscopy is useful for examining the upper airway to
frequently encountered. The main pathologies that present for surgery assess the significance of any swelling, distortion or peri-glottic
include trauma, infection, cancer and craniofacial deformities. All of lesions. This may be complemented by CT, MRI and recon-
these may present an airway challenge in either elective or emergency structed images. Three-dimensional (3D) images and use of post-
settings but a similar approach to the airway can be used in all these reconstruction processing software allows the creation of a vir-
scenarios. Other surgical procedures include dental extractions, tual 3D endoscopy.2 Discussion with both the surgeon and
temporomandibular joint (TMJ) arthrocentesis, salivary gland surgery radiologist regarding pathology, level and severity of stenosis or
and facial aesthetic surgery. presence of sub-glottic extension is useful. It is important to be
It is vital that clear airway management plans including rescue plans aware that supraglottic tumours may cause difficult tracheal
are made at the outset. These must be communicated to the surgical intubation.
and anaesthetic team in advance. Trauma is excluded as it will be
covered in a separate review article. Intraoperative anaesthesia
Keywords Airway management; CICO; craniofacial surgery; dental
The main intraoperative consideration is the choice of an
abscess; enhanced recovery; fibreoptic intubation; head and neck
appropriate airway technique and airway device tailored to the
cancer; maxillofacial; tracheostomy
patient and surgical procedure.
Royal College of Anaesthetists CPD Matrix: 1B02, 1C01, 2A01, 2A03, Airway devices include:
2A05, 3A01, 3A02 Laryngeal mask airways (standard or flexible) for simpler
procedures including dental extractions and superficial
facial surgery
Endotracheal tube (oral, nasal or submental)
If dental occlusion needs to be assessed post-procedure a
Preoperative assessment
nasal tube is preferred. A preformed north-facing nasal
The first priority in airway assessment is to determine whether tube facilitates surgical access, however does not allow for
airway compromise is present. Airway compromise may present easy suctioning. A laser tube for laser surgery or micro-
overtly with stridor, gurgling, drooling or inability to speak. Less laryngoscopy tube may be necessary for examination
overt symptoms that should be specifically enquired about are under anaesthesia procedures.
hoarseness, dysphagia, drooling and orthopnoea as these may A surgical airway (cricothyroidotomy, surgical tracheos-
signify impending airway obstruction. tomy or percutaneous tracheostomy).
Airway difficulty should be anticipated in patients who have Communication with the surgeon as well as with the rest of
had previous radiotherapy and/or complex reconstructive sur- the anaesthetic team regarding the airway plan and rescue plans
gery. In two large studies, independent predictors of difficulty or should be carried out well in advance so that additional re-
inability to facemask ventilate included neck radiation changes, sources/staff are close at hand.
male sex, sleep apnoea, Mallampati score of III or IV, presence of As the airway is shared, it is important to ensure that the
beard, body mass index over 25 kg/m2, age over 55 years, lack of airway conduit used is secure along with all its connections. An
teeth and history of snoring.1 Previous anaesthetic charts can airway conduit can become occluded when a Boyle Davis gag is
provide valuable information regarding airway management. applied.
A standard airway examination should be performed with Other possible requirements include:
particular attention to swellings or masses, mouth opening, Use of a throat pack
tongue enlargement and ability to protrude the tongue. With intra-oral procedures, there is airway soiling, therefore a
throat pack is generally used intraoperatively. It is vital to
Luay Kersan FRCA is a Specialist Registrar in Anaesthesia on the communicate to the theatre team that a throat pack has been
West of Scotland School Rotation, UK. Conflicts of interest: none inserted so that it can be clearly marked on the patient and
declared. documented on a visible location (e.g. theatre whiteboard).
Extended breathing circuits
Urmila Ratnasabapathy FRCA MAcadMEd is a Consultant Anaesthetist
at the Institute of Neurosciences and Spinal Unit, Queen Elizabeth These may be required. Patients are usually positioned on a
University Hospital, Glasgow, UK. Conflicts of interest: none head-up tilt to improve venous drainage. A head ring/horseshoe
declared. headrest and a shoulder support may be required.
ANAESTHESIA AND INTENSIVE CARE MEDICINE --:- 1 Ó 2017 Published by Elsevier Ltd.

Please cite this article in press as: Kersan L, Ratnasabapathy U, Anaesthesia for maxillofacial surgery, Anaesthesia and intensive care medicine
(2017), http://dx.doi.org/10.1016/j.mpaic.2017.06.010
Eye protection
Eye pads with/without viscous ointments are used. Surgical
Buccinator
shields are the alternative to eye pads if the pads are impinging muscle
on the surgical field. Tongue
Antibiotic prophylaxis
(e.g. co-amoxiclav 1.2 g intravenously). Cheek
Steroids
(e.g. dexamethasone 4e8 mg intravenously).
Buccal space Sublingual
This may help reduce postoperative airway swelling.
space
Active warming
Mylohyoid
For longer cases, a forced air warming blanket and intrave- muscle
nous fluid warmer are used.
Venous thromboembolic (VTE) prophylaxis Sub- Hyoid
For longer cases, VTE prophylaxis should be considered (e.g. bone
mandibular
enoxaparin 40 mg subcutaneously, thromboembolic deterrent space Deep investing
stockings and pneumatic calf compression boots). Pressure care cervical fascia
should also be instituted.
Blood transfusion Figure 1 Coronal section of right mandible showing potential paths of
Anti-emetics spread of infection from a carious wisdom tooth.
Multi-modal analgesia
Tracheal extubation must be planned and prepared for care-
fully. In an uncomplicated airway, the trachea can be extubated compromise and to review the results of imaging and flexible
either ‘deep’ or ‘awake’ at the end of surgery. Deep extubation nasendoscopy.
may confer the benefits of a smooth awakening with no cough- The latter is a special condition known as Ludwig’s angina.
ing, however awake extubation minimizes the chance of pul- Airway obstruction occurs due to elevation of the tongue.
monary aspiration of intra-oral debris. Inability to protrude the tongue is a sensitive indicator of this
If a throat pack is in, it should be removed from the patient at the condition. It is affected because of the C shape of the genio-
end of the procedure. Suction under direct vision prior to tracheal glossus muscle. The concavity of the C shape produces the
extubation is important to clear any intra-oral clots that may sublingual space. Oedema or pus in this space prevents the
have formed. A slightly head-up position is helpful for wakening. muscle folding over itself to enable tongue protrusion.4
Generally, if there is sufficient mouth opening, the airway can
Postoperative complications usually be secured initially with general anaesthesia (GA) and
direct/indirect laryngoscopy.
Most oral and maxillofacial surgical procedures have the poten- Where AFOI is required for tracheal intubation, note that
tial to compromise the airway postoperatively.3 topicalization with local anaesthesia may only be partially
It is essential to anticipate the possibility of airway compro- effective in infected tissue.
mise postoperatively and consideration should be given as to In cases of severe airway obstruction or in the case of failed
whether it may be appropriate to: AFOI, an awake tracheostomy under local anaesthesia may be
awaken the patient and extubate the patient’s trachea required. It would be prudent to request that the surgeons pre-
immediately postoperatively pare and infiltrate the neck with local anaesthetic and adrenaline
admit to the intensive therpay unit for a delayed tracheal prior to AFOI in preparation for tracheostomy. It is also best to
extubation carry out the AFOI in the operating theatre rather than in the
insert a tracheostomy. anaesthetic room. Emergency surgical tracheostomy may be
technically more challenging with anterior swelling of the neck.
Head and neck infection If significant laryngeal swelling is noted intraoperatively then
The most frequent source of infection is a dental abscess. This either delayed extubation in the critical care unit or elective
can affect the airway when there is spread into deep fascial tracheostomy can be performed. When tracheal extubation is
spaces. The commonly involved spaces are the buccal, sub- being considered, establish that a ‘cuff down’ leak is present to
mandibular and sublingual space (Figure 1). exclude significant airway swelling prior to extubation.
Trismus is usually the main problem affecting the airway. Pulmonary aspiration is a risk if there is spontaneous or iat-
Marked limitation of mouth opening may necessitate an awake rogenic rupture of the abscess. As such, extra care with airway
nasal fibreoptic intubation (AFOI). Less commonly, but more instrumentation is recommended. In addition to airway compli-
serious, is the potential for airway obstruction. This can occur in cations, pre-maxillary spread can lead to orbital cellulitis which
two situations: in turn can lead to cavernous sinus thrombosis. In severe cases
spread of infection into the parapharyngeal space systemic sepsis or mediastinitis can occur with high mortality.
bilateral infection of the submandibular and sublingual
space. Head and neck cancer
The former may cause no visible swelling. It is important, Tumours are usually squamous cell carcinomas which
therefore, to enquire about symptoms or signs of airway metastasize to lymph nodes in the neck. Oral cancers are
associated with smoking and alcohol excess so cardiorespiratory Spraying the larynx with local anaesthetic may precipitate
co-morbidities are more common. Malnutrition is also more total airway obstruction.
likely if there has been chronic dysphagia. Airway obstruction is often due to direct invasion of the
Airway difficulty can arise due to distortion of the airway by the airway as opposed to extrinsic compression. Passing a
tumour or as a consequence of radiotherapy. Complex recon- fibreoptic scope may also therefore precipitate complete
structive surgery in itself can also alter the anatomy creating a airway obstruction.
difficult airway. Preoperative assessment should focus on identi- Tumours are often friable and prone to bleeding especially
fying any airway obstruction. In non critical airway obstruction, supraglottic tumours.5
nasendoscopy is crucial in guiding airway management. Awake tracheostomy under local anaesthesia
Airway technique options include: This is the safest option in cases of severe airway obstruction,
General anaesthesia where the nasendoscopic view of the larynx is inadequate and
Good visualization of the larynx on nasendoscopy in a patient where AFOI is unsuitable.
that is not acutely stridulous suggests that it is safe to proceed to
GA. It must be remembered that the laryngeal view is likely to be Reconstructive surgery
less favourable in the supine anaesthetized patient compared to
The development of free tissue transfer has led to advanced
the sitting awake patient. Furthermore, the nasendoscopic view
reconstructive techniques for head and neck cancer surgery.
does not always directly correlate with the view that is obtained
Excision of the primary tumour is usually combined with neck
on direct laryngoscopy.5
dissection. If primary closure is not possible, tissue grafts are
Even if it is deemed safe to proceed to GA there remains a
inserted into the resulting defects. These grafts may be local
danger of a ‘can’t intubate can’t oxygenate’ (CICO) scenario
flaps, vascular pedicle flaps or free flaps. Free flaps are formed
arising. Therefore, additional measures to be considered include:
by transfer of free vascularized tissue from a donor site that is
Induction in theatre
then re-anastomosed at the site of the defect. The graft may
High-flow nasal oxygen
consist of just soft tissue or can be composite in the case of bony
This should be applied in theatre prior to induction. With this
defects.
technique, pre-oxygenation is optimized and apnoeic
Specific considerations include a possible difficult airway and
oxygenation can be provided. This can be especially useful
probable requirement for tracheostomy. This is best inserted at
during intubation attempts and in CICO scenarios until front
the start of surgery rather than at the end of major head and neck
of neck access is obtained.
reconstructive work. Controlled hypotension with remifentanil
Front of neck access
infusion (0.05e0.3 mg/kg/minute) is useful during tumour
Surgeons must be prepared to perform emergency tracheos-
resection to reduce blood loss and improve the surgical field.
tomy. If the patient is in danger of hypoxia then surgical cri-
A change of patient position may be required intraoperatively
cothyroidotomy provides faster front of neck access. As
to allow surgical access to harvest the free flap. Occasionally,
previously mentioned, surgical preparation of the neck with
more than one free flap is required.
local anaesthetic infiltration prior to induction saves valuable
After free flap anastomosis the priority is to optimise perfu-
time.
sion to the tissue graft. The blood flow to free vascularized tissue
Jet ventilation
is often halved and can take weeks to return to normal.
Supraglottic or trans-tracheal jetting should be on standby.
To optimize perfusion to the graft:
Trans-tracheal jetting requires preemptive placement of a
An adequate arterial pressure should be maintained well
cricothyroid cannula. Jetting is rarely used in OMFS and can
into the postoperative period.
cause barotrauma.
As laminar flow is viscosity-dependent, a haematocrit of
A technique that has been described in the literature is awake
30% is accepted as the best target for microcirculatory
videolaryngoscopy. This involves performing video-
blood flow.
laryngoscopy in an awake patient. In order to overcome the
Judicious fluid management is also necessary to optimize
gag reflex, topicalisation of the oropharynx with local anaes-
flap perfusion. Over-hydration brings a risk of flap oedema
thesia in conjunction with some degree of conscious sedation is
since there is no intact lymphatic drainage in the free flap
required. These requirements carry additional risk in patients
whereas under-hydration may contribute to flap throm-
with an obstructing tumour.6
bosis. It is recommended that the optimum fluid load
Awake fibreoptic Intubation (AFOI)
should be based on goal directed fluid therapy guided by
AFOI may be an appropriate technique if difficult intubation is
arterial pressure and cardiac output monitoring.7 Zero
suspected because of radiotherapy, reconstructive surgery or in
balance may also be used where the aim is to maintain pre-
situations where airway distortion from the tumour is in the
operative weight. The use of central venous pressure
upper anterior part of the airway as it should allow for the patient
monitoring is thought to be less helpful.7
to maintain their own airway. It is however, important to note
The consensus opinion on blood transfusion supports a
that AFOI can be hazardous in patients with stridor or in tumours
restrictive policy due to the associated increased risk of
nearer the larynx. This situation is more commonly encountered
complications such as wound infection. A transfusion
in ENT surgery rather than OMFS. There are numerous reasons
trigger of 7 g/dl is accepted with higher triggers of 8 g/dl in
as to why AFOI may not be a wise choice in these circumstances:
asymptomatic coronary disease and 10 g/dl in ongoing
Local anaesthesia is difficult to achieve in the presence of
ischaemia.7
tumour.
Temperature control is vital. Postoperative shivering in- Postoperatively intensive flap monitoring is vital. This is
creases oxygen consumption and has been shown to needed at least hourly for the first 48 hours and consists of clinical
decrease free flap blood flow. Hypothermia causes vaso- observation of colour and capillary refill with surface temperature
constriction and reduced flap perfusion. monitoring in a Level 2 or Level 3 critical care unit.7
Antibiotic prophylaxis, VTE prevention, pressure care, post- The application of enhanced recovery after surgery (ERAS) to
operative nausea and vomiting (PONV) prophylaxis and multi- major head and neck cancer surgery has led to other recom-
modal analgesia are all also fundamental to perioperative care. mendations for perioperative care. Minimizing preoperative
Vomiting may cause wound dehiscence and flap failure and pain fasting is emphasized and preoperative carbohydrate loading
can result in sympathetic activation. Local anaesthesia wound coupled with early postoperative nutrition should be considered.
infusion catheters are used for some donor sites in free-flap Pulmonary physiotherapy, early tracheostomy decannulation,
reconstructive surgery. postoperative mobilization and removal of urinary catheters are
In most instances, the patient is gradually awakened in the also encouraged.
intensive care unit, often with a tracheostomy in-situ. In shorter There has been a recent trend of avoiding tracheostomy by
cases where there is no tracheostomy and it is planned to managing patients with endotracheal tubes intra- and post-
awaken and extubate the patient at the end of surgery, it is operatively. This has been with the intention of avoiding com-
desirable to avoid patient coughing and/or surges in blood plications of tracheostomy and entails overnight sedation in
pressure to protect the flap. This may be achieved by extubating critical care postoperatively for toleration of the endotracheal
on remifentanil or exchanging the endotracheal tube for a tube. In several retrospective reviews of small numbers of pa-
laryngeal mask airway. tients, this technique has been shown to be safe in a specially
Management of the airway after maxillofacial free-flap reconstruction
• Oral resection + bilateral neck dissection

Tumour/surgical factors
• Oropharyngeal resection + access procedure
Oral/mid-face/mandibular resection
+ unilateral neck dissection
Significant patient factors?

• Obstructive sleep apnoea Yes Consider Failure or multiple further
• Obesity
TRACHEOSTOMY procedures required
• Poor lung function
No
Endotracheal intubation
• Nasal or oral with extubation
No
Postoperative reassessment No Delayed extubation

• Safe to extubate? • Likely safe 24–48 hours
Yes
Immediate extubation EXTUBATION
Successful
• Transfer to ward/HDU
Singh T, Sankla P, Smith G. Tracheostomy or delayed extubation after maxillofacial free
Br J Oral Maxillofacial Surgery 2016; 54 (8): 878–82.
Figure 2
selected cohort of patients. A recent post-hoc study of a large Rarely, intermaxillary fixation or jaw wiring is needed but this
number of patients concludes that there appears to be no dif- is now more commonly done with elastic bands. In these cir-
ference in the rate of airway complications when comparing cumstances, wire cutters or ordinary scissors for elastic bands
tracheostomy with delayed tracheal extubation but there remains must be immediately available in the postoperative period.
insufficient evidence to definitively support one technique over Bleeding from the maxilla can be extensive. Techniques used
the other.8 Tracheostomy is still required for selected patients to deal with this include positioning the patient head up,
(Figure 2) and in patients undergoing bilateral neck dissection as ensuring free venous drainage, infiltration with large doses of
the risk of postoperative airway oedema is high.9 adrenaline-containing local anaesthetic solutions and controlled
The National Tracheostomy Safety Project mandates that all hypotension (e.g. remifentanil infusion).10 Antibiotic prophy-
patients with a tracheostomy are accompanied by a bedhead sign laxis, multi-modal analgesia, PONV prophylaxis and corticoste-
with key information along with a standardised tracheostomy roids to reduce swelling are also important components of
emergency algorithm. All tracheostomies must have the inner care. A
cannula in-situ.
Decannulation and stoma closure facilitates recovery of res-
REFERENCES
piratory and swallowing function. Most patients can be safely
1 Cook TM, MacDougall-Davis SR. Complications and failure of
decannulated within a week of surgery.
airway management. Br J Anaesth 2012; 109(suppl 1): i68e85.
Craniofacial surgery 2 Crawley S, Dalton A. Predicting the difficult airway. BJA Educ
This includes cleft lip and palate repair, TMJ and orthognathic 2014; 15: 253e7.
procedures. 3 Garcia L. Postoperative nursing considerations for the maxillofa-
Cleft lip and palate surgery is usually performed in children so cial surgical patient. In: Shaw I, Kumar C, Dodds C, eds. Oxford
will not be discussed in this review. TMJ surgery is performed for textbook of anaesthesia for oral and maxillofacial surgery. Oxford:
painful locking or arthritic degeneration and orthognathic sur- Oxford University Press, 2010; 312. ISBN: 9780199564217.
gery is performed for facial asymmetry, facial deformity or dental 4 Morosan M, Parbhoo A, Curry N. Anaesthesia and common oral
malocclusion. The maxilla or mandible may be ‘set back’ or and maxillo-facial emergencies. Contin Educ Anaesth Crit Care
‘advanced’ in orthognathic surgery. Pain 2012; 12: 257e62.
A Le Fort I osteotomy changes the position of the maxilla and 5 Rees L, Mason RA. Advanced upper airway obstruction in ENT
a sagittal split osteotomy changes the position of the mandible. surgery. Contin Educ Anaesth Crit Care Pain 2002; 2: 134e8.
The combination of maxillary and mandibular surgery is called 6 Lohse JA, Piepho T, Noppens RR. Awake video laryngoscopy e a
bimaxillary osteotomy. revolution in the management of the anticipated difficult airway?
Cosmetic indications for surgery tend to present in patients Trends Anaesth Crit Care 2016; 6: 37e42.
that are young and fit. However obstructive sleep apnoea is 7 Dort JC, Farwell DG, Findlay M, et al. Optimal perioperative care
common and congenital facial deformities may occur as part of in major head and neck cancer surgery with free flap
complex syndromes. It is important to be alert to airway diffi- reconstruction. A consensus review and recommendations from
culties which may occur as a result of retrognathia or limited the Enhanced Recovery After Surgery Society. J Am Med Assoc
mouth opening. OtolaryngoleHead Neck Surg 2017; 143(3): 292e303.
Nasal intubation is preferred in orthognathic surgery to enable 8 Cramer JD, Samant S, Greenbaum E, Patel UA. Association of
assessment of dental occlusion. Submental intubation is occa- airway complications with free tissue transfer to the upper aero-
sionally required if the nasal route is difficult (e.g. after cleft digestive tract with or without tracheotomy. J Am Med Assoc
palate repair) or if the surgeon requires access to the upper part OtolaryngoleHead Neck Surg 2016; 142: 1177.
of the face. In submental intubation, the patient’s trachea is 9 Singh T, Sankla P, Smith G. Tracheostomy or delayed extubation
intubated orally. The proximal end of the endotracheal tube after maxillofacial free-flap reconstruction? Br J Oral Maxillofac
along with the pilot balloon is then passed through a surgical Surg 2016; 54: 878e82.
incision made through the floor of the mouth out to the sub- 10 Beck JI, Johnston KD. Anaesthesia for cosmetic and functional
mental skin. The process is reversed at the end of surgery so that maxillofacial surgery. Contin Educ Anaesth Crit Care Pain 2013;
the patient can be extubated orally. 14: 38e42.

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DENTAL AND MAXILLOFACIAL ANAESTHESIA

Anaesthesia for Learning objectives

Management of the airway after maxillofacial free-flap reconstruction

• Oral resection + bilateral neck dissection

Significant patient factors?

Postoperative reassessment No Delayed extubation

Immediate extubation EXTUBATION

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