Cases reported • Mandibular Fractures

1/11. Sevoflurane mask anesthesia for urgent tracheostomy in an uncooperative trauma patient with a difficult airway.

PURPOSE: Proper care of the trauma patient often includes tracheal intubation to insure adequate ventilation and oxygenation, protect the airway from aspiration, and facilitate surgery. Airway management can be particularly complex when there are facial bone fractures, head injury and cervical spine instability. CLINICAL FEATURES: A 29-yr-old intoxicated woman suffered a motor vehicle accident. Injuries consisted of multiple abrasions to her head, forehead, and face, right temporal lobe hemorrhage, and complex mandibular fractures with displacement. mouth opening was <10 mm. blood pressure was 106/71 mm Hg, pulse 109, respirations 18, temperature 37.3 degrees C, SpO2 100%. Chest and pelvic radiographs were normal and the there was increased anterior angulation of C4-C5 on the cervical spine film. Drug screen was positive for cocaine and alcohol. The initial plan was to perform awake tracheostomy with local anesthesia. However, the patient was uncooperative despite sedation and infiltration of local anesthesia. Sevoflurane, 1%, inspired in oxygen 100%, was administered via face mask. The concentration of sevoflurane was gradually increased to 4%, and loss of consciousness occurred within one minute. The patient breathed spontaneously and required gentle chin lift and jaw thrust. A cuffed tracheostomy tube was surgically inserted without complication. Blood gas showed pH 7.40, PCO2 35 mm Hg, PO2 396 mm Hg, hematocrit 33.6%. Diagnostic peritoneal lavage was negative. Pulmonary aspiration did not occur. Oxygenation and ventilation were maintained throughout the procedure. CONCLUSION: Continuous mask ventilation with sevoflurane is an appropriate technique when confronted with an uncooperative trauma patient with a difficult airway.

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2/11. Modified retrograde intubation in a patient with difficult airway.

We report a modified technique of retrograde endotracheal intubation in a patient with limited motility at the atlanto-occipital joint, temporomandibular joint, and cervical spine, presenting for closure of a large oronasal fistula. Despite more recent advances in intubation techniques and technology, retrograde intubation still deserves a place in the anesthetist's armamentarium for the management of the difficult airway.

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3/11. Modified submental orotracheal intubation using the blue cap on the end of the thoracic catheter.

The technique of submental intubation in patients with multiple facial fractures and skull base fracture was originally described by Altemir. This technique provides a secure airway and allows intermaxillary fixation while avoiding the complications of nasotracheal intubation or tracheostomy. However, when the endotracheal pilot balloon and endotracheal tube are pulled through the submental incision site using this technique, soft tissues or blood may enter the endotracheal tube and trauma may result in the surrounding tissues. To overcome these problems, we carried out a modification of submental orotracheal intubation using the blue cap on the end of the thoracic catheter in a patient with mandibular fractures and injury to the skull base and found that this modification resulted in a safer and less traumatic intubation.

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4/11. A case report of malignant hyperthermia in a dental clinic operating room.

A healthy 5-year-old boy presented for arch bar placement under general anesthesia in an operating room in a dental school. The patient had previously undergone general anesthesia without complication, and no family history of anesthetic problems were reported. halothane mask induction, intravenous catheter placement, and nasal intubation proceeded uneventfully without the aid of a muscle relaxant. Halfway through the procedure, signs and symptoms of malignant hyperthermia, including muscle rigidity, hypercarbia, tachypnea, and tachycardia were noted. Immediate treatment, including discontinuation of the triggering agent, dantrolene administration, and cooling measures were applied, and once stable, the child was transferred to Columbus Children's Hospital for further management. The patient experienced no postoperative complications. Further discussion regarding the pathophysiology and management of malignant hyperthermia is provided.

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5/11. ludwig's angina: a case report and review.

A case of ludwig's angina which developed after mandibular fractures in a 14-year-old male patient is reported. We emphasise the serious nature of this condition and the aggressive treatment it requires. It is important to recognise cases of ludwig's angina at an early stage, as well as cases which are at risk of developing into true ludwig's angina if treatment is delayed. Management should be aimed at maintaining an open airway by nasotracheal intubation or cricothyroidotomy, together with treatment of the infection by removal of the source, drainage of pus and parenteral antibiotic therapy. In addition, investigation and management of contributing medical conditions and timely specialist consultation are essential.

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6/11. The brain laryngeal mask. An alternative to difficult intubation.

We report the case of a young man undergoing fixation of bilateral mandibular fractures, where the anaesthetist was unable to intubate. A brain laryngeal mask was employed, thus enabling surgery to proceed. This relatively new device enabled the airway to be safeguarded whilst preserving reasonable surgical access for the attachment of Erich arch bars and a four hole osteosynthetic bone plate. The surgical and anaesthetic procedures are summarised. The laryngeal mask is described and its performance and limitations are discussed. We believe this to be the first report of mandibular fracture fixation performed with a brain laryngeal mask in situ.

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7/11. Superior laryngeal nerve block: an aid to intubating the patient with fractured mandible.

Awake nasotracheal intubation in the patient with a fractured mandible may be facilitated by combining bilateral superior laryngeal nerve block with topical application of local anesthetic to the nose, mouth, and trachea. Successful use of this technique is described in two such patients.

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8/11. pulse oximetry signals local anesthetic-induced methemoglobinemia.

An otherwise healthy patient with a fractured mandible was scheduled to undergo an open reduction under general anesthesia. Just before transport to the operating room, bimaxillary arch bars were placed under local anesthesia with 4% prilocaine and 1:200,000 epinephrine. Although induction of anesthesia and nasoendotracheal intubation were uneventful, pulse oximetry values fell to 89% despite adequate ventilation and an inspired oxygen concentration of 50%. Inquiry by the anesthesiologist and arterial blood gas measurements revealed that methemoglobinemia had developed in response to the large amount 576 mg) of prilocaine administered. A total of 150 mg of methylene blue administered in two doses corrected the problem. The oral surgeon, having recently switched to prilocaine because of a manufacturer's recall of lidocaine, was unaware of the potential of prilocaine to cause this disorder.

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9/11. Awake fibreoptic intubation in the semi-prone position following facial trauma.

A fit 27-year-old man presented with severe facial trauma following an industrial accident. Initial assessment showed severe swelling around the lower jaw and haemorrhage from the mouth, nose, scalp and left ear. The patient was conscious with a Glasgow coma Score of 13 but in respiratory distress. Following adoption of the prone position his airway improved. Relief of the patient's airway obstruction was a priority and the patient underwent awake fibreoptic intubation in the prone position prior to induction of anaesthesia. Computed tomography scans of his head and neck were unremarkable and after fixation of a bilateral mandibular fracture he made an uneventful recovery. intubation in the semi-prone position may be a useful technique in injuries of this type.

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10/11. Nasotracheal intubation in the presence of frontobasal skull fracture.

PURPOSE: To present a case of maxillofacial trauma and basal skull fracture (BSF) in whom nasotracheal intubation (NTI) was successfully used, without complication, to facilitate surgical fixation. To present alternative methods of airway management in this situation and to review the evidence supporting the notion that NTI is contraindicated in the presence of basal skull fracture. CLINICAL FEATURES: A 17-yr-old man was referred for surgical fixation of bilateral mandibular fractures. Cranial computed tomography revealed intracranial air and blood in all four sinuses and distortion of the nasal passage on the right. There was no cerebral injury and the left nasal passage appeared patent. In order to facilitate intraoperative intermaxillary fixation fibreoptic NTI was undertaken in preference to tracheostomy. The patient made an uneventful recovery without evidence of meningitis or direct cerebral injury. CONCLUSION: In selected patients NTI may be performed in the presence of BSF. Available evidence suggests that BSF-should not be regarded as an absolute contraindication to NTI.

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