Airway management in a patient with Le Fort III Fracture
A 27-year-old male was brought to the operating room with severe blunt injury isolated to the face. He was scheduled for open reduction and fixation of facial fractures under general anesthesia.\nThe patient was in the sitting position, head slightly bent down, conscious and oriented. He exhibited a dish-face deformity with periorbital edema, multiple lacerations and dropped upper jaw. He had profuse bleeding from the nose and the mouth []. Both nares were obstructed with no flow of air and the patient was breathing from his mouth with difficulty. When asked to lie down in the supine position, the patient started suffocating and desaturated. The airway assessment revealed the inability to open the mouth. Monitoring included electrocardiogram, pulse oxymeter and non-invasive blood pressure. The laboratory investigations revealed a normal hemogram and coagulation profile.\nRadiological 3 dimensional computed tomography scan examination revealed fractures of bilateral maxilla, mandibular symphisis, left infraorbital region and nose. The skull base and the cervical spine were intact [].\nTracheostomy under local anesthesia was suggested prior to anesthesia and surgery to secure the airway because of the impossibility to perform the standard oral intubation and the contraindicated nasal intubation. The ear, nose, and throat surgeon refused to do the awake tracheostomy because of the unsuitable surgical position (sitting and head bent down). The discussion with the surgeon led to the following strategy: With the index behind the soft palate, the surgeon reduced manually the maxillary fracture by pulling the maxilla forward and upward resulting in clearing the airway and creating an inter-incisor space []. While the surgeon kept his finger in place, topical lidocaine 5% was sprayed into the mouth and the oropharynx. The fiber optic bronchoscope was advanced into the oropharynx through the vocal cords up to the carina. A 7, 5 endotracheal tube mounted on the bronchoscope was threaded into the larynx. Correct tube placement was confirmed clinically and by capnography. Then the patient lied down on the operating table and general anesthesia was induced. Tracheostomy was then performed to allow surgical access and repair of the maxillo-facial fractures. The surgery went uneventfully. The patient was awakened at the end of surgery with tracheostomy kept to ensure safe post-operative care.