Nasotracheal intubation in the presence of frontobasal skull fracture

Abstract

Nasotracheal intubation in the presence of frontobasal skull fracturePurpose: 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 BSE Available evidence suggests that BSF should not be regarded as an absolute contraindication to NTI.Objectif : Pr&enter un cas de traumatisme maxillo-facial avec fracture de la base du cr~ne (FBS) chez qui une intubation nasotrach~ale (INT) a 6t6 utilis& e~cacement et sans complications pour une ost~osynth~se chirurgicale. Pr&enter des alternatives pour le contr61e des voles a&iennes et revoir pourquoi on a toujours consid&~ I'INT comme contre-indiqu~e en pr&ence d'une fracture de la base du cr~ne.

Airway Management in Maxillofacial Trauma: Do We Really Need Tracheostomy/Submental Intubation

“…But there is now enough data to suggest that nasotracheal intubation is not an absolute contraindication in the presence of nasal bone fractures, base of skull fractures and CSF leak [11][12][13]. Rhee K J et al, have shown that complications associated with skull base fractures are not increased when nasotracheal intubations are performed in the field [14].…”

Submental intubation: our experience

“…Nasotracheal intubation is a contraindication in cases of trauma of the skull base (Arrowsmith et al 1998, Marlow et al 1997, Rhee et al 1993) [1,10,12,13] because of possibility of iatrogenic meningitis, difficult intubation and difficulty in performing treatment of fractures of the nasal pyramid at the same time (Smoot et al 1997) [15,16,18].…”

Transmylohyoid Submental Intubation in complex maxillofacial trauma: The easiest method is also the safest method

“…The advantages of these modifications are reported in the literature. 1,3,[10][11][12][13][14][15] 3. Though this method is a good option for the securing the airway of patients with multiple fractures in the maxillofacial region, it is not free of complications.…”

“…Potential complications of nasotracheal intubation are mucosal dissection, injury to adenoids, meningitis, sepsis, sinusitis, epistaxis, dislodgement of bony fragments, and obstruction of the tube by the distorted airway anatomy or rarely intracranial intubation. 3 In patients requiring simultaneous nasal or nasoorbital ethmoid reconstruction after the rigid fixation of mandible and/or maxilla, intraoperative switching over of the endotracheal tube (ETT) from nasal to oral route is required which may compromise the surgical field sterility and may increase the possibility of pulmonary aspiration. Possible difficulty in airway management, disruption of surgical repair, and obstruction to the operative field are additional limitations.…”