Airway Management of The Patient with Facial Trauma

Mandible is the most common site of injury in children because of it’s a) location (nasal bone and mandible are the most prominent part of the face in children); b) ?hanging ratio of cranial volume and facial volume from 8:1 to 2.5:1; c) Direction of the growth of the mandible i.e. downwards and forwards with increasing age.

Airway management in facial trauma defend the use of oroendotracheal intubation because it does not gives the flexibility of assessing the occlusion and maxillomandibular fixation which is are prime requisite in reduction and fixation of facial fractures. Thus conventionally the practice was of using tracheostomy or nasoendotracheal intubation for administering anesthesia. Though nasoendotracheal intubation is a preferred modality in adults but in pediatric facial fractures it increases the risk of bleeding due to hypertrophied adenoids. Techniques like submental intubation and tracheostomy are also used but the complications with these techniques can be avoided with retromolar intubation specifically in pediatric maxillofacial trauma patients.

The prime objective of the study was to assess the adequacy of the retromolar space and the efficacy of retromolar intubation in pediatric mandibular fractures without compromising the anesthetic as well as surgical requirements. Primary requirement for successful placement of endotracheal tube in retromolar region is adequacy of space. In this report, the adequacy of space was evaluated by placing nasopharyngeal airway in retromolar region which created a memory path for insertion of endotracheal tube while the patient was unconscious as described by LT Nguyen et al.

With the absence of third molars in patients aged less than 14 years, the availability of retromolar space adds in another dimension to the intubation technique. Patients intubated with the endotracheal tube in retromolar space have a reliable airway, greater visibility and unobstructed surgical access to the nose and oral cavity. Intra and postoperative complications are relatively low when compared to other intubation techniques and without compromising the patency of the patient’s airway make retromolar intubation a choice of intubation in pediatric patients.

Accidental extubation or dislodgement could be a challenging and discomforting situation for both anesthetist and surgeon. In the present study, there was no episode of accidental dislodgement of ETT, because ETT was safely and easily placed in the retromolar space, finally positioned there with the help of 3-0 silk suture.

The retromolar intubation cannot be used in patients with craniofacial syndromes like Pierre Robin syndrome, Treacher Collin syndrome, Achondroplasia and mandibular hypoplasia mostly because there is a lack of co-operation in these patients for procedure. Though it is needed more studies in future amongst every patient with maxillofacial trauma along with pediatric patients, it is a safer and non-invasive technique.

In conclusion, retromolar region used for endotracheal intubation provided adequate space in pediatric patients, as it is not influenced by eruption of permanent first and second molars. Here, it is possible to achieve the occlusion with placement of endotracheal tube in retromolar space. Thus, it is having a great hold on less complication strategies this technique can be used for intubation where intraoperative maxillomandibular fixation and access to nose and oral cavity is needed.