Facial and Pharyngeal Trauma

Trauma to the face and upper airway poses particular difficulties for the anesthesiologist. Serious skeletal derangements may be masked by apparently minor soft tissue damage. Failure to identify an injury to the face or neck can lead to acute airway obstruction secondary to swelling and hematoma. Laryngeal edema is also a risk in patients who have suffered chemical or thermal injury to the pharyngeal mucosa. Intraoral hemorrhage, pharyngeal erythema, and change in voice are all indications for early intubation.

In general, both maxillary and mandibular fractures will make mask ventilation more difficult, whereas mandibular fractures will make intubation easier. Palpation of facial bones before manipulation of the airway will alert the anesthetist to these possibilities. Patients with jaw and zygomatic arch injuries often have trismus. Although trismus will resolve with the administration of neuromuscular blocking agents, preinduction assessment of airway anatomy may be difficult. Bilateral mandibular fractures and pharyngeal hemorrhage may lead to upper airway obstruction, particularly in a supine patient, although intubation soon after the trauma is usually easier because of loss of skeletal resistance to direct laryngoscopy. A patient arriving at the ED in the sitting or prone position because of airway compromise is best left in that position until the moment of anesthetic induction and intubation.