5.2 Fractured Mandible

Question 1

What are your concerns

Answer 1

• Mode of injury
• Loss of consciousness and current GCS
• Airway involvement
• Associated head and neck injuries
• Intoxication – alcohol, drugs
• Starvation status

Question 2

How would you assess the airway?

Answer 2

Patients with facial trauma often pose the
greatest airway challenges to the anaesthetist.

For this patient with isolated facial trauma,
preoperative airway evaluation
must be detailed and thorough.

• Particular attention should be focused
  on jaw opening,
  mask fit,
  neck mobility,
  maxillary protrusion,
  macroglossia,
  dental pathology,
  nasal patency,
  existence of any intraoral lesion or debris.
• Trismus is often caused by pain and
  can disappear on induction of anaesthesia.
  However, it may persist for mechanical reasons
  and this needs to be discussed with the surgical team.
• Preoperative imaging should be reviewed.
  X-ray of the mandible
  (AP, lateral oblique, or panoramic)
  and neck (AP, lateral), CT if possible.

Question 3

What are the possible associated injuries?

Answer 3

.* Cervical vertebrae fracture

• Head injury
• Airway:
  soft tissue injury with risk of oedema and obstruction,
  tracheal injury
• Other facial fractures
  (i.e. nose,
  maxilla Le Fort fracture type I horizontal,
  type II pyramidal,
  type III transverse)

Question 4

What are Le Fort fractures?

Answer 4

1. They are midfacial fractures caused by anteriorly directed force.
2. In Le Fort I fractures,
   a horizontal fracture line separates the inferior portion of
   the maxilla from the superior two-thirds of the face,

which remain associated with the skull.

The entire maxillary dental arch may be mobile
or wedged in a pathologic position.

2. In Le Fort II fractures,
   the pyramidal mid-face is separated from the rest of
   the facial skeleton and skull base.
3. In Le Fort III fractures,
   the face is essentially separated along the base of the
   skull due to force directed at the level of the orbit.

Question 5

When are you happy to anaesthetise this patient?

Answer 5

If the airway is not compromised and
there is no associated head injury,

I will anaesthetise him once he has sobered
and achieved the starvation status.

There are no other associated injuries, and the chance of head injury has
been ruled out. He is presented for isolated mandible fracture.

Question 6

How would you anaesthetise him?

Answer 6

1. • Prepare for a potential difficult intubation
     (i.e. senior help, skilled assistant, difficult airway trolley).
2. • The route of repair

as it can be intraoral,
subconjunctival,
via a scalp flap.

3. • Induction:

If any forewarning sign of problems with mask ventilation or
endotracheal intubation is observed,

the airway should be secured prior to anaesthesia induction.

This process may involve fibreoptic nasal or

oral intubation or tracheostomy.

4. • Different endotracheal tubes (ETT) may be used:

In this patient, after discussing with the surgeon for options,
my consideration would be to use a nasal tube
as this gives room in the mouth for the surgeons to work in.

Also this will be beneficial in patients with malocclusion or wedge
fracture where insertion of an oral ETT would have been challenging.

5. • The need for a throat pack,
     postoperative intermaxillary fixation,
     and facial nerve monitoring should also be discussed.

Question 7

Mandible fractures make airway difficult?

Answer 7

Isolated mandible fractures usually
do not make intubation more difficult.

However, if it is associated with other facial injuries,
the airway might be more difficult to manage.

In these cases an inhalational induction might be considered.

Remember the risk of an association with a
fracture of the base of the skull
in which case the nasal route has to be avoided.

Question 8

What are the nice guidelines regarding head injuries?

Answer 8

1. Assessment
   . * In patients with
   GCS 15, = assessment is done within 15 min.
   GCS 9–14 = needs immediate assessment.
   GCS < 8 = anaesthetist should be involved.
2. Investigation

• Exclude brain injury with CT scan
  before blaming the depressed level of
  consciousness on intoxication.

3. Transfer
   * Transfer to a tertiary centre would benefit
   if the patient has a GCS < 8
   regardless of the need for surgery.

• If transfer is not possible,
  ongoing liaison with neuro unit is done for
  advice on management.