In a retrospective study, four hundred eighty seven patients of either sex, operated for maxillofacial trauma, during January 2011 to December 2012 as emergency and elective basis were studied in a tertiary care centre. Inclusion criteria were all facio-maxillary trauma and exclusion criteria were all facial soft tissue injuries treated on OPD basis.

In pre anesthetic checkup, a detailed history was taken regarding time and mode of trauma, any pre-existing medical problem. Vital parameters including pulse rate, blood pressure, respiratory rate, temperature and SpO₂ were noted. Detailed note was made of the various injuries including head injury, cervical spine injury, abdominal trauma, chest trauma and orthopaedic trauma. Detailed examination of the maxillofacial injuries was noted. Patients having fractures of two or more than two facial bones were labelled as panfacial fractures. Airway was assessed by mouth opening (Mallampati classification), thyromental distance and neck movements. Nasal patency was checked for all the patients with the help of nasal speculum. CT scan of the face with 3-D reconstruction was seen for assessment of the facial fractures and for nasal patency. All patients were operated upon under general anesthesia. Techniques of intubation were noted under following categories:

Decision for selection of intubation technique was taken on the basis of airway examination, type of fracture, type of procedure and surgeons’ requirement. Nasal intubation was done in patients who required intraoperative intermaxillary fixation. Fiberoptic intubation technique was selected for patients with difficult airway and patients having cervical spine injury. Informed consent was obtained from all patients after detailed explanation of procedure and alternative technique.

Intubation related complications like tooth injury, nasal bleed, meningitis, inadvertent entry into cranial cavity, oro–cutaneous fistula were noted.

Out of the 487 patients operated for maxillofacial trauma 69.6% were male and 30.3% female. Young patients in the age group of 11-40 years accounted for 81.5 % of the total patients [Table/Fig-1].

Overall the major etiology of maxillofacial trauma was road traffic accidents, i.e, 404 patients (82.95%). Among 40 patients with history of fall, majority were construction workers and children [Table/Fig-2].

Isolated fractures were less common as compared to multiple facial bone fractures [Table/Fig-3].

Technique of intubation was decided after discussion among the chief anaesthesiologist and chief surgeon. In 161 (33%) patients nasal intubation was changed to oral intubation for the purpose of nasal bone reduction after the fixation of maxilla and mandible. Fibreoptic guidance for nasal intubation was required in 52 (11%) patients either because of cervical spine injury or difficult airway [Table/Fig-4].

Nasal bleed was the most common complication among patients in whom nasal cavity was used for negotiating the endotracheal tube either directly or with fibreoptic assistance [Table/Fig-5].

Trauma has been labelled as the neglected disease of modern society. It accounts for thousands of deaths both in developed and developing countries. The productive age group of the society is the main sufferer of this disease and universally there is male predominance [5]. Maxillofacial trauma requires special attention as it involves both vital and non-vital organs and a skilful team approach of medical professionals can save the life of the patient from these life threatening injuries.

Management of airway is a major concern in patients with maxillofacial trauma because a compromised airway can lead to death. Gruen et al found that, failure to intubate, secure or protect the airway was the most common factor related to patient mortality, responsible for 16% of inpatient deaths [6]. There are various methods available for airway management in patients with maxillofacial trauma, but choice of a particular technique depends upon many factors like extent of facial injury, the composition and the anatomy of the injury, the choice of surgery, associated injuries (head injury, cervical spine injury), hemorrhage and expertise of anaesthesiologist [7]. It also depends upon whether patient is being intubated in emergency room or in the operation theatre for surgery when the patient is in relatively controlled conditions.

In maxillofacial trauma anaesthesiologist has to share the upper airway field with the surgeon. In these injuries, apart from anaesthetic consideration, surgeon’s requirement is major factor in deciding the technique of intubation. The changing trends of surgery for maxillofacial trauma has also affected the choice of technique of intubation. With the available new techniques and technology almost all the facial fractures are treated with open reduction and internal fixation using microplating. So intraoperative dental occlusion by intermaxillary fixation is required for the proper alignment of the fracture fragments and their rigid fixation. So, surgeons prefer to have nasotracheal intubation as it gives them freedom to operate and accuracy of dental occlusion [8]. In our study, oral intubation was done only in cases of fracture zygoma and fracture nasal bone.

Cases where intra operative intermaxillary fixation was required, the airway was managed with naso-tracheal intubation technique either under direct vision or with fibreoptic guidance. whenever nasotracheal intubation is planned evaluation of nasal cavity with anterior rhinoscopy is recommended [9,10]. A close look at the CT Scan of the mid face gives information about any septal deviation, turbinate hypertrophy and foreign bodies, the adequacy of nasal passage and nasopharyngeal space. Fibreoptic guidance was used in cases of cervical spine injury and difficult airway (Mallampati class IV) or depending upon the anaesthetist’s preference.

Although most of the anaesthesia text books include basilar fractures and nasoethomoidal fractures in the list of contraindications of nasotracheal 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 [11–13]. 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]. In our study also there is no evidence of intracranial passage of nasotracheal tube in the skull base fractures. There is no case of nasotracheal tube related meningitis. As per our institution protocol all the patients were given prophylactic antibiotics. The only complication noted was nasal bleed in 20 cases which either stopped by itself or by nasal packing which was otherwise also required in cases of nasal bone correction.

In 33% patients, nasal bone reduction was also required along with other facial fractures. This could not be done in the presence of nasal tube. In our institution we managed these cases with a novel technique. First, nasal intubation was done either under direct vision or with fibreoptic guidance. fixation of mandible, zygomatico-maxillary complex and repair of soft tissue was completed. After this, surgeon opened the intermaxillary fixation and naso-tracheal tube was changed to oro-tracheal tube for nasal bone reduction. Closed reduction of nasal bone and packing is done after changing the tube. Due precautions were taken to maintain sterility and thorough suctioning was done to prevent aspiration before changing the tube. This avoided the need of tracheostomy and submental intubation and their associated complications. Tracheostomy is associated with complications such as haemorrhage, pneumomediastinum, pneumothorax, tracheal stenosis etc., and submental intubation can cause haemorrhage, oro-cutaneous fistula, injury to sublingual gland, wharton’s duct,and lingual nerve [15,16].

Submental intubation was done in 12 patients (2.46%) where nasal intubation was not possible due to severe soft tissue trauma of nose or cases in which pre-existing nasal pack could not be removed as these cases were taken for surgery immediately after emergency nasal packing. Out of these, 3 patients had significant submental scarring and one developed oro-cutaneous fistula. Tracheostomy was already there in 30 (6.16%) patients when taken up for maxillofacial surgery. These patients were on long term ventilatory support for either head injury or poor chest condition. The complications related to tracheostomy were not noted in the study as tracheostomy was not performed as part of intraoperative airway management.

Decision of airway management in maxillofacial trauma has to be taken after mutual discussion of the surgeon and anaesthesiologist keeping in view the patient’s condition and demands of surgery. Nasotracheal tube is safe even in the presence of nasal fractures, base of skull fractures and CSF leak. Technique of intraoperatively changing the nasotracheal tube to orotracheal tube in cases of panfacial fractures is a simple and logical method without any complication. In the era of rigid fixation of fractures and the possibility of leaving the patient with an open mouth, an alternative technique of airway management, i.e, nasotracheal to orotacheal intubation may replace the need for tracheostomy or submental intubation, thus avoiding their associated complications.