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Nasotracheal intubation in the presence of frontobasal skull fracture

Abstract

Purpose

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 BSF Available evidence suggests that BSF should not be regarded as an absolute contraindication to NTI.

Objectif

Présenter un cas de traumatisme maxillo-facial avec fracture de la base du crâne (FBS) chez qui une intubation nasotrachéale (INT) a été utilisée efficacement et sans complications pour une ostéosynthèse chirurgicale. Présenter des alternatives pour le contrôle des voies aériennes et revoir pourquoi on a toujours considéré l’INT comme contre-indiquée en présence d’une fracture de la base du crâne.

Éléments cliniques

Un homme de 17 ans a été référé pour ostéosynthèse chirurgicale de fractures mandibulaires bilatérales. La tomographie axiale révélait la présence d’air intracrânien et du sang dans les quatre sinus avec déformation des voies nasales du côté droit. Il n’y avait pas de lésion cérébrale et les voies nasales gauches semblaient perméables. Dans le but de faciliter l’ostéosynthèse intermaxillaire, une INT par fibroscopie a été effectuée de préférence à une trachéotomie. Le patient a récupéré normalement sans évidence de méningite ni de blessure cérébrale directe.

Conclusion

Chez des patients choisis, l’INT demeure possible en présence de FBC. Les données disponibles suggèrent de ne pas considérer une FBC comme une contre-indication absolue à l’INT.

References

  1. Hall DB. Nasotracheal intubation with facial fractures. JAMA 1989; 261: 1198.

    Google Scholar 

  2. Zmyslowski WP, Maloney PL. Nasotracheal intubation in the presence of facial fractures (Letter). JAMA 1989; 262: 1327–8.

    PubMed  Article  CAS  Google Scholar 

  3. Schultz RC. Nasotracheal intubation in the presence of facial fractures (Letter). Plast Reconstr Surg 1990; 86: 1046.

    PubMed  Article  CAS  Google Scholar 

  4. Bragg CL. Nasotracheal intubation versus tracheostomy in the presence of facial fractures (Letter). Plast Reconstr Surg 1991; 88: 740.

    PubMed  Article  CAS  Google Scholar 

  5. Altermir FH. Nasotracheal intubation in patients with facial fractures (Letter). Plast Reconstr Surg 1992; 89: 165–6.

    Google Scholar 

  6. Seebacher J, Nozik D, Mathieu A. Inadvertent intracranial introduction of a nasogastric tube, a complication of severe maxillofacial trauma. Anesthesiology 1975; 42: 100–2.

    PubMed  Article  CAS  Google Scholar 

  7. Bouzarth WF. Intracranial nasogastric tube insertion (Editorial). J Trauma 1978; 18: 818–9.

    PubMed  CAS  Google Scholar 

  8. Fremstad JD, Martin SH. Lethal complication from insertion of nasogastric tube after severe basilar skull fracture. J Trauma 1978; 18: 820–1.

    PubMed  Article  CAS  Google Scholar 

  9. Muzzi DA, Losasso TJ, Cucchiara RF. Complication from a nasopharyngeal airway in a patient with a basilar skull fracture. Anesthesiology 1991; 74: 366–8.

    PubMed  Article  CAS  Google Scholar 

  10. Horellou MF, Mathe D, Feiss P. A hazard of nasotracheal intubation (Letter). Anaesthesia 1978; 33: 73–4.

    PubMed  Article  CAS  Google Scholar 

  11. Stehling LC. Management of the airway.In: Barash PG, Cullen BF, Stoelting RK (Eds.). Clinical Anesthesia, 2nd ed. Philadelphia: JB Lippincott Co., 1992: 685–708.

    Google Scholar 

  12. Stone DJ, Gal TJ. Airway management.In: Miller RD (Ed.). Anesthesia, 4th ed. New York: Churchill Livingstone, 1994: 1403–35.

    Google Scholar 

  13. Florete OG Jr. Airway management.In: Civetta JM, Taylor RW, Kirby RR (Eds.). Critical Care, 2nd ed. Philadelphia: JB Lippincott, 1992: 1419–36.

    Google Scholar 

  14. O’Connell F. Management of the airway and endotracheal intubation.In: Murray MJ, Coursin DB, Pearl RG, Prough DS (Eds.). Critical Care Medicine. Perioperative Management. Philadelphia: Lippincott — Raven, 1996: 57–70.

    Google Scholar 

  15. Gotta AW. Management of the traumatized airway.In: American Society of Anesthesiologists. Annual Refresher Course Lectures. Philadelphia: Lippincott, 1994: 226, 1–7.

    Google Scholar 

  16. Bähr W, Stoll P. Nasal intubation in the presence of frontobasal fractures: a retrospective study. J Oral Maxillofac Surg 1992; 50: 445–7.

    PubMed  Article  Google Scholar 

  17. Keenan RL. Nasal intubation in the presence of frontobasal fractures: a retrospective study. J Oral Maxillofac Surg 1992; 50: 447–8.

    Google Scholar 

  18. Rhee KJ, Muntz CB, Donald PJ, Yamada JM. Does nasotracheal intubation increase complications in patients with skull base fractures? Ann Emerg Med 1993; 22: 1145–7.

    PubMed  Article  CAS  Google Scholar 

  19. Taker AAY. Nasotracheal intubation in patients with facial fractures (Letter). Plastic Reconstr Surg 1992; 90: 1119–20.

    Google Scholar 

  20. Altemir FH. The submental route for endotracheal intubation. A new technique. Journal of Maxillofacial Surgery 1986; 14: 64–5.

    Article  Google Scholar 

  21. Hönig JF, Braun U. Laterosubmental tracheal intubation. An alternative method to nasal-oral intubation or tracheostomy in single-step treatment of panfacial multiple fractures or osteotomies. (German) Anaesthesist 1993; 42: 256–8.

    PubMed  Google Scholar 

  22. Stoll P, Galli C, Wächter R, Bähr W. Submandibular endotracheal intubation in panfacial fractures (Letter). J Clin Anesth 1994; 6: 83–6.

    PubMed  Article  CAS  Google Scholar 

  23. Katsnelson T, Farcon E, Adamo AR. More on submandibular endotracheal intubation for panfacial fractures (Letter). J Clin Anesth 1994; 6: 527–8.

    PubMed  Article  CAS  Google Scholar 

  24. Farole A, Piotrowski JC. A unique indexing splint for use in combined Le Fort and nasal injuries to avoid tracheostomy. Oral Surg Oral Med Oral Pathol 1990; 70: 399–400.

    PubMed  Article  CAS  Google Scholar 

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Correspondence to Joseph E. Arrowsmith.

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Arrowsmith, J.E., Robertshaw, H.J. & Boyd, J.D. Nasotracheal intubation in the presence of frontobasal skull fracture. Can J Anaesth 45, 71–75 (1998). https://doi.org/10.1007/BF03011998

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Keywords

  • Airway Management
  • Facial Fracture
  • Mandibular Fracture
  • Nasotracheal Intubation
  • Maxillofacial Trauma