Le Fort III fracture presents a unique airway challenge to anesthesiologists. It is defined by a fracture line that passes through the nasofrontal suture, maxillo-frontal suture, orbital wall, and zygomatic arch, which... [ view full abstract ]
Le Fort III fracture presents a unique airway challenge to anesthesiologists. It is defined by a fracture line that passes through the nasofrontal suture, maxillo-frontal suture, orbital wall, and zygomatic arch, which separates the midface from the cranium. A postero-inferiorly displaced midface can lead to soft tissue airway obstruction and obscure the airway, making it difficult to ventilate and intubate. Furthermore, methods of intubating may be limited by poor mouth opening and fractures involving the nasal structures.
Here we discuss an otherwise healthy 7 year old female with Le Fort III fracture following an automobile collision into a pole requiring ORIF of multiple facial fractures. Physical exam was notable for moderate periorbital edema and a depressed nose. Airway exam was limited as patient was only able to open her mouth 1 to 2cm. Despite the concerning physical exam, patient was able to lie supine without marked obstruction or desaturation. This observation was important to make with regards to airway management. If the patient obstructed while supine, she would not have tolerated a traditional approach to intubation. Given her age, she would not have tolerated an awake fiberoptic intubation either. In such cases, the surgical team could manually reduce the maxillary fracture prior to intubation to clear the airway or as a last resort, consider a surgical airway. Fortunately, this was not the case for our patient. The anesthesia team felt it would be safe to mask induce followed by an oral tracheal intubation with video laryngoscopy as obstruction was limited. In anticipation of a difficult airway, a fiberoptic bronchoscope and cricothyroidotomy kit were available. In the OR, patient tolerated mask induction with sevoflurane, and ventilation was gradually taken over by bag mask ventilation. Patient was successfully intubated using a video laryngoscope with a grade 1 view. ENT readjusts the armored endotracheal tube to submental level for better access to the midface. A fiberoptic bronchoscopy confirms the endotracheal tube is 4cm above the carina. Surgery continues without major complications, however, patient remains intubated at end of case due to concern for post-surgical inflammation. She was extubated POD2 without complications and discharged POD 7.
This case illustrates the importance of understanding and anticipating the complications associated with Le Fort III fractures.
