口腔颌面外科学——麻醉与手术

局麻药中肾上腺素对高血压拔牙患者血压和脉搏的影响，下颌下径路经口气管内插管在颌面部骨折治疗中的应用，髁突多发性骨折微型钛板内固定的近期观察，介入治疗在下颌骨动静脉畸形的临床应用，儿童上颌前牙区埋伏多生牙的临床分型与治疗，口腔内入路行髁突高位骨折复位固定的临床治疗。[编者按]     

经腮腺前嚼肌径路治疗下颌支骨折

目的 探讨经腮腺前嚼肌径路(TMAP)进行下颌支骨折内固定术的方法及治疗效果。方法 对17例(24侧)下颌支骨折患者行患侧耳屏前切口,切开皮肤皮下组织暴露腮腺嚼肌筋膜,向前分离皮瓣至腮腺前缘,解剖面神经颊支,沿嚼肌纹理方向钝性分离,切开下颌支骨膜,在直视下对骨断端行复位内固定,观察术后患者的咬合关系、面神经功能及其他并发症。结果 此手术径路暴露充分,视野较好,可直视下进行手术操作,术后患者咬合关系恢复良好,部分病例面神经轻瘫,术后3个月内均恢复正常。结论 经腮腺前嚼肌径路是治疗下颌支骨折复位内固定术的较好方法。     

眶下径路治疗颧骨复合体骨折的临床评价

目的：对眶下径路治疗颧骨复合体骨折的临床疗效进行评价。方法：对65例颧骨得合体骨折作临床分析,经眶下径路作开放整复加微型钛板坚强固定手术。结果：（1）眶下径路术野暴露充分;（2）颧骨复合体骨折复位快,对位精确;（3）微型钛板固定坚固;（4）无面神经损伤等并发症;（5）疗效优良率达96．9％。结论：眶下径路适宜于颧骨复合体骨折的治疗。     

经颌下置管全麻在复杂全面部骨折中的应用

目的：介绍特殊全面部骨折手术中一种经颌下置管全麻的方法并探讨其适应症及注意事项。方法：7例全面部骨折、无法实施鼻插全麻患者,口插全麻并稳定后制备口底与颌下间隧道并将气管导管导出颌下、固定。手术结束后将导管导回口腔。结果：所有患者口腔插管和口底导出均顺利,导管位置无改变,双肺呼吸音对称。术中麻醉平稳,管理方便,不影响手术操作。术后局部无气肿、感染、气道阻塞、神经损伤。结论：在无法鼻插全麻前提下,经颌下置管全麻避免了气管切开,同时满足了颌骨骨折术中咬合对位的要求,是特殊全面部骨折麻醉手段的有效方法。     

口腔颌面部损伤病人麻醉诱导气管插管方式的比较

口腔颌面部重度损伤病人往往气管插管操作困难。故选择合适的麻醉诱导插管方式至关重要。本文就我院 91年以来 48例口腔颌面部重度损伤患者手术时不同麻醉诱导插管方式分析报告如下。1　临床资料1 .1　一般资料　本组 48例 ,男性 41例 ,女 7例 ,年龄 1 1～ 68岁 ,损伤类型 :上颌骨多发骨折 5例 ,2例合并颅脑损伤 ;下颌骨多发骨折 1 8例 ;上下颌骨骨折 7例 ;面部多处刀砍伤合并颧骨骨折或上颌骨骨折 3例 ;颌面部爆炸伤 5例 ;颧骨骨折合并上颌骨骨折 4例 ;上颌贯通伤 4例 ;下颌贯通伤 2例。1 .2　麻醉处理　 48例均行气管内插管静复或静吸全麻…     

内镜辅助下经下颌下径路行早期口腔癌(cT1-2N0)择区性颈淋巴清扫术的前瞻性研究

目的:内镜辅助下或依靠机器人经耳后径路或其改良径路行早期口腔癌(cT1-2N0)的择区性颈淋巴清扫术(selective neck dissection,SND)已有报道,然而,此种术式所带来的美观效果是以较大的手术创伤为代价.本文探讨内镜辅助下经下颌下径路行早期口腔癌(cT1-2N0) SND的手术创伤和美观效果.方法:54例早期口腔癌患者(cT1-2N0)随机分为内镜组和开放组2组.对患者围术期和术后相关指标进行评估,包括颈清扫切口长度、颈清扫时间、术中出血量;术后引流量和引流时间、总住院时间、清扫淋巴结数目、患者美观满意度、围术期并发症、肩部功能和随访情况.结果:内镜组平均手术时间为(124.04±13.47) min,较开放组(73.47±15.36) min长.但内镜组平均切口长度仅为(4.23±0.56) cm,同时术后引流量和引流时间、总住院天数、术后肩部疼痛程度和美观效果均较开放组为优,而且2组清扫的淋巴结数目无显著差别.结论:内镜辅助下经下颌下径路行SND的时间较开放组长,但手术创伤小,美观效果好.     

颌骨骨折合并颅底损伤患者经口底入路气管插管的临床效果

目的：探讨经口底隧道入路气管插管在手术治疗颌骨骨折伴颅底伤患者中的效果。方法2014年1月—2015年10月在佛山市中医院口腔医疗中心住院治疗的颌面部外伤患者7例,所有患者均有颅底损伤合并颌骨骨折。因不能采用常规经口腔或经鼻腔入路插管,7例患者均选用口底隧道入路插管。结果7例患者术后伤口均获得一期愈合,颌面部皮肤瘢痕隐蔽,没有脱管等其他并发症发生。结论经口底隧道入路行气管插管麻醉适用于颌骨骨折合并颅底骨折患者的治疗。     

上颌骨全切除术改良的手术径路

目的　根据上颌骨解剖学上的特点 ,结合各类手术径路的优点 ,设计一种改良的上颌骨全切除术的手术径路 ,旨在改善术后的外形与功能。方法　共有 17例患者采用了该上颌全切除术的手术径路 ,即 :切口设计在下唇 ,沿颏面沟与颌下、腮腺耳前切口连接至同侧发际。切口设计依据为避开上颌区 ,隐蔽切口位于面颌部正常的皮肤皱折区 ,术中对面神经下颌缘支、下颊支、颏神经、腮腺导管以及内眦部等均加以保存。其中行上颌骨全切除 14例 ,次全切除 3例。结果　经 1～ 12个月术后随访 ,疗效满意。其中 11例术后放疗患者均未出现任何皮肤坏死及下颌水肿。因保存了面神经下颌缘支和下唇肌支 ,仅 1例发生轻度口角歪斜畸形。结论　本文提出的上颌骨全切除术改良的径路 ,能充分暴露并完整切除上颌骨肿瘤 ,术后有较满意的外形及功能 ,可作为上颌骨全切除的一种常规手术径路。若病变超过上颌骨区的范围 ,则不应采用本文介绍的手术径路     

颏下进路气管插管术在颌面部多发性骨折中的应用

目的:颌面部多发性骨折的患者为鼻腔气管插管的禁忌证,通常需行气管切开,为避免气管切开的并发症及后遗症,观察经皮颏下切开气管插管术的临床效果。方法:先经口腔行气管插管术,成功后将气管导管后端由口内转移出口外,固定于颏部。结果:该方式手术操作简单,避免了气管切开带来的严重的并发症。结论:经皮颏下气管插管术简单、实用、安全,适合于有鼻腔插管禁忌证的颌面部外伤患者。     

3种径路鼻内镜下治疗上颌窦囊肿150例疗效分析

目的：探讨3种径路鼻内镜下治疗上颌窦囊肿的疗效差异。方法：分析近年来收治的150例上颌窦囊肿病例的临床资料,依据囊肿不同位置及是否伴有其他病变,对其采取3种不同手术径路切除,即经上颌窦自然口径路切除58例,经下鼻道开窗径路切除39例,经上颌窦前壁径路切除53例,评价3种径路的治疗效果。结果：150例患者,经过6～12个月的随访,术后鼻腔通气良好,面部胀痛、头痛、头昏等临床症状消失,经鼻内镜及鼻窦CT检查,无脓性分泌物,无囊肿复发。结论：根据上颌窦囊肿位置类型及伴有的疾病不同,鼻内镜下选择不同径路手术,上颌窦囊肿的术后康复效果更理想。     

Submental Intubation in Maxillofacial Surgery: A Prospective Study

We designed a prospective study with the objective to evaluate the efficacy, indications and our experience of submental intubation in different types of maxillofacial surgeries. From May 2008 to August 2010, 23 patients with different conditions were intubated by submental route of tracheal intubation and patients were evaluated on different parameters during and after surgery to find its efficacy, indications and utilization in maxillofacial surgeries. All the patients were managed well with this technique of intubation with no significant difference in intubation and extubation time. We did not face any uneventful complication. There was only one reported complication that is rupture of the bulb of cuffed flexometallic tube but was managed well by changing tube. We found skull base access surgery as a new indication for submental intubation. The submental route for endotracheal intubation may be utilized as an alternative to blind nasal intubation or tracheostomy in the surgical management of patients involving complex maxillofacial surgeries. We hypothesized that the submental intubation should not be used where long term ventilation support is needed. We did a technique modification to deliver the endotracheal tube out from the submental region to avoid pilot cuff damage. Our study proposes that skull base access surgery is a safe and potential indication for submental intubation. In our experience submental intubation is a simple, secure and effective procedure for operative airway control in major maxillofacial surgeries.     

Complications from submental endotracheal intubation: a prospective study and literature review

Submental endotracheal intubation, as compared to the use of tracheotomy, is an alternative for the surgical management of maxillofacial trauma, as described by Altemir FH (The submental route for endotracheal intubation: a new technique. J Maxillofac Surg 1986; 14: 64). Although the submental endotracheal intubation is a useful technique, a wide range of complications have been reported in the literature. The core aim of this article is to present additional data from 17 patients who have undergone submental endotracheal intubation and who have received at least 6 months of postoperative follow up. A prospective study was carried out on patients who suffered maxillofacial trauma between 2008 and 2011. Age, gender, etiology of trauma, fracture type, complications, and follow up were evaluated. Case series, as well as retrospective and prospective studies regarding submental endotracheal intubation in maxillofacial trauma, were also reviewed. This study demonstrated a low rate of complications in submental endotracheal intubation and no increase in operative time within the evaluated sample. The submental endotracheal intubation may be considered a simple, secure, and effective technique for operative airway control in major maxillofacial traumas.     

Endotracheal tube stabilization in the air medical setting

Airway control is critical to the preparation and transport of patients by air medical services. Our experience with an endotracheal tube stabilization device employed in all adult orally intubated patients is described.Details of application, types of injury, and characteristics of patient management were reviewed. The stability of the device was determined on the face and the stability of the endotracheal tube was evaluated.Sixty-three intubated, adult patients transported via our air medical team were included in this study. Indications for intubation included burns, inhalation injury, maxillofacial trauma, upper airway obstruction and thoracic trauma. Maxillofacial injuries included scalp/facial lacerations, craniofacial asymmetry, Le Fort III fractures and electrical burns. Maxillofacial injuries and secretions did not compromise device stability. The device could be placed on all patients regardless of condition or climate at time of device application.Use of a standard endotracheal tube stabilization device is recommended in the air medical setting. It protects against accidental extubation, provides stability regardless of craniofacial trauma or secretions, and allows for easy application and consistent positioning of the endotracheal tube relative to holder.     

Submental endotracheal intubation in concurrent orthognathic surgery: a technical note.

INTRODUCTION: Achieving the necessary occlusion for orthognathic surgery is not possible with conventional oral intubation since the tube interferes with the occluding teeth. Sometimes nasotracheal intubation is impossible due to developmental malformations requiring repair. Also, the oral or nasotracheal tube may interfere with the operation or may be damaged during the procedure. In 1986, Hernandez Altemir described a method of submental endotracheal intubation. His intentions were to avoid tracheostomy in maxillofacial trauma cases where short-term intermaxillary fixation was required. PATIENTS: Between January 2000 and May 2003, 13 patients were operated on, using submental intubation. Eight of these (three females and five males) had surgery for orthognathic malformations. METHODS: The Hernandez Altemir technique was modified to ease the procedure: a sterile nylon guiding tube and the '222 rule' incision were introduced. Eight cases with concurrent complex orthognathic surgery, using this modified technique are reported in this paper. RESULTS: There were no operative or postoperative complications related to the procedure. CONCLUSION: The technique is easy to use, rapid and free of complications compared to 'alternative' intubation methods (tracheostomy, retromolar location of tube, etc.). Submental scarring is acceptable. It is recommended for orthognathic procedures in selected cases.     

Current Perspectives in Intra Operative Airway Management in Maxillofacial Trauma

Objective

Maxillofacial trauma presents a complex problem due to the disruption of normal anatomy. In such cases, we anticipate a difficult oral intubation that may hinder intraoperative IMF. Nasal and skull base fractures do not advocate use of nasotracheal intubation. Hence, other anesthetic techniques should be considered in management of maxillofacial trauma patients with occlusal derangement and nasal deformity. This study evaluates the indications and outcomes of anesthetic management by retromolar, nasal, submental intubation and tracheostomy.

Methodology

Of the 49 maxillofacial trauma cases reviewed, that required intraoperative IMF, 32 underwent nasal intubation, 9 patients had tracheostomy, 5 patients utilized submental approach and 3 underwent retromolar intubation.

Results

Among patients who underwent nasal intubation, eight cases needed fiberoptic assistance. In retromolar approach, though no complication was encountered, constant monitoring was mandatory to avoid risk of tube displacement. Consequently, submental intubation required a surgical procedure which could result in a cosmetically acceptable scar. Though invasive, tracheostomy has its benefits for long term ventilation.

Conclusion

Intubation of any form performed in a maxillofacial trauma patient is complex and requires both sound judgement and considerable experience.     

Modifizierte submentale endotracheale Intubation bei kieferorthopädischen Eingriffen

Background

In 1986 Altemir described a method of submental endotracheal intubation in order to avoid tracheostomy in maxillofacial trauma cases where short-term intermaxillary fixation was required. His method has become widely established for airway maintenance in midfacial fractures.

Case

We present a 21-year-old male patient with cleft lip and palate on the left side. The patient underwent Le Fort I maxillary osteotomy. Nasal intubation was impossible due to nasal malformation. In this case we used submental endotracheal intubation for airway maintenance. We introduced new methods: a sterile nylon guiding tube and our new “2-2-2 rule” incision to make the procedure easier.

Results

The occlusion could be checked easily. There were no complications during and after the operation. The submental wound healed nicely.

Discussion

The described case shows that the technique is easy to use compared to “alternative” intubation methods. Submental scarring is acceptable. We recommend the technique for orthognathic use.     

Fiberoptic endotracheal intubation in oral and maxillofacial surgery

The advent of a fiberoptic endoscope has made endotracheal intubation feasible in a wide variety of patients who were previously considered for tracheostomy. Patients who pose increased anesthetic risks due to hypomobility of the mandible can be induced and successfully intubated by a skilled operator without incident by any one of the currently accepted fiberoptic techniques.^1–8 Various devices have been designed to facilitate the use of fiberoptic endotracheal intubation.^6,8,9Many reports have discussed fiberoptic endotracheal intubation, using case reports to exemplify the technique employed,^10–13 but to date none has addressed the specific needs of the oral and maxillofacial surgeon. This article presents 1) the indications for fiberoptic endotracheal intubation in patients undergoing various types of oral and maxillofacial surgery, 2) the intubation technique used with the fiberoptic bronchoscope, and 3) our results in 42 consecutive patients.     

Intraoperative lacrimal intubation to prevent epiphora as a result of injury to the nasolacrimal system after fracture of the naso-orbitoethmoid complex

Treatment of fracture of the naso-orbitoethmoid (NOE) complex is difficult. There are not only aesthetic issues but also functional consequences related to the lacrimal system. Because prophylactic lacrimal intubation for such fractures remains controversial, we have assessed the effectiveness of intraoperative lacrimal intubation to prevent epiphora as a result of such injuries. Thirteen patients diagnosed with craniomaxillofacial fractures including fractures of the NOE complex were included in the study; 10 had unilateral fractures and 3 bilateral. Computed tomography (CT) showed all patients had displaced fragments that had the potential to damage the lacrimal duct. In 7 patients the fractures included the canthal region and in 6 they did not. All patients were treated by open reduction and internal fixation under general anaesthesia, followed by intraoperative lacrimal intubation unilaterally or bilaterally as required. Lacrimal intubation with a silicone tube was successful in all 13 patients (16 sides). The tube was removed 2–9 months (mean 3.8) postoperatively and no subsequent epiphora were seen during follow-up (mean (3–29 months) 11.3 months). Lacrimal intubation for at least 2 months may prevent epiphora caused by injury to the nasolacrimal system after fractures of the NOE complex.     

呼气末CO2监测在口腔颌面外科困难气管插管中的应用效果评价

目的：评价纤维支气管镜联合呼气末CO₂监测用于口腔颌面外科困难气道患者经鼻腔气管插管的效果。方法：选择2018年11月—2019年1月口腔颌面外科预计困难气道的全身麻醉患者60例,ASA分级Ⅰ~Ⅱ级,随机分为2组（n=30）：对照组在保留患者自主呼吸下使用纤维支气管镜引导经鼻腔气管插管;试验组在保留患者自主呼吸下,使用呼气末CO₂监测联合纤维支气管镜经鼻腔气管插管。记录首次气管插管成功率、使用纤维支气管镜气管插管时间,尝试次数以及气管插管并发症发生率。采用GraphPad Prism 6软件包对2组资料进行t检验、 χ²检验,筛选差异指标。结果：2组首次气管插管成功率无显著差异（对照组为90.0%,试验组为93.3%,P=0.2196）;2组平均纤维支气管镜插管尝试次数无显著差异对照组为（1.2±0.2）次、试验组为（1.1±0.1）次,P=0.6451:;试验组使用纤维支气管镜插管时间显著低于对照组对照组为（29.5±2.3）s,试验组为（15.8±1.2）s,P=0.0192:;插管过程中,2组心动过速（HR>100次/min）发生率无显著差异（对照组为6.6%、试验组为3.3%,P=0.1746）;2组插管时血压升高（高于基础血压20%）发生率无显著差异（对照组为10.0%,试验组为6.7%,P=0.2541）;试验组插管时氧饱和度下降（SpO₂<90%）发生率显著低于对照组（对照组为13.3%,试验组为6.7%,P=0.0412）;试验组鼻出血的发生率显著低于对照组（对照组为16.7%,试验组为6.7%,P=0.0224）;2组术后咽痛的发生率无显著差异（对照组为6.7%,试验组为3.3%,P=0.1652）;2组均未发生术后声音嘶哑;2组术后不良记忆的发生率无显著差异（对照组为6.7%,试验组为3.3%,P=0.1652）。结论：呼气末CO₂监测联合经鼻腔纤维支气管镜引导气管插管可缩短气管插管时间,减少插管时氧饱和度下降及鼻出血发生率,提高气管插管效率和安全性。