Anaesthesia for maxillofacial surgery

Maxillofacial surgeons are responsible for the operative management of pathologies such as head and neck cancer, facial trauma, infections, craniofacial deformities and temporomandibular joint dysfunction. Airway management for these patients can be particularly challenging for the anaesthetist. This article will focus on key aspects of airway assessment and the development of a comprehensive management strategy; including recognizing impending airway compromise, advanced airway management skills, appropriate rescue techniques and planning for tracheal extubation. We will describe the key aspects of clinical management for common maxillofacial surgical presentations, with reference to the most recent evidence base and clinical guidelines.     

Anaesthesia for maxillofacial surgery

Maxillofacial surgeons are responsible for the operative management of oromaxillofacial cancer, facial trauma, facial and dental infections, craniofacial deformities, orthognathic conditions and temporomandibular joint dysfunction. Airway management for these patients can be challenging for the anaesthetist. This article focuses upon key aspects of airway assessment and the development of a comprehensive understanding of the management of these complex patients, including recognizing impending airway compromise, advanced airway skills, rescue techniques and planning for tracheal extubation. The fundamental aspects involved in the clinical management of common maxillofacial surgical presentations are described, with reference to the most recent evidence and clinical guidelines.     

Anaesthesia for maxillofacial surgery

Maxillofacial surgery covers a broad range of procedures on the head and neck, combining oral and facial procedures with the ear, nose and throat (ENT), plastics, neurosurgery and base of skull specialities. The main issues are that of managing a shared airway, providing good head, neck and oral access, the potential for difficult airways and measures to reduce tissue bleeding and oedema, both intraoperatively and postoperatively. Good communication between all members of the team is essential.     

Anaesthesia for maxillofacial trauma

Facial trauma is common and can produce both physical and psycho-logical problems for patients. Managing patients in both the emer-gency setting and elective theatre environment can be extremely challenging, so airway interventions should be carefully planned so the safest and most effective technique can be chosen. This may mean that direct laryngoscopy may not be the safest or most straight-forward option and awake tracheal intubation, videolaryngoscopy, submental intubation or awake tracheostomy may be a better choice in a given set of circumstances. An understanding of common mechanisms of injury and pathologies and the likely difficulties that will be present are essential. Senior anaesthetic input and effective teamwork are required to provide excellent levels of care for these patients.     

Anaesthesia for facial trauma

Facial trauma is common and can produce both physical and psychological problems for patients. Managing patients in both the emergency setting and elective theatre environment can be extremely challenging, so airway interventions should be carefully planned so the safest and most effective technique can be chosen. This may mean that direct laryngoscopy may not be the safest or most straightforward option and awake tracheal intubation, videolaryngoscopy, submental intubation or awake tracheostomy may be a better choice in a given set of circumstances. An understanding of common mechanisms of injury and pathologies and the likely difficulties that will be present are essential. Senior anaesthetic input and effective teamwork is required to provide excellent levels of care for these patients.     

Anaesthesia for facial trauma

Facial trauma is common and can produce both physical and psychological problems for patients. Managing patients in both the emergency setting and elective theatre environment can be extremely challenging, so airway interventions should be carefully planned so the safest and most effective technique can be chosen. This may mean that direct laryngoscopy may not be the safest or most straightforward option and awake fibreoptic intubation, videolaryngoscopy, submental intubation or awake tracheostomy may be a better choice in a given set of circumstances. An understanding of common mechanisms of injury and pathologies and the likely difficulties that will be present are essential. Senior anaesthetic input and effective teamwork are required to provide excellent levels of care for these patients.     

帝视内镜和纤维支气管镜用于口腔颌面骨折手术患者经鼻气管插管的比较

目的评估和比较帝视内镜(Disposcope,DS)和纤维支气管镜(FOB)用于口腔颌面骨折手术患者经鼻气管插管的临床效果。方法选择择期行口腔颌面骨折手术患者60例,男32例,女28例,年龄18~65岁,ASAⅠ或Ⅱ级。患者随机分为DS组和FOB组,每组30例。两组均采取经鼻气管插管,DS组采用DS引导插管,FOB组采用FOB引导插管。记录插管时间、首次插管成功率、插管总成功率。记录术后24h患者声音嘶哑、咽痛、黏膜损伤、牙齿松动等不良反应发生情况。结果 DS组插管时间明显短于FOB组(P0.05)。两组首次插管成功率和插管总成功率差异无统计学意义。两组术后24h声音嘶哑、咽痛、黏膜损伤、牙齿松动发生率差异均无统计学意义。结论DS或FOB均有助于口腔颌面骨折手术患者经鼻气管插管,两者插管成功率和插管相关并发症相似,但使用DS插管时间较FOB缩短,且操作和维护方便,可在基层医院推广应用。     

Outcomes of immediate dental implants in vascularised bone flaps for mandibular reconstruction

Background

The aim of this study is to assess the outcomes of immediate implant placement for dental rehabilitation following mandibular reconstruction with vascularised bone flaps in a single Australian tertiary cancer centre.

Methods

A retrospective analysis of patients who underwent immediate dental implant or delayed placement in vascularised bone flaps was performed. Primary outcome measures assessed included the number of implants placed, operative time, complication rates, time to radiotherapy initiation, dental rehabilitation rates and time to dental rehabilitation.

Results

In total, 187 dental implants were placed in 52 patients, of which 34 patients underwent immediate implant placement and 18 had delayed implant placement. There were no significant differences in the postoperative complication rate (32% immediate vs. 33% delayed, P = 0.89) or time to postoperative radiotherapy (median 42 days immediate vs. 47 days delayed, P = 0.24). Dental rehabilitation was achieved in 62% of the immediate cohort versus 78% of the delayed cohort. The time to be fitted with a dental prosthesis was significantly shorter in the immediate cohort (median 150 days immediate vs. 843 days delayed, P = 0.002).

Conclusions

The placement of immediate dental implants at the time of primary reconstruction of the mandible is a safe procedure and facilitates timely dental rehabilitation.     

Anterior skull base surgery for malignant tumors: a multivariate analysis of 27 years of experience

INTRODUCTION: Few studies have examined prognostic factors that have an impact on outcomes in anterior skull base surgery by multivariate analysis. METHODS: We retrospectively examined our institution's skull base experience from 1973-2000. RESULTS: During this time, 166 patients underwent an anterior skull base resection for malignancy (median age, 53 years; range, 6-92 years). The 5-year relapse-free and disease-specific survival was 41% and 57% (median follow-up, 53 months). Multivariate analysis found that dural invasion, primary histologic diagnosis, and margin status had a significant impact on relapse-free and disease-specific survival. CONCLUSIONS: These data indicate that patients with anterior skull base malignancies are treated successfully with skull base surgery. Patients demonstrating adverse prognostic variables such as dural invasion, adverse histologic findings, and/or positive margins should be considered for the addition of adjuvant therapy or innovative therapies as they become available in the future.     

Anaesthesia for gastrointestinal surgery

Patients with gastrointestinal disease will present with a range of nutritional, fluid and electrolyte disturbances. This article will discuss how to recognize these problems and try to minimize their impact on recovery. A growing body of evidence shows that adoption of a package of care known collectively as enhanced recovery significantly reduces postoperative morbidity and reduces length of hospital stay. For anaesthetists the changes involve analgesic regimens and perioperative fluid and nutrition management. This evidence has been brought together in the national Enhanced Recovery After Surgery Programme and has been introduced to many hospitals for elective bowel surgery patients. The principles of the programme will be discussed. Aspects of it can be applied to many other surgical groups.     

Salvage surgery after radical accelerated radiotherapy with concomitant boost technique for head and neck carcinomas

BACKGROUND: Definitive radiotherapy (RT) for head and neck cancer is increasingly used to preserve organ function, whereas surgery is reserved for treatment failure. However, data are sparse regarding the feasibility of salvage surgery, particularly for unselected patients after accelerated RT. METHODS: From 1991 to 2001, 297 patients, most with stage III to IV cancer (Union Internationale Contre le Cancer) were treated with concomitant boost RT (median dose, 69.9 Gy in 41 fractions) with or without chemotherapy (in 33%, usually cisplatin with or without 5-fluorouracil). The 75 patients seen with local and/or regional failure were studied. We analyzed the factors influencing the decision to attempt surgical salvage, the oncologic outcome, and the associated complications. RESULTS: Seventeen (23%) of the 75 patients had a salvage operation. This included all five patients with laryngeal cancers but only 16% to 20% of patients with tumors in other locations. Most patients could not be operated on because of disease extension (40%) and poor general condition/advanced age (30%). Patients with low initial primary T and N classification were more likely to undergo surgery (p = .002 and .014, respectively). Median post-recurrence survival was significantly better for patients who had salvage operations than for those without surgical salvage treatment (44 vs 11 months, p = .0001). Thirteen patients were initially seen with postoperative complications (mostly delayed wound healing and fistula formation). CONCLUSIONS: After definitive accelerated RT with the concomitant boost technique, only a minority of patients with local or regional recurrence underwent salvage surgery. Disease stage, tumor location, and patient's general condition at the initial diagnosis seemed to be the main factors influencing the decision to attempt surgical salvage. For patients with initially resectable disease who undergo radical nonsurgical treatment, more effective follow-up is needed to favor early detection of treatment failure, which may lead to a timely and effective salvage surgery.     

Anaesthesia for surgery of the trachea and main bronchi

Major surgery on the trachea and airway is an anaesthetic challenge, which necessitates the simultaneous control of the airway, maintenance of gas exchange and good surgical exposure. Advance planning, good communication and teamwork among surgeon, anaesthetist and theatre staff are never more important. A major indication for laryngeal and tracheal surgery is laryngotracheal stenosis, a rare condition, which can cause significant morbidity and life-threatening airway obstruction. In the era of modern medicine, post-intubation injury has superseded infection and external trauma as the commonest aetiology. Definitive surgery is usually carried out in tertiary specialist centres, where segmental resection of the trachea with primary end-to-end anastomotic reconstruction is usually the technique of choice. Provision of anaesthesia for bronchial sleeve resection and removal of inhaled foreign bodies faces similar challenges.     

Anaesthesia for surgery of the trachea and main bronchi

The anaesthetic challenges of major tracheobronchial surgery relate to airway control, ventilation management, maintaining optimal surgical exposure and appropriate patient selection. Although such surgery is generally performed in specialist centres, the strategies for dealing with central airway obstruction and bronchoscopy under general anaesthesia are of broader importance. Furthermore, an intra-thoracic airway obstruction presents difficulties that require a different mindset to the more familiar scenario of an extra-thoracic airway obstruction. Tracheal stenosis following a period of prolonged tracheal intubation is now the leading indication for tracheal resection. A standard approach involves total intravenous anaesthesia, a right-sided arterial line, epidural analgesia and early extubation. Usually, a sterile armoured cuffed endotracheal tube is placed under direct surgical vision for the period of segmental resection followed by reintroduction of the native orotracheal tube under bronchoscopic vision for the primary end-to-end anastomotic reconstruction.     

Aesthetic cervicofacial surgery for head and neck tumor patients

Carefully selected head and neck tumor patients can safely undergo a wide variety of aesthetic surgical procedures. The malignancy must first be adequately treated and clinically controlled before elective surgery. Each tumor patient's general health and life expectancy must be honestly assessed prior to aesthetic surgery, because operating on an individual who cannot survive to enjoy the benefits is injudicious. Through the combined efforts of sophisticated oncology and plastic surgery, the patient survival rate can be improved as quality of life is enriched in appropriately selected and carefully managed individuals.Presented at the Sixteenth Annual Meeting of the American Society for Aesthetic Plastic Surgery, Los Angeles, California, April 20, 1983     

颌面骨整形重建外科Visual FoxPro数据库编程方法

目的：以颌面骨整形重建临床医疗环境为编程对象，探索建立VFP关系型数据库的编程方法。方法：数据库编程软件采用Microsoft Visual FoxPro(VFP)6．0，系统分为一般信息模块，先天性颌面骨畸形模块，创伤后颌面骨畸形模块，肿瘤切除手术后颌面骨畸形模块，各模块包括其相对应的实际环境数字化环节。结果：数据库数据完整，结构紧密，逻辑性强，查询方便，具有初步智能化功能和Web功能，可升级更高级软件，可并入上一级数据库。系统维护方便、费用低。结论：本编程方法可以建立颌面骨整形重建外科专业数据库。