Injuries of the maxillofacial region

Features and classification of injuries of the maxillofacial region. Sprains and fractures of teeth. Fractures of the mandible. Jawfall: causes, clinical manifestations. The anatomical shape of damaged residues. Treatment of mandibular fractures.

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Дата добавления 13.09.2014
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1. Features and classification of injuries of the maxillofacial region

Questions persist traumatology an important medical and social problems due to intense urbanization , increasing number of vehicles , the pace and rhythm of life are increasing from year to year . In all countries, in accordance with the frequency and severity of injuries , the growing number of injuries suggests that the threat of injury for people aged up to 60 years longer than cardiovascular disease , as well as malignant tumors ( VA Kozlov , 1988). Together with a general increase in injuries observed increase in the frequency and severity of maxillofacial injuries, and combined defects. This is evidenced by a large number of Russian studies ( VA Petrenko and et al. , 1999; Sysolyatin PG , IA Arsenova , 1999) as well as foreign scientists (Y. Jallut et al., 1992 ; Hoffmeister et al., 1992). Number of maxillofacial injuries in the total number of bone lesions ranged from 3.2 to 3.8% ( NM Alexandrov and colleagues . , 1986). Number of patients with facial trauma in the total number of stationary dental patients , in accordance with the materials individual creators Rasen and ranges from 21 to 40% ( VV and Burdin et al. , 1998). Almost all of the creators noticed by improving facial fractures by 10-15 %, which should be considered when organizing stationary , as well as outpatient treatment . These data provide a basis for planning dental treatment , as well as baseline data to determine the number of hospital fund calculations required number of materials, devices for the treatment of patients with traumatic injuries of the maxillofacial region . Often defects of the maxillofacial region are found in people of working age from 18 to 50 years - 91%. Marked seasonality of injury in the summer and autumn months, the number of patients with facial injuries is increasing.This is explained by an increased frequency of road and street injuries, and injuries associated with agricultural activities . Studies have demonstrated that the first place of injuries maxillofacial occupy : home (83%) , motor ( 12%), manufacturing (4.5% ), sports (0.5 %). Home injury in the bulk of cases was accompanied by alcohol intoxication . It is worth noting the increase in the number of gunshot wounds of the maxillofacial region in recent years. Number of mandible fractures from 77 ranges from 95 % , the upper jaw 3 to 20 % , both jaws 2 to 8 %. Injuries maxillofacial respectively distributed localization followed way: facial soft tissue defects in 19% of fractures of the zygomatic bone 15% , fractures of the nose 4.5% higher jaw fractures 3.5% , mandibular fractures by 58%. A certain regularity between periods do appeals victims in institutions, localization, overlooking injury , as well as the nature of the defect. In the study of the record sheets , we found that on the first day after the injury in the emergency station approached 92 % of patients with soft tissue defects person gunshot defects - 89 % , fractures of the nose - 68% , multiple injuries of facial bones - 69 % double mandibular fractures - 58 %. In the most recent period of 10 days after the injury , patients with fractures received cheek bones - 32% , single mandibular fractures - 18%, numerous injuries bones little face - 31 %. Based on the study of the structure damage maxillofacial area was created a huge amount of their classifications. In compiling the classification biggest challenge is the selection of indicators that need to enter into it . The current level of computer technology allows you to enter to determine the greatest number of indicators. From a scientific point of view, this approach is understandable , but for everyday medical practice needs a short , comfortable , easy to remember classification . It is necessary that at diagnosis were provided by the following factors : localization , respectively - soft tissue injuries specific anatomical area with damage to major blood vessels , nerves , tongue , salivary glands , trauma maxillofacial skeleton ( mandible , maxilla , zygomatic bone , nasal bones ) ; according to the source of mechanical damage , gunshot , burns, frostbite ; according to the nature injured - Combines, Combines, through blind , tangents , penetrating ( the oral cavity , maxillary sinus , nasal cavity, orbit , pharynx ) . The proposed structure of the diagnosis are all part of the external skeleton , as it is the definition of damage needed to select the method of treatment. In the " soft tissues " are only those organs and systems , the failure of which determines the nature and source of injury . The need to provide penetrating and non-penetrating wounds yavna as for penetrating wounds twice as heavy as more than a festering , gapping , and more adverse outcomes . Separation wounds upper, middle and lower zones of the face allows you to emphasize bone damage associated with features of the anatomical structure , their multifunctional purpose.

2 . Sprains and fractures of teeth

Sprains and fractures of teeth occupy 3 % of all traumatic injuries of the jaws. When injuries are often damaged jaw front teeth group . Often trauma teeth and alveolar processes may be accompanied by soft tissue injury perioral area. Dimensions and nature of the injury depends on the force of the impact , as well as the area of traumatic subject. Allocate full , partial dislocations and impacted . With partial dislocation victim complains of pain in the tooth to the touch , inability meal, change the location of the tooth, its mobility . At external examination: edema, hemorrhage mucosa alveolar process ; tooth takes the wrong position in the dentition , agile , percussion its rough painful. When X-ray examination found limitation periodontal ligament on the side of the tooth displacement , and on the other - an increase.

Complete dislocation characterized periodontal break for only the root, the withering away of the neurovascular bundle , in some cases - the alveoli walls fracture and loss of the tooth socket. At full dislocation patients complain about the lack of teeth in the dentition . When external inspection hole dislocated tooth filled with clot , the mucosa of the gingival margin is broken , often determined by fracture wall socket. In such cases it is necessary to explore the well to determine the nature of her injuries for subsequent tooth replantation .

Impacted dislocation is considered a kind of complete dislocation , characterized by perforations, the introduction of the tooth root in the compact disc alveoli and alveolar bone spongy substance . Neurovascular bundle while always damaged. When impacted dislocation victim complained of pain in the injured tooth , change its location in the dentition . When the external examination determined repositioning of the tooth crown with a roll it in any direction , or dip into the hole. Tooth immobile due to its introduction into the bone structure. X-ray examination ( intraoral styling ) for sprains teeth done to avoid fracture of the tooth , as well as the choice of the method of treatment .

Treatment.

Before local anesthesia fingers or forceps to remove teeth done reposition dislocated tooth . When complete dislocation of the tooth can be Scribe replantation conventional method , respectively . When dislocation impacted almost all authors do not recommend one-step repositioning exercise , unnecessarily impacted teeth can gradually unjustly nominated , as well as to assume the correct position. Removal of impacted tooth shown when fully submerged, as well as the destruction of the tooth wells , with the development of acute inflammation in it and adjacent soft tissues. In the case of pulp necrosis , it is removed and the channels with seal according to generally accepted methods of therapeutic dentistry . Immobilization of tooth create , depending on the criterion ligature ligature in combination with fast-curing plastic, smooth tire - bracket ligated according to Hippocrates , 1c on n . e IM Oksmanu , KS Sound (1965) or bus - kappa dual tire parallel (Fig. 1)

Fig.1. Dining ligation : a) Hippocrates , b) Sound , c) at Oksmanu . Term immobilization is usually 5-7 weeks.

Fractured tooth. BACKGROUND tooth fracture match the same as with dislocation . Teeth of the upper jaw broken more often than mandibular teeth , especially the front . Isolated fractures of teeth : longitudinal, transverse , oblique ; complete or incomplete , depending on the opening of the pulp. Isolated fractures of the crown and the root; depending on the location of the fracture is isolated fractures of the upper , middle and lower third of the tooth. Depending on the localization of the fracture patient complains of pain from mechanical, thermal stimulation, the mobility of the damaged tooth . On examination, there is soft tissue swelling perioral area , bleeding in the mucosa and skin. At the turn of the crown broke off is determined by its different shapes , often with the opening of the pulp chamber . At the turn of the root crown from time to time acquires a pink or purple color . Tooth becomes mobile , it is painful percussion . To select a method of treatment to be applied odontometriyu and radiographic examination ( intraoral radiography, orthopantomography ) . Treatment. At the turn of the tooth crown without opening the cavity is treated by grinding sharp edges , filling seal or tab. When the pulp is damaged , it is removed , before sealing channels , as well as restore the anatomic crown of the tooth . Break off the crown at full production allowed pin tooth stump or dense pin - tab. At the turn of the root in the lower third of the pulp is removed , sealed channel , as well as operation is conducted in accordance with the views of root resection . If the tooth root fracture occurred in the middle part , stored pulp, tooth weakly mobile, it is possible to compound the root function due to plastic cement , and odontoblasts . The literature describes methods for fixation of fractures of the roots with the aid of the pin -channel of different materials, including at longitudinal and oblique fractures that are fixed outside the hole of the tooth and then replanted . In such cases often occur inflammatory complications that lead to the subsequent removal of the tooth. Subject to mandatory removal of longitudinal fractures roots , oblique, transverse fractures in the middle third of the tooth root . Alveolar bone fractures occur when exposed to traumatic force on a small portion thereof . Alveolar process of the maxilla more susceptible to injury . Fracture of the alveolar process is often accompanied by a fracture and dislocation of teeth. Patients complain of pain in the area of ??the fracture , increasing with interdigitation , taking food ; non-compliance with the bite . When the external examination marked hemorrhage into the mucous alveolar bone and adjacent departments breaks mucosal mobility alveolar bone fragments , teeth painful percussion . Diagnosis is palpation , odontometricheskom and X-ray examination . Depending on the selected method of treatment of damage . Immobilization is performed using a smooth tire - bracket , tires, mouthguard use near intact teeth. In some cases , for example, are used in wide defects Tooth wire tires with toe loops intermaxillary rubber traction. When dental pulp necrosis , the latter is removed , sealed channels . Upon detection of dislocations and fractures of teeth using such a treatment strategy , as when they separated defects.

3. Fractures of the mandible

mandibular fracture injurie maxillofacial

Treatment of mandibular fractures contained in restoring the anatomical shape of damaged residues providing physical relations dental lines renewal functions of the muscles involved in chewing. The main principles of the initial treatment to be considered a clear reduction , as well as the correct fixation of bone fragments . Implementation of data bases allows for primary bony fusion in a very short time. Distinguish 3 types of treatment of mandibular fractures : conservative ( orthopedic ) ortopedohirurgicheskoe as well as online . Currently mandibular fractures , around 90 % , according to various authors , treated conservative treatment ( Balin and VN et al . 1998 VA and Petrenko et al . 1999 ;) . The most frequently used method of conservative treatment is considered tooth wire splinting , whose foundations were laid in the early centuries SS Tigershtedtom . basic principles of orthopedic treatment were described in the section " Methods of immobilization ."

Operative orthopedic methods of treatment of the mandible. One of the most famous ways is to use ligatures CTN according to J. Blak ( 1923). The essence of this method is contained in an around the body of the mandible wire ligatures , as well as their attachment to nadesnevoy lid (Fig. 2) .

Fig.2. Options for implementation of circular ligatures CTN

This method of fixation is shown : the chin of fractures in the edentulous mandible , oblique fractures of the body, the chin of the lower jaw fractures in children during milk occlusion . Method of operation : after conductive anesthesia performed manually reposition fragments . Modeled supra frame or plastic quick- removable prosthesis is used as the affected tires. Some distance from the strip fracture 2 cm soft tissue puncture is done with a scalpel , using a needle for a blood transfusion as a conductor, wire or nylon spend ligatures in the alveolar processes , delay , and the ends twisted ligatures over tire or prosthesis. In some cases, the remaining site of fractures there is a need in the dynamic suspending the edentulous mandible fragments to the top using supragingival tires or dentures method VA Malyshev (1959). The essence of the method : the lower jaw overlap external ligature as in the method of J. Blak, their ends are twisted and hooks are made of them ; making incisions in the mucous membrane as pear holes and ridges skuloalveolyarnyh tamper , boron with holes through which wire ligature is performed , and twist them to bend as the hook . Scratches mucous stitched to the upper and lower hooks wear rubber rings . SR Mektubdzhan (1974) changed the methodology of dynamic suspension and the proposed use of the L-shaped hooks, strengthen mucous through punctures in the skin region of the piriform aperture. The upper and lower hooks worn rubber rings , used tires supragingival of self-hardening plastic. VV Don (1975 ) used an unusual methodology for fixation of fractures of the mandible , successfully combining components of surgical and orthopedic treatment ( Figure 3)

Fig . 3 . Methods of treatment of mandibular fractures according to Don

The essence of the method is contained in the lower jaw fragments bond within the dentition and the angle K-wire , and fixing it to the necks of the teeth on the lower jaw . Author described three variants of this method :

1. For fractures in the mandibular angle needle injected to a depth of 2 cm in the preceding section of the mandible branch , create reposition fragments , and the free end is bent spokes and strengthen the teeth or ligatures bystrotverdeyushchie plastic.

2 . For fractures in the angle of the mandible , and in the absence of posterior teeth needle injected almost vertically in the alveolar bone of the distal fragment , then, after repositioning of fragments bent L-shaped and to strengthen the medial vestibular plane teeth fragments .

3 . When edentulous jaws needle is introduced into the distal fragment is , and over the medial fragments around the spokes of sformirovyvaetsya bystrotverdeyushchie nadesnevoy plastic roller which is to strengthen the lower jaw in a circular wire ligatures . K. Muschka ( 1973) for fractures of the mandibular angle suggested to keep coronary process or reverse edge of the mandible branch wire loop and strengthen its ends to the tooth tire. VA Sukachyov GI Osipov (1976) was administered in such fractures retromolar region with cutting needle on the end and attached it to the teeth of the lower jaw . YG Kononenko , GP Ruzyne (1991 ) for the bond angle fractures have used compression- distraction device , after choosing a basis method VV Don (Fig. 4) .

Figure 4. technique for introducing compression-distraction method for the treatment of mandibular fractures

Compression substance connected with tooth tire, with the support of freely revolving rivet consists of an internally threaded screw and rod with male thread to screw it into the screw. Device allows you to connect the fragments in the correct position and fasten them to create dosage compression.

The most common means of orthopedic treatment is the method of tooth splinting wire proposed SS Tigershtedtom during World War 1 . Curved tires from duralumin , nichrome or orthodontic wire ( diameter 0.8-1.5 mm lateral ) are fitted with smooth ( odnochelyustnymi ) and toe loops ( dvuchelyustnymi ) for intermaxillary reposition and immobilization of bone fragments . Tyres must recreate dental arch and adjoining crown of each tooth . Attaching the tires to the tooth carried by wire ligatures ( transverse diameter 0.3-0.4 mm). Tire must be strengthened to the greatest number of teeth , it should not border on the gingival margin, in order to avoid its injury . At the moment of use smooth tires Tigershtedta bus - brace strut bend with tire and tire with an inclined plane. Indication for the use of these tires are mandibular fractures with no displacement or just reponiruemye within the front teeth , fractures of the alveolar processes ; no groups of teeth in the dentition . But this , it proved to be excellent method is not without flaws ; because in the future the method was improved by different authors. Most interesting, in our opinion, are considered prescription PI Popudrenka , AI Stepanov ( 1955, 1957 ), which for ease of tooth splinting the engagement with regular hooks with rubber rings worn on flat tires odnochelyustnye . VS Vasiliev (1968) in order to simplify the method of tooth splinting proposed use conventional tires with tape toe stainless steel hinges (Fig. 5) .

Figure 5. conventional tape tires Vasilyeva

L. Sazama ( 1952) , A. Clement (1965), offered to secure the wire tire bystrotverdeyushchie use plastic, which , covering tire , pressed into the interdental spaces. According to the creators , the proposed method speeds up and simplifies the tooth splinting . AI Barons (1968) designed and introduced four variants permanent ligature splinting in the treatment of fractures of the mandible : a complete ligature splinting the entire dentition , selective ligature splinting , ligature compound in combination with a smooth or duralumin metal wire tire . As the use of ligatures bronze- aluminum wire . VK Pelipas (1969) proposed to use Nylon thread , which strengthens the teeth of iron hooks , as well as enhance the facially bystrotverdeyushchie plastic. Not counting the tooth and extraoral systems for the immobilization of bone fragments , even by using various laboratory systems: brazed fixing the tire , steady incline plane nazubodesnevuyu tire Weber, pelota , tires : MM Vankevich , AA Limberg , VY Kurland .

4 . Jawfall: causes, clinical manifestations , treatment

Jawfall called persistent head displacement of the mandible beyond its normal mobility with the release of the glenoid fossa , accompanied by dysfunction of the joint. Dislocation is complete if the joint surfaces completely lose contact with each other , and incomplete, ie subluxation , if stored between partial contact . Dislocations are called in the distal bone, taking part in the formation of the joint ( dislocation of the shoulder , hip dislocation , dislocation of the lower jaw , etc.).

The incidence of dislocations in various joints depends on the anatomical and physiological characteristics of the joints : the shape and size of the articular surfaces , the elasticity of the joint capsule , ligaments and muscles location , range of motion in the joint. Easiest dislocation occurs in globular and trochlear joints. According to NA Rabuhinoy , jawfall comprise about 2.5-5.5 %. Distinguish sprains congenital and acquired ( traumatic , pathological , habitual ) . Congenital dislocation occur in utero and are the result of incorrect or incomplete development of the articular surfaces (eg , congenital dislocation of the hip).

Traumatic dislocations arise from indirect influence , less direct trauma . In dislocation of the head of the mandible can be shifted from one or both sides in different directions : forward, backward, up and down. Typical of the lower jaw is dislocated front . Pathological dislocation caused by the defeat of one or both of the articular surfaces , para-articular tissues pathological process (tumor , osteomyelitis, osteodystrophy in osteoarthritis or chronic arthritis , osteochondropathy , bone dysplasia , muscle contraction clonic epilepsy , etc.) and often occur with little external influence or by gradual displacement of the articular surfaces . Habitual dislocations occur during normal movements without any external influence and can be caused by joint hypermobility , incongruent articular surfaces . Traumatic and pathological dislocations can become habitual.

The main complaint of patients with dislocation of the mandible is a pain and the inability to movements in the temporomandibular joint ( TMJ ) . By clinical examination noted fixation of the mandible in the wrong position . The lower jaw is displaced downward and forward . Patient's mouth half open . When you try to passive movements of the lower jaw there is any resistance to a change in position , the so-called symptom " springy fixation ." On palpation TMJ head of mandible in the glenoid fossa is not defined . Functions speech , chewing, in a patient with a dislocated mandible sharply violated.

In dislocation always ruptures the capsules . An exception is the dislocation of the lower jaw, in which due to the large volume and good elasticity of the joint capsule sprain can occur without damaging it . After dislocation occurs rapidly muscle retraction , and so pronounced that no special measures can not be overcome. When twisting the mandible can be detected as swelling and tenderness periarticular tissues due to their injury in trauma , subcutaneous and intra-articular hematoma due to vascular injury , fracture , base of the condyle of the mandible , head of the mandible , temporal bone in the body of the glenoid fossa . In such cases we say about the complicated fracture- dislocation and

When X-ray of a patient with anterior dislocation of the mandible on linear TMJ tomograms in the sagittal projection of the head of the mandible will be located at the front ramp of the articular tubercle . Normally, at the highest open mouth head is located at the top of the bottom of the articular tubercle . Note, however, that the range of jaw movements in the population varies from 38 mm to 52 mm , while TMJ hypermobility reaches 62 mm . In this connection, when you open your mouth the patient more than 50 mm head of mandible can go beyond the top of the articular tubercle preserving partial contact of the articular surfaces ( subluxation ) or ramp located at the front of the articular tubercle ( dislocation) . In other words, subluxation or dislocation may be a variant of normal functional in patients with joint hypermobility . Error is observed radiographically transfer subluxation or dislocation of the mandible in the clinical diagnosis in patients who do not have the above-described clinical symptoms of the disease.

Principles of treatment . To reposition traumatic dislocation dislocated bone in a joint is moved in the same way , what happened dislocation . This intervention is urgent . Prior to reposition the mandible anterior dislocation or Hippocratic method Blekhman necessary to regional anesthesia by Dubov or Berchet oak .

After the elimination of dislocation patient should impose submental sling for 3-5 days, to recommend acceptance of soft food, limit the load on the TMJ. Elimination of dislocation reduction provided not only how to overcome the resistance of muscle caused by retraction. In this regard, chronic reduction (less than 2 weeks) jawfall shown under endotracheal anesthesia and full pathological mandibular dislocation due to, for example, the presence of tumor articular surfaces and operative treatment.

Anesthesia in maxillofacial surgery .

Introduction.

General specific changes in patients, the most significant in terms of the conduct of anesthesia are: acute or chronic respiratory failure due to scarring, inflammatory or traumatic processes in the oral cavity, pharynx, larynx or trachea, eating disorders, multiple surgeries and anesthesia, psycho-emotional changes due disfiguring face processes.

Common problems include anesthesia significant blood loss due to the strong vascularization of the head and face, the possibility of altered response to drugs in multiple anesthesia, particularly intubation and airway management, the need to perform operations in the reflex-active zones, emotional factors, and particularly when the patient experiences operations on the face, the eyes, in the respiratory tract, the undesirability of tissue infiltration with local anesthetic in plastic surgery.

In many operations in these areas and apply local anesthesia explorer

In modern anesthesiology these types of anesthesia is usually combined with the methods of the overall impact (sedative, neuroleptic, analgesic drugs, ways elektroanalgezii, transcutaneous electroneurostimulation). Mask inhalation anesthesia is of limited use, as it creates some inconvenience for the surgeon and the difficulty of maintaining airway patency. Those shortcomings have circulated in the past insufflation anesthesia, which, moreover, is accompanied by significant air pollution operating inhaled anesthetics. These methods, in recent years more and more inferior general endotracheal anesthesia, although that technique may be intubation great difficulty.

The special features of anesthetic technique relates the need for reliable and convenient especially for the surgeon connecting elements between the endotracheal tube adapter and respiratory system anesthesia machine, careful fixation of endotracheal tubes, reinforced the importance of the use of endotracheal tubes and connecting elements, special hour for feeding the gas mixture through the nose or conventional masks but with the possibility of joining the adapter in the distal part.

In many operations, and diseases has advantages intubation through the nose. When intervening in the nasal cavity, oropharynx for preventing aspiration of blood is applied not only to the inflation cuff of the endotracheal tube, but additionally pharynx gauze tamponade. Swab pre-wetted (followed by push-ups) isotonic sodium chloride solution or paraffin oil. End of the tampon should remain outside the mouth, have a thread or clamp fixation (author known case of severe asphyxia due to airway obstruction after extubation swab).

In many operations, difficult to control the state of the patient on the usual grounds for the anesthesiologist (the state of the pupils, the color of the lips and oral mucosa), so it is especially important hardware monitoring becomes even using electrocardioscope and oximeter.

Application of controlled hypotension is possible, although the method is immaterial reduces intraoperative blood loss. During microsurgical interventions on the inner ear and larynx some surgeons are controlled hypotension useful.

Features anesthesia with goiter, with operations in the trachea and bronchi, in dental surgery and procedures are discussed in the relevant chapters.

Anesthesia in maxillofacial surgery

Anesthesia during operations on the face, tongue, palate, jaw, traumatic injuries of these areas may be very difficult for anesthesiologists who have no experience in this area.

Widespread use can have local and conduction anesthesia provided good command of these methods anesthesiologist or surgeon, especially for operations that do not require special measures respiratory protection. Local infiltration anesthesia may be used in malotravmaticheskih operations in the face and neck. Intravenous or inhalation anesthesia Mask during spontaneous breathing is applicable at less traumatic operations not associated with a high risk of airway obstruction and having a short duration. However, the location of the surgical field near airway creates additional difficulties in maintaining their patency.

The most reliable conditions for the conservation of the airway and prevent aspiration of blood from the surgical wound created when endotracheal technique. In the last decade endotracheal anesthesia is regarded as the method of choice for maxillofacial interventions (including early childhood), a growing number of surgeons and anesthetists. Accordingly, the application is limited insufflation anesthesia equipment, net intravenous and inhalation anesthesia mask.

Depending on the nature of the disease and the type of operation selected intubation technique: typical orotracheal, nasotracheal (blind or direct laryngoscopy), oro-or nasotracheal using fiberscope through existing or specially traheosgomu superimposed. It should also establish a testimony to the form of anesthesia with intubation: the inevitable technical difficulties clearly preference is given to the technique of intubation under local anesthesia, since the introduction of high-speed intravenous anesthetics and muscle relaxants can be dangerous.

Although the indications for surgical tracheostomy in modern anesthesiology and resuscitation limited (as in oral and maxillofacial surgery), in certain situations, it should be performed immediately. If the anesthetist has no experience in maxillofacial surgery, in particularly difficult hsloviyah intubation can be fatal for the patient. Trying her conduct can only be done under local anesthesia (through the nose, mouth or blindly fibroscopy). In case of failure, intubation should oyt done through superimposed tracheostomy under local anesthesia. We believe that only an anesthesiologist who works in the department of oral and maxillofacial surgery and has extensive practical experience, the right to use general anesthetic and muscle relaxants when performing tracheal intubation in especially difficult circumstances or real threat respiratory disorders. In emergency care (acute inflammatory diseases, injuries maxillofacial region) in the surgical wards of general indications for tracheostomy should be expanded.

Nasotracheal intubation is indicated for operations in the lips, buccal cavity of the mouth, chin, jaw, in patients with impaired mobility temporomandibular joint, narrowing the mouth opening scars. It is carried out blind, controlled, or direct laryngoscopy using fiberscope according to that is preferred. Implement local anesthesia or general anesthesia with spontaneous breathing. At the complicated approach to the airway muscle relaxants are administered only after endotracheal intubation. Use sterile tubes with cuffs, fixing them to the head of the patient. Provide the most reliable airway reinforced tube, which is used for the introduction of a conductor or fiberscope. The connecting element between the tube and the anesthetic machine must be securely fixed and maintain clearance (suitable flexible reinforced connector). If mouth opening allows, it is advisable to backfill around the throat tube (remember about fixing the outer end of the tampon).

Technical features of anesthesia for the most common diseases and operations.

Consider the technical features of anesthesia for the most common diseases and operations, and in some particularly difficult situations.

Surgery for cleft lip is usually carried out in early childhood (up to 1 year), with uraniscochasma - 5 - 6 years. Besides the features of anesthesia in these age groups, consider typical for these operations need to prevent aspiration of blood. Most anesthesiologists and surgeons now prefer endotracheal general anesthesia. Intubation technique usually has no significant features. Anesthesia was performed according to the general principles recommended for children. Operations can also be performed with anesthesia, effected insufflation method. To do this, after the introduction of the child in a mask anesthesia or intravenous route vkladyvayut his position with his head thrown back (Fig. 1) and introduced into the mouth gag operating equipped with a channel for insufflation (or intranasally catheter insufflation). Anesthesia was maintained at a high flow of oxygen (more than two MOU) ftorotanom can be supplemented with nitrous oxide. Head position to avoid aspiration of blood, if systematically suck it out of the wound (sometimes injected into the region of the pharynx additional catheter connected to suck). When insufflation inevitably significant pollution anesthetic operating atmosphere. The method can be modified by conducting oxygen insufflation during intravenous anesthesia. In this case you should not use drugs that suppress breathing.

Complex problems may occur if the children of operations for congenital disilazii mandibular-facial region, which is expressed in a significant displacement of the posterior mandible (retrognathia), deletion of the pharynx (glossoptoz), incorrect position of the hyoid bone, sometimes - the splitting of the palatine bone. With this disease, also called Robin syndrome, typically so-called bird-like face with sunken chin sharply (Fig. 2) (adult men often conceal this defect beard). In severe violations already in the neonatal period may occur acute respiratory failure (wheezing, asthma, aspiration pneumonia) requiring surgery for health reasons. The latter consists in the implementation of muscular plasticity (transposition of large chewing muscles - to reduce retrognathia, mentohyoid muscle - to reduce glossoptoza). Operation completed splinting (fixing) with traction of the mandible. Edema and respiratory disorders may complicate the postoperative course.

Undesirability of imposing a tracheostomy is well known in childhood that makes anesthetist even in complex plastic surgery in the oropharynx endeavor to hold anesthesia using oro-or nasotracheal intubation. Difficulty performing tracheal intubation with Robin syndrome are well known. In connection with this use fibreoptic devices shown. The presence and the threat of acute respiratory disorders are the basis (if it is impossible intubation) to perform a tracheostomy.

Under simple plastic surgery can be performed a wildcard or insufflation anesthesia anesthesia during spontaneous breathing.

Surgery for scar formation in the guttural throat, jaw, immobility of the temporomandibular joint, surgical correction of malocclusion, prognatii, resection of the mandible are usually difficult for the anesthesiologist and have features associated with the technique of intubation. Usually prefer nasotracheal intubation or blind controlled laryngoscopy, fibroskoia under local anesthesia or under general anesthesia during spontaneous breathing. Only the possibility of making an effective forced ventilation mask is permissible to enter a convenience intubation muscle relaxant. When prognatii requires the longest laryngoscope blade.

Resection of the upper or lower jaw, tongue malignant tumors refers to vysokotravmatichnym often lengthy operations, accompanied by significant blood loss. Shows the general endotracheal anesthesia for the method using muscle relaxants and mechanical ventilation. If possible, perform nasotracheal intubation, and if it is difficult, then decide the issue in favor of tracheostomy.

Traumatic injuries of the maxillofacial region can significantly impede implementation of anesthesia. To the complexity of endotracheal anesthesia equipment and joins the danger of aspiration syndrome due to exposure to blood and gastric contents into the respiratory tract. Enter gavage and empty stomach is not always possible. Damage to the jaws, pharynx make it virtually impossible atraumatic intubation even with laryngoscopy. Blind intubation attempts are unacceptable because of the risk of additional injury. In severe injuries of the face and jaws should intubate the trachea using fiberoptic or impose a tracheostomy and intubation through it (the latter preferably in non-surgical ward). If the patient is intubated through the nose, the tube should be left in the trachea for 1 - 3 days after surgery. Postoperatively in maxillofacial injuries due to edema may worsen respiratory disorders in which should not delay the implementation of a tracheostomy.

Phlegmons floor of the mouth and neck in the anesthesia aspect represents one of the most complex and specific anesthetic problems. Risk of anesthesia and surgery associated with the development of deep and widespread edema floor of the mouth, tongue, pharynx, larynx, causing swallowing disorders, respiratory failure to open the mouth (inflammatory contracture TMJ). There is a typical clinical picture of acute disorders: stridor, cyanosis, inability to open his mouth, sharp pain in the study, agitation, and resistance of the patient attempts to inspection. At default operations may accidentally autopsy purulent focus in the mouth or respiratory tract. The surgery usually is in the showdown cellulitis in the submandibular area or other departments. Often patients are so excited and exhausted, that the execution of any procedure without anesthesia or under local anesthesia is impossible. The risk of general anesthesia in these pathological conditions is very high.

The primary difficulty and risks of general anesthesia factor is that with a strong inflammatory edema difficult to maintain the airway patency. The anesthesiologist should be aware that the swelling of internal structures can be significantly stronger than that defined in the oropharynx and oral examination of the external surfaces of the submandibular region and other parts of the neck and face. Relatively good respiratory function in unaffected consciousness and spontaneous breathing can dramatically deteriorate quickly under general anesthesia, muscle relaxation and off independent breathing. Sudden stoppage airway obstruction is at the stage of critical respiratory disorders, in seconds the patient's condition deteriorates. In the absence of breathing is untenable forced ventilation mask, intubation attempts did not succeed due to the swelling bottom of the mouth, tongue, pharynx and the laryngeal inlet. Sometimes can not even direct laryngoscopy. Critical asphyxia in such cases requires immediate tracheostomy, which may be problematic again because of the rapid spread of edema.

In view of these dangers, if necessary, general anesthesia phlegmons floor of the mouth and neck, we strongly recommend the following procedure. Anesthesia specialist should hold the highest possible category and qualifications. It is desirable that he had experience in maxillofacial surgery. We remind you of this, because there are cases when the conduct of anesthesia for these patients were taken anesthesiologists are not prepared to work in maxillofacial surgery, sometimes young professionals, even without the knowledge of the department head or a more experienced anesthesiologist. Complications arose very quickly led to the development of critical condition and the patient's death. Organization of anesthesia should include the preparation of a set of tracheostomy, the trachea and the injection of oxygen into it; desirable to have a bronchoscopy and electrocardioscope. Anesthesiologist and surgeon should discuss joint action plan, the surgeon, ready to begin the operation, must be present in the operating room since the beginning of anesthetic events.

Premedication with atropine should include the full dose (0.01 - 0, 015 mg / kg). Emphasize the wrong calculation of required dose of atropine, depending on heart rate: patients with tachycardia mistakenly administered small doses of atropine, which have vagomimetic action and increase the danger of reflex reactions. Need for the atropine premedication full dose is determined by the increased activity of receptor sinocarotid, laryngeal and other reflex zones of the inflammation that can lead to dangerous vagal reflex disorders, hypotension with bradycardia or vagal cardiac arrest. Reflex disorders exacerbated by hypoxia, giperkateholaminemii due to pain, the excitation of the patient. Children instead of atropine can be entered in the age metacin dose.

Until a reliable airway and perform intubation unacceptable administered to a patient quickly and potent intravenous anesthetics (barbiturates, propanidid) apply halothane and chloroform, and the more chloroethyl. When providing surgical care to patients in non-specialized department, we believe the method of choice, providing the lowest risk of anesthesia, conducting the first phase of anesthesia and tracheal intubation under local anesthesia (with clear indications for surgery under general anesthesia). Tube is introduced through the nose, preferably by bronchoscopy, after careful surface anesthesia of the nasal passages and oropharynx by spraying lubrication and local anesthetic solution. It is also desirable with a spray gun, this solution was administered to the larynx and the lower level of the vocal cords. Sometimes the local anesthetic fails to carry out blind nasotracheal intubation, or even to perform laryngoscopy When tracheal intubation, anesthesia can further be carried out by conventional methods, using different drugs for the induction of anesthesia, maintaining anesthesia and muscle relaxants, etc.

In specialized departments of maxillofacial surgery and surgical dentistry has experience with the following methods of anesthetic management, usually combining general, explorer and local anesthesia.

Diverticulum cervical esophagus may also be difficult for the anesthesiologist and increase the risk of anesthesia. With larger diverticulum it accumulates contents (food mass, saliva), which can serve as a source of aspiration. Narrowing of the esophagus at the neck of his department can be extended esophageal wall thickened. These changes may be the reason that by receiving Sellick not be reliably prevent aspiration: diverticulum or advanced esophagus can not be effectively blocked by pressure on the cartilage of the larynx. Aspiration syndrome can occur especially hard due to the fact that the contents of the diverticulum or enlarged esophagus has a special texture (sometimes resembles thick cream). When injected into the bronchi such mass can not suck or removed through the bronchoscope. Only active lavage (lavage) of the bronchi using a special bronchoscope can improve the condition of the respiratory system and eliminate severe violations of ventilation.

Given the risks and complications listed, we recommend the following procedure anesthesiologist. Prior to surgery, it is necessary to appreciate the location, size and contents of the diverticulum (or spread of the esophagus), the anatomical features of the esophagus. Anesthesiologist should be present at the X-ray examination and participate in esophagoscopy. Under the control of the screen should evaluate the feasibility and effectiveness of pressing the esophagus by receiving Sellick.

Before the start of anesthesia should prepare the necessary tools for bronchial lavage and other activities in the event of aspiration syndrome.

Immediately before anesthesia and surgery is necessary to try to empty the diverticulum thick stomach probe or by esophagoscopy. If that fails, and the nature and changes of esophageal diverticulum can not guarantee reliable preventive aspiration syndrome reception Sellick, then shows intubation under local anesthesia in the usual way or by fiberoptic, as described above.

When diverticula located below the level of the larynx, in the absence of anatomical changes in the structure and location of the esophagus, when can we expect that the technique will be able to prevent aspiration Sellick, the patient is administered anesthesia in the usual way (premedication, the use of high-speed and muscle relaxant anesthetic when performing intubation). After tracheal intubation, and the method chosen are anesthetized by general rules.

Plastic surgery on her face. Should allocate reconstructive surgery performed for medical reasons since the neonatal period, and cosmetic surgery performed for aesthetic reasons.

Reconstructive plastic surgery in children of different age groups performed at a congenital or traumatic origin strains parts of the face (nose, ears, etc.). Features relating to pediatric anesthesia problems and conventional techniques already described in operations in the maxillofacial region (especially intubation device tubes, connecting elements, etc.).

When operations performed for cosmetic reasons should be especially careful to identify risk factors of anesthesia and surgery. By the operation may be admitted only those with low degrees of anesthetic risk. Mandatory preliminary examination of the patient in the anesthesia aspect, training and supervision in the immediate postoperative period.

From the viewpoint of the operation of vehicles, general anesthesia is preferred because it is not broken when the form of facial tissue, as when infiltration anesthesia. However, sometimes surgeons perform plastic surgery under local anesthesia in patients with high anesthetic risk, which, according to anesthesiologists, general anesthesia is contraindicated.

Result plastic surgery may depend on bleeding tissue and non-infringement coagulation system. Some surgeons believe that local anesthesia adding epinephrine to the local anesthetic solution creates the best conditions to operate. Others prefer to operate under general anesthesia. There are also advocates of the cosmetic surgery on the face controlled hypotension.

For skin transplants especially important to avoid circulatory disorders in the transplant. The task includes the anesthesiologist extremely attentive to the state of hemodynamics during anesthesia and rejection of funds infringing musculocutaneous bloodstream.

Nose plastic surgery is advisable to carry out under general anesthesia, since the local inevitable discomfort, especially if the intervention affects the bones of the nose. Mandatory tamponade nose at the end of surgery may be the cause of respiratory disorders after surgery. If the operation is carried out under endotracheal anesthesia, the tracheal extubation should be performed only after recovery of consciousness.

Excision and moving the face and neck, causing a chemical or thermal burns to the face and neck in order to reduce or eliminate the age-related skin changes are painful and invasive surgery (especially burn type), which is suitable general anesthesia. Optimal conditions for the surgeon creates intravenous anesthesia without the use of a mask or endotracheal tube. Given the traumatic surgery is not always possible for purely intravenous anesthesia to achieve the desired depth without her breathing disorders. With anesthetic standpoint, it is easier to provide guaranteed gas exchange and other requirements under anesthesia combined anesthesia, endotracheal method using muscle relaxants and mechanical ventilation. With all the options should be ready anesthesia or anesthetic breathing apparatus and kit for emergency intubation.

Of anesthetic techniques can be applied classical neyroleptanalgezii (preferably with muscle relaxants and mechanical ventilation), ataralgesia, anesthesia based on drip infusion of ketamine with diazepam, sodium hydroxybutyl-rata in combination with a small dose of barbiturate. Inhalation anesthesia is not contraindicated ftorotanom combined with nitrous oxide and oxygen.

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