Contemporary anesthesia in craniomaxillofacial trauma surgery: a scoping review from 2002–2022

Introduction

Craniomaxillofacial (CMF) trauma and anesthesia are disciplines that are intricately related. Surgeons who treat CMF trauma are deeply aware of and versed in the anesthetic thoughts and issues surrounding these patients. Conversely, providers of anesthesia understand that CMF trauma changes many aspects of how they can deliver an anesthetic. A wide breadth of literature exists on how these two interrelated fields overlap, examining questions about the airway, specific anesthetic drugs and delivery methods, and particular cases and algorithms. However, it is a vast field from both sides of the equation. Hence, the authors sought to perform a scoping review, examining the contemporary literature to find publications that overlap to provide an updated review to providers dealing with surgical or anesthesia aspects of these cases. The authors decided that a scoping review to examine the literature, as opposed to a more methodical assessment of the evidence with a systematic review, would provide a superior review, given the size and scope of the work. This work aims to establish a broad base, informing the reader of recent publications, context, and references. We present this article in accordance with the PRISMA-ScR reporting checklist (available at https://joma.amegroups.com/article/view/10.21037/joma-24-2/rc).

Methods

Design

This work is a scoping review that followed the methodology used in a systematic review for data collection (1).

Eligibility criteria

This scoping review aimed to explore new literature in the overlapping areas of CMF trauma and anesthesia. So, articles were limited to a timeline of 2002 to 2022. No limitation was assigned to the type of publication (case reports, clinical trials, and other forms of research were all included) to capture better and understand current perspectives and therapies as well as future directions and works. The search was limited to human studies and those published in English. Exclusion criteria evolved during the search, given the many works reviewed (discussed in the selection process).

Information sources and search strategy

The MEDLINE (via Ovid), Embase (via Elsevier), and Cochrane Library (via Wiley) databases were searched from 2002 to the present using a combination of database-specific controlled vocabulary terms and keywords searched in the title or abstract for the following concepts: maxillofacial trauma; anesthesia or intubation or laryngoscopy or emergence delirium or postoperative nausea and vomiting (PONV) or multimodal pain or ketamine or tracheotomy (table available at https://cdn.amegroups.cn/static/public/JOMA-24-2-1.docx). An experienced medical librarian (S.C.) devised and conducted the searches with input on keywords from the other authors. The search was validated against a set of pre-selected articles. Editorials, letters, comments, conference abstracts, and articles not in English were excluded from the search. In order to increase specificity, animal-only research was also excluded. The original searches were conducted on November 18, 2022. The searches were independently peer-reviewed by another librarian using a modified PRESS checklist (2). The complete, reproducible search strategies for all included databases are in the Appendix 1. Hand-searching bibliographies of included articles identified additional references. All citations were imported into Covidence, a systematic review screening software. Twelve thousand four hundred fifty-one studies resulted, with 2,749 identified as duplicate results. Nine thousand seven hundred-two studies underwent selection (Figure 1).

Figure 1 PRISMA [2020] flow diagram: contemporary anesthesia in craniomaxillofacial trauma surgery: a scoping review from 2002–2022.

Selection process

Two reviewers (A.C.J. and D.T.J.) independently screened references by title and abstract in the Covidence systematic review screening software. Conflicts were resolved by further discussion and consensus. This review yielded 358 publications for the next phase of full-text review. These articles were independently screened by the same two reviewers at the full-text level. Conflicts at this stage were once again resolved by consensus with a discussion about the applicability of the objects of the review. This compilation yielded a final result of 263 publications (see Appendix 1 for full list).

Data collection process and synthesis methods

Since this scoping review aimed to investigate what new literature has been presented, no specific data was collected systematically from each study. Instead, the resulting full-text reviews were grouped, and each addressed as a separate cohort in the results section, with the author’s summaries and interpretation of each cohort given. Similarly, no risk bias assessment nor effect measures were completed since discrete data was not obtained.

The final included articles were grouped into the following categories: general CMF trauma and anesthesia, gun-shot wounds (GSW), medications, nasal fractures, nasal intubation, submental intubation, traumatic brain injury (TBI) and cervical spine, tracheal and laryngeal injury, burns, and other. This formatting allowed the grouping of publications with similar topics and areas of focus for discussion.

Results

Quantity and quality of included works

The authors agreed on further exclusion criteria during the abstract and full-text review process. First, publications looking at out-of-hospital care [such as emergency medical services (EMS) reviews or studies on the battlefield] were excluded as they represent a large amount of literature generally focused on one of the areas (CMF trauma, anesthesia) but rarely both. These studies also frequently focused on emergency medical services level providers as opposed to CMF surgeons and anesthesia providers, who were the primary audience for this publication. Second, there was an expansive breadth of literature that did overlap but was non-specific for CMF injury, for example, publications looking at tracheostomy in brain injury. Though some patients had concurrent facial injuries, the authors felt this represented a large amount of adjacent literature that did not meet the paper’s intent and warrants its review due to its size and scope. Lastly, numerous studies were generally small (20–30 cases), prospective or retrospective reviews comparing specific brands of intubation equipment against the standard armamentarium. The authors felt that these represented specific industry publications and only contributed to the literature in an introduction to a new device. However, the authors did include more extensive studies and those that compared methodology, for example, direct laryngoscopy versus video laryngoscopy, without a specific brand name device.

The included articles were broken down by category for review and discussion.

• General CMF trauma and anesthesia: 44 publications: 1 systematic review, 1 prospective study, 15 retrospective reviews, 2 case series, 4 case reports, and 21 review articles or chapters;
• GSWs: 3 publications, all retrospective reviews;
• Medications: 30 publications: 2 systematic reviews with meta-analysis, 20 prospective studies, 3 retrospective reviews, 3 literature reviews, 1 chapter review, and 1 case report with a literature review;
• Nasal fractures: 14 publications: 10 prospective studies, 4 retrospective studies;
• Nasal intubation: 10 publications: 1 systematic review and meta-analysis, 2 prospective studies, 2 retrospective studies, 1 case series, 2 case reports, 1 technique paper, and 1 survey;
• Submental intubation: 85 publications: 1 systematic review, 7 prospective studies, 32 retrospective reviews, 2 literature reviews, 5 case series, 10 case reports, and 28 chapters, techniques, or review papers;
• TBI and cervical spine: 9 publications: 1 narrative review, 1 literature review, 2 prospective studies, 2 retrospective studies, and 3 review articles;
• Tracheal and laryngeal injury and burns: 46 publications: 1 systematic review, 3 literature reviews, 1 prospective study, 15 retrospective reviews, 2 case series, 17 case reports, and 7 review articles or chapters;
• Other: 21 publications: 1 systematic review and meta-analysis, 2 literature reviews, 3 prospective trials, 4 retrospective reviews, 7 case reports, and 4 pilot studies.

Discussion

General CMF trauma and anesthesia

This group of publications includes 44 papers that generally examine the combination of CMF trauma patients with various types of injuries, airway management, anesthetic strategies, and intubation techniques (see references 4–47 in Appendix 1). Table 1 displays the highlighted works in this section.

Many of the publications referenced the landmark work by Hutchison et al. in 1990, where the authors laid out six significant items that can contribute to a difficult airway in the CMF trauma patient and still serve as an excellent conceptual pillar in these patients (10):

• Posteroinferior displacement of a fractured maxilla parallel to the inclined plane of the base of the skull may block the nasopharyngeal airway;
• A bilateral fracture of the anterior mandible may cause the fractured symphysis and the tongue to slide posteriorly and block the oropharynx in the supine patient;
• Fractured or exfoliated teeth, bone fragments, vomitus, blood, secretions, and foreign bodies, such as dentures, debris, and shrapnel, may block the airway along the oropharynx and larynx;
• Hemorrhage from distinct vessels in open wounds or severe nasal bleeding from complex blood supply of the nose may also contribute to airway obstruction;
• Soft tissue swelling and edema, which result from trauma of the head and neck, may cause delayed airway compromise;
• Trauma of the larynx and trachea may cause swelling and displacement of structures, such as the epiglottis, arytenoid cartilages, and vocal cords, increasing the risk of cervical airway obstruction.

All the articles reviewed discussed some essential yet salient points. Detailed knowledge of maxillofacial anatomy is necessary for correct diagnosis and management, and basic principles of advanced trauma life support should be followed. The airway is a priority while maintaining cervical spine immobilization. There is no single best airway management technique; management should be based on clinical judgment and the practitioners’ skills. Communication between the surgeon and anesthesia provider is critical in planning and should be done early in the process, with backup plans and options discussed.

Many airway management strategies are possible to include supraglottic devices (single or double lumen, some with the ability to intubate through), direct laryngoscope blades (e.g., Macintosh or Miller), video laryngoscopy, fiberoptic guided devices, retrograde intubation, blind intubation techniques, submental intubation, temporization with trans-tracheal jet ventilation, and surgical airways to include cricothyrotomy, tracheostomy (open or percutaneous), and frank intubation through severe wounds.

The setting of care, acuity of airway issues in global consideration of the patient and injuries, and any injuries that may preclude or limit specific techniques (such as skull base fractures and nasal intubation) must be evaluated and used to direct airway management. The need for intraoperative maxillomandibular fixation (MMF) and selecting the airway technique to allow this during surgery is critical.

The majority of the fifteen retrospective reviews supported using alternative airway techniques instead of simply performing a tracheostomy in patients requiring intraoperative MMF. Of particular interest, in 2009, Lee et al. performed a retrospective review of 91 patients treated over one year with facial fractures treated with oral intubation, with the tube secured in either the retromolar space or missing tooth space (a technique described as retromolar intubation), allowing intraoperative MMF, with no issues (3). They preferentially used a 6.5 endotracheal tube (ET) in females and a 7.0 in males to ensure the tube could fit into these spaces and secured the tubes using 2-0 silk suture (as opposed to wire). They did not specify whether their ET tubes were reinforced or standard. Sittitavornwong et al. published in 2021 a retrospective review to quantify this retromolar space better (4). The authors used 41 trauma patients and did a cross-sectional analysis using their computed tomography (CT) scans to see how big the space was compared to reinforced ET tube sizes. Their results suggest that 6.0, 6.5, and 7.0 reinforced ET tubes can be positioned reliably, but their data was not statistically significant for 7.5 and 8.0 ET tubes. Zhang et al. published a 2016 paper that retrospectively looked at 200 patients with facial trauma and the frequency of the techniques, times required, cost, and associated complications (5). Their results support retromolar intubation as a first-line strategy in patients with missing or unerupted third molars, followed by submental intubation and tracheostomy only in patients who require long-term airway management.

Similarly, many studies advocated for these alternate methods over tracheostomy, except where long-term airway management was indicated. Daniels et al., in their 2020 retrospective review of 1,057 facial trauma patients, supported this finding of submental intubation and other strategies to avoid tracheostomy, as did Raval and Rashiduddin in their 2017 retrospective review of 177 facial trauma patients who advanced the fiberoptic bronchoscope as their primary methodology of choice to avoid tracheostomy (6,7). An overwhelming majority of the other retrospective reviews and review/chapter-style articles supported these findings.

Some of the studies looked at different methods of airway management. Vadepally et al. published a 2018 retrospective review of 18 patients using retrograde nasal intubation in oral and maxillofacial surgery patients with a reduced maximal incisal opening of less than 2 cm, which included trauma patients as well as patients with temporomandibular joint disorders and demonstrated no significant complications (8). Sun et al. conducted the only prospective study in the cohort in 2009, using a light-guided catheter (light-wand technique) to perform blind nasotracheal intubation on 100 patients with anticipated difficult airways, which included fractures and trauma as well as tumors, dentofacial deformities, and temporomandibular joint ankylosis (9). They reported 94 out of 100 first-pass success and no recorded hypoxemic events. Other studies examined blind intubation techniques and temporizing measures such as transtracheal jet ventilation and can be found in the references if interested.

Many of these new studies support techniques that specifically mitigate the need for tracheostomy, though the majority reviewed here are retrospective reviews. Due to a large volume of literature, the submental intubation technique is addressed separately in a later section. These works support a base of evidence, but prospective and more extensive studies are needed in these areas.

The authors believe the central takeaway point is that many effective techniques exist. However, what matters is the familiarity and expertise of each technique and the case factors like fracture pattern and need for intraoperative MMF, highlighting the need for thorough discussions between the operative surgeon and anesthesia team before the operating room to facilitate thoughtful airway management selection.

GSWs

Three publications were identified that specifically looked at GSW, and all were retrospective reviews focused on airway management (see references 48–51 in Appendix 1, with one additional paper discussed). It is essential to note that the authors exclude studies looking at out-of-hospital care, specifically wartime and battlefield care, of which many studies exist. Table 2 displays the highlighted works in this section.

Tsakiris et al. published in 2002 a retrospective review that identified 92 patients, of which 20 required a surgical airway, 17 tracheostomies (a mix of early and late), and 3 required cricothyroidotomy (11). Glapa et al. [2007] performed a similar study with 55 patients, with 14 patients requiring tracheostomies and 2 receiving cricothyroidotomy (12). Orthopoulos et al. [2013] looked at 115 patients in a retrospective review with isolated GWS to the face and head. Twelve patients required tracheostomy, and 2 received cricothyroidotomy (13). In all the studies, many patients required multiple operations.

Ballistic facial and cranial injuries represent a complex and challenging subset of injuries. Affected patients often have complex, urgent airway and hemorrhage issues and other injuries. These studies support a higher incidence of tracheostomy in these patients compared to facial fractures from other mechanisms.

A detailed discussion of the pathophysiology of ballistic injuries is beyond the scope of this work. However, the authors would recommend Contemporary Management of Maxillofacial Ballistic Trauma by Breeze et al. in 2017 by any interested parties, summarized here (14). The kinetic energy of a ballistic injury carries the projectile through soft tissue until striking hard tissue where energy deposition occurs resulting in fragmentation and secondary missile formation from both the device and the hard tissue fragments. Control of the airway is an immediate surgical consideration and need, along with catastrophic hemorrhage. Providers should have a low threshold for tracheostomy in these patients due to the risk of delayed swelling causing loss of airway in an uncontrolled and unpredictable manner, especially if any structure of, or around, the airway is affected by the injury.

Medications

A subset of publications examined specific medications in the setting of CMF trauma. There were 30 included studies (see references 52–81 in Appendix 1). Table 3 displays the highlighted works in this section.

Corticosteroids are commonly used in anesthesia, and facial trauma patients are no exception. Singh et al. published a systematic review and meta-analysis in 2021 looking at the benefits of systemic corticosteroids balanced against their adverse effects in maxillofacial trauma surgery (15). Ninety-four trials were reviewed, and 13 were included in their review, finding steroids reduced facial edema and postoperative pain but impaired wound healing. They concluded that the evidence was weak and that further investigation was needed. Haapanen et al. performed a prospective randomized trial published in 2017 to investigate corticosteroids’ effects on PONV in facial fracture patients (16). One hundred-nineteen patients were randomized to two groups, a control group that received no steroids (60 patients) and a group that received 10 mg of dexamethasone intravenously during surgery (59 patients), and then two further doses of 10 mg intramuscularly 8 hours apart, for a total of 30 mg. PONV was more frequent in the control group, 20%, versus 13.6% in the steroid group, but it was not statistically significant. It is worth noting that in this study, all patients received an inhalational anesthetic instead of a total intravenous anesthetic.

Besides their use in decreasing edema at the facial surgical sites, they also have a potential benefit in reducing airway swelling. Though no specific trials looked at this in the setting of facial trauma found in this scoping review, Epstein published a 2007 review looking at some of the evidence behind their use in preventing postoperative upper airway obstruction that the authors would refer to interested readers (17). There is also a landmark study that the authors included, the CRASH trial by Roberts et al. because it examined the use of corticosteroids in head injuries (18). This 2004 trial was a multi-center international study that looked at the effects on death within 14 days in patients with significant head injuries and included 10,008 patients. The primary outcomes were death within two weeks or permanent disability at 6 months post-injury, and the results showed no benefit in mortality from the treatment. Overall, all of the evidence found in this review weakly supports steroid use in the setting of facial trauma and demonstrates some benefits and drawbacks.

Several prospective trials looked at regional blocks with local anesthesia. Bertuit et al. published a 2021 paper looking at 107 patients undergoing either mandibular fracture open reduction with internal fixation or mandibular osteotomies, with randomly assigned groups either receiving bilateral mandibular V3 blocks with ropivacaine 0.75% or a placebo and looking at morphine consumption at 24 hours as the primary outcome to determine pain (19). The block group had a statistically significant reduction in morphine consumption, though interestingly, an equal incidence of PONV in both groups. Mesgarzadeh et al. published a similar prospective trial in 2014 looking at pure mandibular symphysis fractures undergoing open reduction and internal fixation (ORIF), separating 50 patients into a treatment group and a control group (20). The treatment group received bilateral mental nerve blocks with bupivacaine. They had similar results, with a statistically significant reduction in postoperative opioids. These studies help support using regional blocks in facial trauma surgery to decrease pain and postoperative opioid use.

Three prospective studies examined the effects of a non-steroidal anti-inflammatory (NSAID) medication in pain reduction for facial fracture patients. Jain et al. [2017] looked at 40 American Society of Anesthesiologists (ASA) physical classification 1 or 2 adults undergoing ORIF of isolated mandibular fractures (21). They were randomized to receive either 50 mg of tramadol or 8 mg of lornoxicam intravenously, and the pain was measured at five intervals in the first 24 hours postoperatively. Better pain control was statistically significant in the NSAID group. Nezafati et al. [2017] performed a similar study in 50 patients undergoing ORIF of mandible fractures. However, they randomized five groups to receive ketorolac intravenous (IV) 30 or 60 mg at the start of surgery or 30 or 60 mg at the termination of surgery and one group with no NSAIDs as a control (22). Pain was measured multiple times in the first 24 hours postoperatively. The 60 mg group had the lowest mean pain score, though there was no statistical significance between the 30 and 60 mg group given at the termination of surgery.

Lastly, Eftekharian et al. [2017] performed a similar trial on 50 patients undergoing ORIF for mandible fractures, giving one group 30 mg of ketorolac at the termination of surgery versus a control group who received IV fluid (23). The treatment group had a statistically significant reduction in pain four hours after surgery. These studies support the consideration of a multimodal pain control paradigm and the consideration for including an NSAID around the termination of surgery to minimize postoperative pain and reduce narcotic medication.

In 2013, Roberts et al. published the CRASH-2 trial, a landmark randomized control trial looking at the effects of tranexamic acid (TXA) on death, vascular occlusive events, and transfusion requirement in bleeding trauma patients (24). Importantly, this was not specific to CMF trauma. The study involved 274 hospitals in 40 countries and enrolled 20,211 patients. The intervention was 1 g TXA over 10 minutes for a loading dose followed by another 1 g infused over 8 hours or a matching placebo. The results showed a statistically significant decrease in all-cause mortality measured at 28 days in the treatment group. There was strong evidence for early treatment (within one hour of injury) for reduced death from bleeding.

The CRASH-3 trial in 2019 examined the use of TXA in patients with TBI (25). It was a randomized, placebo-controlled trial enrolling 175 hospitals in 29 countries. Twelve thousand seven hundred thirty-seven patients were enrolled, and the trial arm had patients receive 1 g TXA within the first 3 hours of injury. The results demonstrated an increased survival for patients with mild to moderate TBI but not for patients with severe TBI. The three CRASH trials are only briefly summarized here, and the authors recommend reading these landmark trials and results, given their practice-changing implications.

The use of TXA in reducing blood loss during ORIF of multiple facial fractures was examined by Dakir et al. in 2014 in a small prospective trial with twelve patients (26). Six patients were given 10 mg/kg of TXA, while the other six received normal saline as a control group. The same surgical and anesthesia teams operated on all the patients. There was a statistically significant difference in blood loss, with the control group losing 411.67 mL more blood on average than the treatment group.

The CRASH-2 trial was the landmark work that supports using TXA to reduce blood loss, and the smaller study from Dakir et al. supports that finding in CMF-related surgery. There is more work to be done in creating CMF-specific evidence, but it is suggestive that more specific research in this area would be fruitful.

Two further works are suggested for interested readers. The first is by Dougherty et al. in 2017 and looks at evidence-based medicine in facial trauma (27). It provides a comprehensive review of medical evidence to aid treatment decisions and is recommended for interested readers. The second is a systematic review of postoperative antibiotics in facial fracture patients by Habib et al. in 2019 which dives deeply into that specific and controversial topic (28).

Other works included in the references (references 66–81 in Appendix 1) include studies examining different medications used for awake fiberoptic intubations, medications used for creating hypotensive anesthesia, and studies examining emergence delirium, and the authors would encourage interested readers to examine these works.

Nasal fractures

Fourteen publications examined aspects of closed nasal fracture treatment and anesthesia (see references 82–95 in Appendix 1). These generally focused on performing this operation under monitored anesthesia care (MAC) versus a general anesthetic (GA), emergence agitation (EA), nerve blocks, antibiotics, and different medication strategies and comparisons. Table 4 displays the highlighted works in this section.

Many factors are involved in the surgeon’s decision to perform a closed reduction of nasal bone fractures under either local anesthetic, sedation with MAC, or GA, including the severity of the injury, timing, cost, patient desires, and medical comorbidities. Several studies looked at comparing MAC and GA. Kyung et al. [2018] retrospectively looked at 45 patients who underwent closed reduction of nasal bone fractures and analyzed intraoperative vitals, adverse effects, and length of time in the operating room and hospital (29). They also conducted patient interviews about satisfaction and aesthetic and functional outcomes. There was no difference in sore throat, postoperative pain, or surgery results, and no statistically significant difference in cosmetic and functional outcomes. Lee et al. [2013] looked at the same question using a prospective trial, with 60 patients enrolled into two evenly divided treatment groups (30). One group received GA with propofol-sevoflurane-N₂O, while the other received dexmedetomidine and MAC. Intraoperative vitals, postoperative pain scores, and PONV were analyzed. Intraoperatively, blood pressure was higher and heart rates lower in the MAC group; otherwise, no differences were noted. Both papers conclude that closed nasal reduction can be performed under either GA or MAC, depending on the patient and injury-specific factors. This supports the current literature on the topic.

Two studies looked at EA following closed nasal reduction under GA. Kim et al. [2012] prospectively compared 40 patients in two groups, one receiving propofol and the other receiving sevoflurane for maintenance of GA (31). Nine patients in the sevoflurane and two in the propofol group had EA as defined by Aono’s four-point scale (AFPS) of 3 or 4, suggesting EA rates may be less with propofol. Lee et al. [2019] examined the difference prospectively of EA in patients receiving either succinylcholine or rocuronium-sugammadex undergoing closed nasal reduction under GA (32). Forty-two patients were randomized into two equal groups, and EA was measured using the Rickers Sedation-Agitation Scale. EA was more common in the succinylcholine group, 19 of the 21 patients, versus the rocuronium-sugammadex group, 10 of the 21 patients. These studies suggest that considering medications to try and reduce EA in patients undergoing closed nasal fracture reduction under GA is important, and thoughtful selection could lead to a decreased prevalence of EA and its adverse sequelae.

Kim et al. [2013] retrospectively reviewed 85 cases comparing the use of an anterior ethmoidal nerve block on postoperative pain (33). Patients who received the block required statistically significantly fewer injectable analgesics than those who did not. Perez et al. [2019] prospectively looked at 52 patients who underwent closed nasal fracture reduction under local anesthesia (34). The first group received topical endonasal anesthesia and external transcutaneous infiltrative anesthesia, while the second had the addition of endonasal infiltrative anesthesia. The group that received the additional endonasal infiltrative block had a statistically significant decrease in pain during reduction maneuvers and packing. These studies support careful consideration and optimization of nerve blocks and local anesthetic to minimize pain during and after closed nasal reduction.

Jeon et al. [2021] performed a retrospective study using data over 10 years nationally in Korea to examine rates of antibiotic use associated with closed nasal fracture reduction (35). Three thousand six hundred seventy-eight patients were included, and the overall rate of postoperative antibiotic prescription was 51.4%, with second-generation cephalosporins being the most prescribed antibiotic. In 2021, Jung et al. performed a single-center retrospective review examining the same question and found a 67.3% prescription rate of antibiotics (36). Using nasal packing, anesthesia type, and surgeon specialty showed no difference in infection-related complications. The literature does not currently support antibiotic use with closed nasal reduction, though more specific research needs to be done.

Hollins et al. [2023], Closed Reduction of Nasoseptal Fractures: Key Concepts for Predictable Results, was included by the authors as an excellent work that warrants inclusion and discussion (37). Retrospective review of 103 patients undergoing closed reduction under deep sedation or general anesthesia, with 4 patients needing revision septorhinoplasty surgery (3.9%). The authors advocate that one of their critical concepts is the anesthesia, which allows for multiple attempts at reduction of the structures of the septum and nasal bones, which, as treating providers know, is extremely difficult under local anesthesia. The authors would refer anyone who treats this injury to this article for further reading.

Other studies included in the references include comparisons of various medications used for MAC (dexmedetomidine and alfentanil versus ketamine and alfentanil, different concentrations of propofol/ketamine mixtures), and the use of fentanyl-soaked nasal packings (Appendix 1).

Nasal intubation

Nasal intubation plays a significant role in the intubation strategy for CMF trauma patients. A nasotracheal tube allows for the stabilization of occlusion and the application of MMF during surgery. The scoping review included ten papers with many publication types (see references 97–106 in Appendix 1). Table 5 displays the highlighted works in this section.

Hoshijima et al. [2022] published a systematic review and meta-analysis looking at nasal protection strategies and reducing nasal pressure injuries using protective dressings or modified fixation methods of the nasotracheal tube (38). Five trials were included, and meta-analysis showed a statistically significant decrease in nasal pressure injuries. Both methods, padding the ala and modifying the fixation with a head wrap or set up to reduce nasal pressure, demonstrated a reduction of pressure injuries, though these were not statistically compared. Yang et al. in 2020 performed a randomized control trial comparing a hydroactive padded dressing versus tape on the nasal ala in orthognathic surgery (39). Four hundred fifty patients were divided into two equal groups, and assessments were performed sequentially for up to 72 hours after surgery. The incidence of alar pressure injury in the tape group was 14.2% compared to 4.4% in the hydroactive dressing group. This review supports using padding or dressing to reduce pressure injury from the tube on the nasal area.

Most CMF and anesthesia providers are aware of nasal pressure injuries and use some combination of suturing of the nasotracheal tube, padding, dressing to the ala, and headwraps to reduce the chance of this complication. Koshika et al. [2020] published a retrospective study with their results of three years of using a new device to aid in this problem (40). In 2018, the authors began 3D printing a device that sits on top of the head as part of a headwrap configuration and holds the tube in a position to take pressure off the nasal complex. They report 335 patients treated with their method with no complications or pressure injuries. This study highlights the evolving incorporation of 3D printing, in-house design, and application to address mixed CMF and anesthesia issues and represents an exciting frontier.

Methods for preparing the nasal complex for nasal intubation include serial dilations with nasopharyngeal airways and using a urethral catheter to assist passage and dilation. However, a 2014 survey by Donohue et al. of 77 anesthesia providers in London inquiring about methods used in nasotracheal intubation revealed that 79% had not heard of the catheter-assisted technique (41). For those unfamiliar with this helpful technique, Wong et al. published a 2011 technique paper detailing the method (42).

Hosseinzadeh et al. [2013] published a prospective study looking at the common practice of warming the nasal tube before intubation (43). Theoretically, the warming softens the tube, increasing flexibility and decreasing trauma to normal structures. Sixty patients were placed into either a study arm or control arm, with the study arm having tubes placed into 50-degree (Celsius) water for 5 minutes. The study was performed in a double-anonymized fashion. Though the study arm had a higher incidence of blind intubation success, it was not statistically significant, and there were no other significant differences between the two groups. This research suggests that it may be helpful, though further research is needed.

One of the significant concerns about using nasotracheal intubation in CMF trauma patients is the relative contraindication of performing it in a patient with trauma to the midface, pharynx, or skull base due to concerns of passing the tube into dangerous anatomic spaces. Ersoy et al. [2011] published a case report on this problem, where the tube dissected into the surrounding nasopharyngeal tissues (44). Unfortunately, there is little evidence on this topic as it represents a rare and potentially devastating complication outside of sporadic case reports and series. Performing a fiberoptic intubation may be reasonable, trying to maintain visualization throughout the process or selecting an alternate airway method. Ultimately, this should be a team decision between the surgeon and anesthesia provider based on the injuries, airway, and case factors. Mesgarzadeh et al. [2012] reported a case of severe midface trauma with an intruded maxilla (LeFort fracture) where the surgeon disimpacted the maxilla using wire to open up the pharynx and nasal passage to allow nasal intubation (45). Though unusual, the CMF surgeon could consider the fracture pattern and a similar strategy depending on the case and circumstances.

Another complication arises when the nasotracheal tube becomes damaged during surgery. Piroli et al. [2019] published a case series and review article on this topic (46). Damage can occur to the tube or cuff and can present at any time during surgery. Some of the most common reasons for damage are manipulation with a Magill forceps during intubation and lacerations from bony spurs in the nasal passage, generally from the bony aspect of the nasal septum. When damage occurs and is identified, the surgeon and anesthesia provider must evaluate the adequacy of ventilation, vital signs, and stage of surgery and determine whether to proceed or exchange the airway.

Though not CMF trauma-specific, Yamamoto et al. [2022] published a retrospective study on nasal versus oral intubation in trauma patients (47). Twenty-nine thousand two hundred and seventy-one patients were included, of which 667 were intubated nasally. The timing of intubation for this study was during part of the initial resuscitation. The nasally intubated cohort has higher in-hospital mortality and a higher incidence of noninfectious pulmonary complications. This evidence supports the commonly held practice of not maintaining nasal intubations outside of the OR setting. If a patient needs to remain intubated following a CMF procedure with nasal intubation, consideration should be given to exchanging to oral intubation or tracheostomy.

Submental intubation

Submental intubation is described as oral intubation, followed by tube passage through an incision through the floor of the mouth, exiting in the submental region of the neck. First introduced by Hernández Altemir in 1986, the advantage is that the tube does not pass between the dentition, so MMF is possible during surgery (48). This technique offers an alternative to tracheostomy for patients in whom nasal intubation is not possible or feasible. Though well-known and commonly practiced among CMF providers, this technique may be less frequently seen and reported than more common airway management strategies like nasal intubation and tracheotomy. The authors would refer anyone unfamiliar with the basics of the technique and steps to any cited papers, as the following will entail a more detailed discussion of the nuances reported in the literature. Table 6 displays the highlighted works in this section.

Some publications dealt directly with submental intubation (see references 108–191 in Appendix 1). The number of publications first demonstrates the increasing amount of evidence supporting this technique, and almost all these publications advocate for it as a vital airway management strategy for the CMF surgeon and anesthesia team.

Goh et al. published in 2020 a systematic review of submental intubation, covering publications from 1986 to 2018 (49). A total of 116 studies were included after the review, encompassing 2,229 patients treated with submental intubation. They reported indications including overwhelming trauma (81%) with other indications such as orthognathic surgery, disease, and cosmetic surgery. Technical preferences were for a single-tube technique (84%) versus a two-tube technique (6%), and the preferred device was a reinforced endotracheal tube, also known as an armored tube (85%). They reported a 7% complication rate, including scarring, infection, damage to the tube, accidental disconnection during surgery, and salivary fistula. They conclude that submental intubation is a quick, effective, and safe procedure that offers an alternative to tracheostomy.

Similarly, Lim et al. [2018] performed a literature review between 1986 and 2016, reporting on 70 publications covering 1,021 patients (50). Similar to Goh et al., trauma was the most common indication (87%), and the complication rate was 9%, covering the same complications mentioned above. These two extensive reviews covered many of the same papers, hence why their results were similar in the authors’ opinion. A deeper exploration into the publications and literature search for our project found interesting variations. The first variance is in naming. The term submental intubation was the most common name. However, other names for the technique include transmylohyoid intubation and, when used in a paramedian fashion, lateral submental intubation and submandibular intubation.

There was variation across the literature for where the submental incision was created. The two most common locations were either midline or paramedian, just off-midline. Some publications, like Ramalingam et al. in 2014, advocated for a “2-2-2” rule, making the incision 2 cm lateral for the midline, 2 cm in size (and below the inferior border of the mandible), and an intraoral incision 2 cm in size (51). The advantage of a paramedian or lateral approach is sparing disruption of the muscle attachments to the lingual midline portion of the mandible (the geniohyoid, genioglossus, and anterior digastric). Gadre et al., in their 2010 retrospective review of 400 cases of submental intubation, argue that the incision and tube need not be placed into the submental triangle but can be posterior to the mandibular first molars (52). They advocate for staying anterior to the first molars to avoid damage to the facial artery but argue that depending on the fracture pattern, it can be advantageous to place the tube more posteriorly and, coupled with a blunt dissection into the floor of the mouth, the vital structures remain safe.

Similarly, there is variation in how the incision is created in the mouth. Some authors advocate for a lingual sulcular incision and subperiosteal dissection to create a pocket for the tube to emerge intraorally. Some advocate for an incision directly on the floor of the mouth once blunt dissection is carried up to it and structures identified to prevent damage to particularly the submandibular ducts. One of the best publications on this question was done by Taglialatela et al. [2006], a retrospective review of 107 cases done using the method of direct incision into the mucosa of the floor of the mouth and demonstrating similar complication rates to a subperiosteal dissection, with no significant complications of damage to the salivary ducts (53). In fact, the original paper by Hernández Altemir notes that subperiosteal passage is not essential (48). However, all the publications universally say that regardless of whether the tube is placed midline or paramedian, and regardless of where the intraoral incision is placed, staying as close as possible to the mandible lingually is recommended to avoid damage to adjacent structures.

One technique paper by Hanamoto et al. in 2011, reported on the technique of using two endotracheal tubes, which essentially involves intubation, then passing a second tube through the submental incision and connecting the tubes (54). Some papers looked at alternate methods to aid in avoiding complications. Saheb et al. [2014] reported a case series where percutaneous dilators were used to create the passage into the mouth to reduce the risk of damage to vital structures (55). Jung et al. in 2020 published a case report using a laparoscopic trochar to create the passage and pass the tube to reduce the chance of a blood clot occluding the tube during passage and hindering ventilation (56). Saravanan et al. [2005] and Arya et al. [2005] looked at combining submental intubation with initial retrograde intubation, showing that these two techniques can be combined (57,58). One publication by Kapoor et al. [2012] explores their technique of combining submental intubation with a wire fixation, whereby after the submental intubation is completed, the tube is then wired to the lingual surface of the molars to create a second fixation point to decrease chances of tube dislodgement during surgery (59). These studies illustrate that refinements are being explored to this technique to increase the predictability and reduce complications, and though not standard, they are worth exploring and considering.

Other variations were reported as well. Ali et al. [2017] published a prospective randomized control trial evaluating awake submental intubation versus asleep (60). Twelve patients were in each arm of their trial, and they found no significant differences but reported that the awake group required slightly less time. Though the primary indication for submental intubation is trauma, other indications are becoming more explored. Biglioli et al. [2003] and Sharma et al. [2008] examined using submental intubation in transfacial cranial base surgery, supporting it as a viable option against tracheotomy (61,62).

Complication rates across the reported literature range from about 5–10%, as demonstrated by the previous extensive systematic and literature review. de Toledo et al. [2013] published a literature review of complications and found that in the resulting 711 studies, there was a 6.3% complication rate (63). Reported complications in all these studies include bleeding, damage to the tube or dislodgement during surgery, infection, salivary fistula, and scarring. For the seven prospective studies in this review, encompassing 353 patients in total, there were 19 reported complications at a rate of 5.38%. The 32 retrospective reviews covered 1,498 submental intubated patients: 58 reported complications, or 3.87%. Though these numbers are a total and do not reflect an evaluation of the quality of evidence, they support the general idea that a complication can be expected about 5–10% of the time. However, most are easily managed; no life-threatening complication was identified or reported in the literature.

Two case reports explored the rarer occurrence of complications with the pilot balloon, Neha et al. [2021] and Yoon et al. [2004], along with proposed management (64,65). Anyone practicing this technique should review these articles to ensure familiarity with management if it occurs.

Specific literature on the indications for submental intubation compared to tracheotomy was reported. Emara et al. in 2019 published a prospective trial in severe craniofacial trauma patients where nasotracheal intubation was contraindicated (66). Thirty-two patients were randomized to either arm, and the times and complications were compared. Submental intubation had an average of 8.35 minutes compared to 30.75 minutes in the tracheotomy group. No complications resulted in the submental group versus several in the tracheotomy group. Schütz et al. in 2008 and Ramalingam et al. in 2016 also published studies comparing the interventions with similar results (67,68). All the papers discuss and acknowledge that a significant consideration between the techniques is the need for prolonged ventilatory support. If indicated, a tracheotomy should be considered over the submental intubation.

TBI and cervical spine

Some publications were identified that concerned airway management with cervical spine injury or anesthesia and TBI (see references 192–203 in Appendix 1). Table 7 displays the highlighted works in this section.

Wiles [2022] published a narrative review on airway management in patients with suspected or confirmed traumatic spinal cord injury (69). This patient population often requires intubation due to other injuries, and approximately 40% of cervical spine injuries are judged to be unstable (76). Interestingly, the review examined evidence of the effectiveness of manual in-line stabilization (MILS). A critical review of the existing evidence reveals that this practice has little evidence behind it, and newer studies are suggestive that it may increase the subluxation of damaged cervical segments. Multiple studies, as cited in this review, evaluated different intubation methods in these patients and found that, in general, there is a higher incidence of a higher grade glottic view (Cormack-Lehane grade 3 or 4). However, much of this information was done or involved with cadaveric studies and without review of further neurologic complications, so though interesting, application to clinical practice is limited. More studies are needed to evaluate cervical spine protection and intubation paradigms.

Similarly, there is little evidence to support performing awake or asleep fiberoptic intubation in these patients. Only one randomized control by Dutta et al. [2020] examined this, comparing awake tracheal intubation of a fiberoptic bronchoscope against a McGrath video laryngoscope (70). Lateral measurements of angulation were assessed radiographically in 46 patients equally distributed to each method, and the fiberoptic group demonstrated a statistically significant decrease in movement at C1 and C2 but not C3. Overall, Wiles conclude and highlight that airway management in this patient population remains uncertain, and all airway interventions are associated with some degree of movement of the cervical spine, with the clinical significance largely unknown (69).

Two prospective studies examined specific airway management strategies in cervical spine injury. Agarwal et al. [2010] had 40 patients randomly assigned to two groups, one for oral intubation and the other for nasal intubation (71). Both groups were intubated awake and with a light-wand style device while maintaining cervical collar immobilization. A single expert anesthesiologist performed all the procedures and demonstrated slightly increased time and number of attempts in the nasal group, though the results were not statistically significant. The study supports the awake light-wand method as a viable method of maintaining immobilization, though comfort and experience with the technique are required.

Sut et al. [2017] used a prospective trial to assess the effectiveness of the gum elastic bougie (GEB) against an intubating laryngeal mask airway (ILMA) in patients with simulated cervical spine injury (72). One hundred thirty-four patients were assigned equally to three groups: GEB, ILMA, and a video laryngoscope group to act as a control. Cervical collars were applied after induction, and first-attempt success was highest in the GEB group and lowest in the ILMA group, 95% versus 66% (statistically significant). The authors conclude that GEB, regarded as a cheaper and more universally accessible option, is advantageous in this patient population.

The other literature examined TBI and concussion in anesthesia. King et al. [2019] published a literature review on perioperative consideration for these patients, and Audu et al. [2020] published a similar review article on the same topic (73,74). Both publications elucidate that mild TBI is common, especially in trauma patients who often need surgical intervention acutely as part of their management. Generally, there is little evidence or known data on how anesthesia affects or influences this, outside of consideration of cerebral autoregulation and known physiology. The question evolves into when elective surgery is safe for these patients. Though little evidence exists, various biomarkers have been proposed to help identify this criterion. Similarly, there is no evidence supporting one anesthetic technique over another. Recommendations from these publications, as well as the excellent review article by Abcejo et al. [2018], include increased awareness of concussion and symptoms in the pre-operative workup, postponing elective surgery until post-concussion symptoms have resolved, awareness that brain physiology may be altered in these patients, and familiarity of the Brain Trauma Foundation Guidelines to minimize risk (75). These guidelines include avoidance of unnecessary hyperventilation, maintaining systolic blood pressures above 100 mmHg in patients 50–69 years and above 110 mmHg in those less than 50 years and those older than 69 years, minimizing hypoxia, and avoiding unnecessary corticosteroids (77). Overall, this area has little evidence to aid decision-making and strategies and would benefit hugely from further studies.

Tracheal and laryngeal injury and burns

Literature review addressing tracheal and laryngeal injuries resulted in some publications identified (see references 204–249 in Appendix 1). Specific literature related to burns in the head and neck and inhalational injury resulted in 17 publications. Table 8 displays the highlighted works in this section.

Laryngotracheal trauma is an uncommon injury but one that can be serious. The first step in management is airway assessment and control, which is a focus of many of the reviewed publications. There are many options for management, but all publications agree that this needs to be considered and accomplished by experienced members of the trauma and anesthesia teams on a case-by-case basis. Schaefer et al. [2014] published a literature review on the management of acute blunt and penetrating laryngeal trauma (78). Their conclusions, which mirror many of these publications, are that early assessment with a directed history and physical is essential, followed by options including early management with intubation through a variety of methods, cricothyroidotomy, tracheotomy, possibly with a CT scan to aid in diagnosis if assessed to be safe, followed by consideration for surgical exploration and repair. Mercer et al. [2010] published a literature review to create management guidelines for penetrating neck injuries to aid in delimitating management (79). Ultimately, they recommend considering the same factors as mentioned above, along with consideration for the zones of the neck. Due to the relative rarity of these injuries, intubation methodology and surgical decision-making are primarily based on the clinical presentation and multifactorial considerations of the patient and injury.

Several of the retrospective reviews gave interesting insights. Harvin et al. [2016] looked at 103 patients across seven level 1 trauma centers in the United States with cervical tracheal injuries (80). They grouped patients by postoperative airway management into immediate or early extubation (less than 24 hours), prolonged intubation (over 24 hours), and immediate tracheotomy. Each group was of similar size. The findings included that the tracheotomy group had a lower mortality, 0% versus 13% in the intubated group, but was associated with a statistically significant increase in surgical site infections. They also identified that the prolonged intubation and tracheotomy groups generally had more severe injuries than the early extubation, and in considering the more critically ill patients for prolonged intubation versus tracheotomy, this involved a risk-benefit consideration on a case-by-case basis.

Tallon et al. [2007] and Randall et al. [2014] both performed retrospective reviews of these injuries in the Canadian trauma system and came to similar conclusions that management is complex and case-dependent with weak existing evidence (81,82). Wu et al. [2019] looked at the prevalence of these injuries in conjunction with craniofacial trauma (83). Their review of 12 patients meeting criteria found that statistically significant presenting findings that can clue the provider into a laryngotracheal injury included (in order of the most to least sensitive) subcutaneous emphysema, neck pain, dyspnea, hoarseness, neck swelling, stridor, hemoptysis, and thoracic trauma.

A study by Dillon et al. [2013] examined the choice of emergent surgical airway in cricothyrotomy versus tracheotomy (84). They reviewed 4,312 documented emergent airways at their level 1 trauma center and found 34 cases requiring surgical treatment, 24 of which were tracheotomies and 10 cricothyrotomies. Interestingly, about half of these were performed by the general surgery or trauma service, and the other half by services primarily operated on the head and neck, with a roughly equal distribution. They cite the need for more extensive studies as results would be necessary in directing training.

Many of the case reports looked at highly severe injuries, including complete transections of the trachea. Jean et al. [2018] published a case report where they intubated the patient through the transected tracheal that was visible through the open neck wound, highlighting that this can be considered as an option for emergent airway management (85). Overall, the review highlighted that these types of injuries can range from benign to emergent and need to be evaluated by experts from both the anesthesia and surgical side. Decisions should be made on a case-by-case basis.

Specific to burn injuries, Unal et al. [2022] published a systematic review looking at pediatric patients with burn injuries and neck and facial scarring undergoing subsequent anesthetics (86). Forty-one articles were selected, reviewing 56 patients in total. This population’s most common complex airway indicators were limited mouth opening, neck extension, and flexion. The severity of the burn scarring and contractor can dramatically change the anatomy and, in some cases, make identification of surgical airway landmarks unrecognizable. They report that the key to dealing with these patients’ airways is aggressive planning, consideration of awake techniques with the fiberoptic scope being a first-line method over direct laryngoscopy, and the surgical team being ready to intervene if necessary. Another important consideration is that these patients often require staged and multiple surgeries, so the airway must be evaluated carefully before each surgery, as the anatomy may change with growth and changes in the scarring and tissue contracture.

Huang et al. [2022] used a retrospective review to review the correlation of objective signs criteria for evaluating inhalation injury and the need for intubation (87). They reviewed records for 335 facial burn patients, of whom 121 were intubated for airway concerns. Seventy-three of the 121 were found to have inhalation injuries on later bronchoscopy. Two criteria, shortness of breath and high total body surface burn area (TBSA), were shown to be statistically significant for independent risk factors for inhalation injury. Every one percent increase in TBSA was associated with a 1.038-fold increase in the odds of inhalation injury. Similarly, Badulak et al. [2018] published a retrospective review of 218 patients trying to elucidate the same question of physical exam findings correlating to a need for intubation (88). Specifically, they looked at the American Burn Association (ABA) criteria compared to classic physical exam findings (see reference paper for details of indications). They found that the ABA criteria were strongly correlated to a need for long-term intubation, with 77.5% of the patients who exhibited ABA criteria needing long-term ventilatory management. Comparatively, the traditional indicators for intubation had only a 22.5% predictive rate. Both studies conclude that more research is needed. However, practitioners should consider intubating patients demonstrating full-thickness facial burns, stridor, respiratory distress, demonstrated airway changes on laryngoscopy, hemodynamic instability, hypoxia/hypercarbia, suspected smoke inhalation, and singed facial hair.

Interestingly, several case reports detail specific and inventive methods of securing endotracheal tubes in burn patients requiring longer-term intubation. Endotracheal tube stabilization can be a complex problem as straps and tape can increase injury friction and disrupt skin grafting, and in edentulous patients, this can become even more problematic. Case reports included using intermaxillary fixation screws, one or two, placed into the anterior maxillary vestibule and wired to a tube to hold it in place (91-94). The case series by Gray et al. [2010] looked at placing a nasogastric tube with a bridle technique in pediatric patients and securing the tube to the NG tube to hold it in place (89). Enomoto et al. [2021] described a custom oral appliance made to aid in securing the tube (90). These articles highlight the need for interdisciplinary evaluation and treatment and how the CMF surgeon can aid and contribute to care in some difficult circumstances.

Other

This category captured affiliated publications pertinent to this research but was not categorized into the other areas (Table 9). This yielded 21 publications with a broad spectrum of types of publications (see references 250–270 in Appendix 1).

One topic addressed by several publications was the question of nasogastric tube placement in the setting of CMF trauma. Spurrier et al. in 2008 performed a literature review and found 23 cases with reported inadvertent intracranial placement of the nasogastric tube in CMF trauma patients (95). One case report reported an episode of this, and an additional case report demonstrated intracranial placement of a nasopharyngeal airway during resuscitation. These serve as a stark reminder that any inserted device, especially in the setting of trauma, can end up in an unintended position, and the use of nasal devices in midface and basilar skull trauma should be carefully considered.

Al Shetawi et al. [2016] reported a case of a spontaneous intraoperative tension pneumothorax in a routine CMF trauma surgery, developing immediately following an uneventful nasal intubation and requiring immediate decompression and placement of a chest tube (96). Their literature review found only five other cases reported of this happening. However, it reminds the CMF surgeons and anesthesia providers that this situation is a possible sequelae during routine surgery. Casap et al. in 2011 performed a literature review to examine missing teeth in CMF trauma patients (97). This team reviewed 10 years of institutional data, 1,411 patients, and found 7 with aspiration of foreign bodies in the airway due to the trauma or subsequent intubation. Though rare, treating teams must be aware of this possibility and review pre-operative imaging with this thought in mind to aid in ruling out foreign objects like teeth in the airway, especially if otherwise unaccounted.

Many institutions and anesthesia practitioners are starting to use bispectral index monitors (BIS) more frequently, and not only in the setting of a total intravenous anesthetic. To adapt during facial surgery, the authors have routinely observed BIS monitor placement in an alternate position on the nasal dorsum. One pilot study by Romito et al. [2022] looked prospectively at ten patients, comparing BIS data from the standard forehead placement against the nasal dorsal position (98). The study was performed on patients in the neurocritical care setting, not the operating room, but the results did not support using this alternate position. More extensive and comprehensive studies are needed to validate this alternate use of the BIS monitor.

Several studies focused on the comparison of direct laryngoscopy versus video laryngoscopy. Aziz et al. [2016] performed a comprehensive retrospective review examining 346,861 cases of attempted tracheal intubation to identify 1,427 cases of failed direct laryngoscopy on the first attempt (99). They found that video laryngoscopy was the most frequent choice for secondary technique (compared against a supraglottic airway, flexible bronchoscope, lighted style, and optic stylet) and had the highest success rate for rescue intubation. Gupta et al. [2021] performed a systematic review and meta-analysis of randomized control trials looking at direct versus video laryngoscopy in oromaxillofacial surgery (100). They concluded that the evidence suggests that a video technique leads to a shorter intubation time, increased success on the first attempt, and reduced need for adjunctive maneuvers compared to direct.

Regarding CMF, Tabrizi et al. [2018] performed a randomized prospective study comparing direct versus video laryngoscopy in patients with bilateral mandible fractures (101). Seventy-eight patients were included in roughly two groups, and the video technique increased the success of first-attempt intubation. This literature supports the practice of video laryngoscopy technique as a first line for CMF trauma patients.

Conclusions

Anesthesia and CMF trauma surgery are inherently related fields with much overlap. Practitioners of one discipline must be intimately familiar with the other to provide safe, high-quality care, as the various sections emphasize. The concordance of these fields is an ever-evolving area, with more high-quality studies and research needed to build evidence-based results to support clinical practices. The authors hope this work provides an expansive look at the evolution, development, and progression of important bridging concepts from the last 20 years of practice.

Limitations

There are several limitations to this scoping review. It covered only works in English and did not examine literature published before 2002. Due to the size and scope of the review, it only highlights what the authors believed to be critical papers and points from those writings, which carries inherent bias of the author team based on experience.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the PRISMA-ScR reporting checklist. Available at https://joma.amegroups.com/article/view/10.21037/joma-24-2/rc

Peer Review File: Available at https://joma.amegroups.com/article/view/10.21037/joma-24-2/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://joma.amegroups.com/article/view/10.21037/joma-24-2/coif). D.B.P. serves as an unpaid editorial board member of Journal of Oral and Maxillofacial Anesthesia from November 2023 to October 2025. The views expressed herein are those of the authors and do not reflect the official policy of the Department of the Army, Department of the Airforce, the Uniformed Services University of Health Science, Department of Defense, or the US Government, nor any institution. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372: [Crossref] [PubMed]
2. McGowan J, Sampson M, Salzwedel DM, et al. PRESS Peer Review of Electronic Search Strategies: 2015 Guideline Statement. J Clin Epidemiol 2016;75:40-6. [Crossref] [PubMed]
3. Lee SS, Huang SH, Wu SH, et al. A review of intraoperative airway management for midface facial bone fracture patients. Ann Plast Surg 2009;63:162-6. [Crossref] [PubMed]
4. Sittitavornwong S, Mostofi P, DiLuzio K, et al. Does the Retromolar Area Provide Adequate Space for an Oral Endotracheal Tube Without Interfering With Intermaxillary Fixation? J Oral Maxillofac Surg 2021;79:2455-61. [Crossref] [PubMed]
5. Zhang X, Wang X, Gu Q, et al. Evaluation of alternative airway management strategies in surgical repair of severe cranio-maxillofacial trauma. Minerva Chir 2016;71:372-6.
6. Daniels JS, Albakry I, Braimah RO, et al. Experience with Airway Management and Sequencing of Repair of Panfacial Fractures: A Single Tertiary Healthcare Appraisal in Najran, Kingdom of Saudi Arabia - A Retrospective Study. Ann Maxillofac Surg 2020;10:402-8. [Crossref] [PubMed]
7. Raval CB, Rashiduddin M. Airway management in patients with maxillofacial trauma - A retrospective study of 177 cases. Saudi J Anaesth 2011;5:9-14. [Crossref] [PubMed]
8. Vadepally AK, Sinha R, Kumar AVSSS. Retrograde intubation through nasal route in patients with limited mouth opening undergoing oral and maxillofacial surgery. J Oral Biol Craniofac Res 2018;8:30-4. [Crossref] [PubMed]
9. Sun Y, Jiang H, Zhu Y, et al. Blind intubation device for nasotracheal intubation in 100 oral and maxillofacial surgery patients with anticipated difficult airways: a prospective evaluation. Eur J Anaesthesiol 2009;26:746-51. [Crossref] [PubMed]
10. Hutchison I, Lawlor M, Skinner D. ABC of major trauma. Major maxillofacial injuries. BMJ 1990;301:595-9. [Crossref] [PubMed]
11. Tsakiris P, Cleaton-Jones PE, Lownie MA. Airway status in civilian maxillofacial gunshot injuries in Johannesburg, South Africa. S Afr Med J 2002;92:803-6.
12. Glapa M, Kourie JF, Doll D, et al. Early management of gunshot injuries to the face in civilian practice. World J Surg 2007;31:2104-10. [Crossref] [PubMed]
13. Orthopoulos G, Sideris A, Velmahos E, et al. Gunshot wounds to the face: emergency interventions and outcomes. World J Surg 2013;37:2348-52. [Crossref] [PubMed]
14. Breeze J, Tong D, Gibbons A. Contemporary management of maxillofacial ballistic trauma. Br J Oral Maxillofac Surg 2017;55:661-5. [Crossref] [PubMed]
15. Singh AK, Dhungel S, Bhattarai K, et al. Do the Benefits of Systemic Corticosteroids Outweigh Adverse Effects During Maxillofacial Trauma Surgery? A Systematic Review and Meta-Analysis. J Oral Maxillofac Surg 2021;79:1530.e1-1530.e21. [Crossref] [PubMed]
16. Haapanen A, Thorén H, Törnwall J, et al. Postoperative nausea and vomiting in facial fracture patients: A Randomized and controlled trial on the effect of dexamethasone. Int J Oral Maxillofac Surg 2017;46:1267-70. [Crossref] [PubMed]
17. Epstein SK. Corticosteroids to prevent postextubation upper airway obstruction: the evidence mounts. Crit Care 2007;11:156. [Crossref] [PubMed]
18. Roberts I, Yates D, Sandercock P, et al. Effect of intravenous corticosteroids on death within 14 days in 10008 adults with clinically significant head injury (MRC CRASH trial): randomised placebo-controlled trial. Lancet 2004;364:1321-8. [Crossref] [PubMed]
19. Bertuit M, Rapido F, Ly H, et al. Bilateral mandibular block improves pain relief and morphine consumption in mandibular osteotomies: a prospective, randomized, double-blind, placebo-controlled clinical trial. Reg Anesth Pain Med 2021;46:322-7. [Crossref] [PubMed]
20. Mesgarzadeh AH, Afsari H, Pourkhamne S, et al. Efficacy of bilateral mental nerve block with bupivacaine for postoperative pain control in mandibular parasymphysis fractures. J Dent Res Dent Clin Dent Prospects 2014;8:172-5. [Crossref] [PubMed]
21. Jain AD, Vsm R, Ksn SB, et al. A Comparative Assessment of Postoperative Analgesic Efficacy of Lornoxicam versus Tramadol after Open Reduction and Internal Fixation of Mandibular Fractures. Craniomaxillofac Trauma Reconstr 2017;10:171-4. [Crossref] [PubMed]
22. Nezafati S, Khiavi RK, Mirinejhad SS, et al. Comparison of Pain Relief from Different Intravenous Doses of Ketorolac after Reduction of Mandibular Fractures. J Clin Diagn Res 2017;11:PC06-10. [Crossref] [PubMed]
23. Eftekharian HR, Ilkhani Pak H. Effect of Intravenous Ketorolac on Postoperative Pain in Mandibular Fracture Surgery; A Randomized, Double-Blind, Placebo-Controlled Trial. Bull Emerg Trauma 2017;5:13-7.
24. Roberts I, Shakur H, Coats T, et al. The CRASH-2 trial: a randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients. Health Technol Assess 2013;17:1-79. [Crossref] [PubMed]
25. Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial. Lancet 2019;394:1713-23.
26. Dakir A, Ramalingam B, Ebenezer V, et al. Efficacy of Tranexamic Acid in Reducing Blood Loss during Maxillofacial Trauma Surgery-A Pilot Study. J Clin Diagn Res 2014;8:ZC06-8. [Crossref] [PubMed]
27. Dougherty WM, Christophel JJ, Park SS. Evidence-Based Medicine in Facial Trauma. Facial Plast Surg Clin North Am 2017;25:629-43. [Crossref] [PubMed]
28. Habib AM, Wong AD, Schreiner GC, et al. Postoperative prophylactic antibiotics for facial fractures: A systematic review and meta-analysis. Laryngoscope 2019;129:82-95. [Crossref] [PubMed]
29. Kyung H, Choi JI, Song SH, et al. Comparison of Postoperative Outcomes Between Monitored Anesthesia Care and General Anesthesia in Closed Reduction of Nasal Fracture. J Craniofac Surg 2018;29:286-8. [Crossref] [PubMed]
30. Lee K, Yoo BH, Yon JH, et al. General anesthesia versus monitored anesthetic care with dexmedetomidine for closed reduction of nasal bone fracture. Korean J Anesthesiol 2013;65:209-14. [Crossref] [PubMed]
31. Kim YS, Chae YK, Choi YS, et al. A comparative study of emergence agitation between sevoflurane and propofol anesthesia in adults after closed reduction of nasal bone fracture. Korean J Anesthesiol 2012;63:48-53. [Crossref] [PubMed]
32. Lee SJ, Sung TY, Cho CK. Comparison of emergence agitation between succinylcholine and rocuronium-sugammadex in adults following closed reduction of a nasal bone fracture: a prospective randomized controlled trial. BMC Anesthesiol 2019;19:228. [Crossref] [PubMed]
33. Kim HS, Lee HK, Jeong HS, et al. Decreased postoperative pain after reduction of fractured nasal bones using a nerve block of the anterior ethmoidal nerve. Int J Oral Maxillofac Surg 2013;42:727-31. [Crossref] [PubMed]
34. Pérez-García A, Esteban-Vico JR, Lorca-García C, et al. Endonasal Infiltrative Anesthesia for Nasal Fracture Reduction. Plast Surg Nurs 2019;39:22-4. [Crossref] [PubMed]
35. Jeon YR, Jung JH, Song JH, et al. Antibiotic use in nasal bone fracture: a nationwide population-based cohort study in Korea. Arch Craniofac Surg 2021;22:254-9. [Crossref] [PubMed]
36. Jung JH, Jeon YR, Song JH, et al. Antibiotic use in nasal bone fracture: a single-center retrospective study. Arch Craniofac Surg 2021;22:319-23. [Crossref] [PubMed]
37. Hollins A, Pyfer B, Breeze J, et al. Closed reduction of nasoseptal fractures: key concepts for predictable results. Br J Oral Maxillofac Surg 2023;61:344-50. [Crossref] [PubMed]
38. Hoshijima H, Mihara T, Nagumo T, et al. Nasal protection strategy reduces the incidence of nasal pressure injuries during nasotracheal intubation: Meta-analysis with trial sequential analysis. Medicine (Baltimore) 2022;101:e30638. [Crossref] [PubMed]
39. Yang G, Gao C, Cai J. Prevention of Nasal Ala Pressure Injuries With Use of Hydroactive Dressings in Patients With Nasotracheal Intubation of Orthognathic Surgery: A Randomized Controlled Trial. J Wound Ostomy Continence Nurs 2020;47:484-8. [Crossref] [PubMed]
40. Koshika K, Hoshino T, Shibata Y, et al. New Device for Securing Nasotracheal Intubation Tube During Oral and Maxillofacial Surgery. Bull Tokyo Dent Coll 2020;61:275-9. [Crossref] [PubMed]
41. Donohue C, Sohanpal I. Reducing nasal trauma from nasal intubation-a survey of current practice. Anaesthesia 2014;69:71.
42. Wong A, Subar P, Witherell H, et al. Reducing nasopharyngeal trauma: the urethral catheter-assisted nasotracheal intubation technique. Anesth Prog 2011;58:26-30. [Crossref] [PubMed]
43. Hosseinzadeh H, Taheri Talesh K, Golzari SE, et al. Warming Endotracheal Tube in Blind Nasotracheal Intubation throughout Maxillofacial Surgeries. J Cardiovasc Thorac Res 2013;5:147-51. [Crossref] [PubMed]
44. Ersoy B, Gürsoy T, Celebiler O, et al. A complication of nasotracheal intubation after mandibular subcondylar fracture. J Craniofac Surg 2011;22:1527-9. [Crossref] [PubMed]
45. Mesgarzadeh AH, Zanjani F. Difficult nasoendotracheal intubation in a patient with severe maxillofacial trauma. J Emerg Trauma Shock 2012;5:243-5. [Crossref] [PubMed]
46. Piroli A, Cutilli T, Lupi E, et al. Different Solutions for Damaged Nasotracheal Tube during Maxillofacial Surgery: A Case Series. Adv Ther 2019;36:1812-6. [Crossref] [PubMed]
47. Yamamoto R, Fujishima S, Sasaki J. Nasal intubation for trauma patients and increased in-hospital mortality. Eur J Trauma Emerg Surg 2022;48:2795-802. [Crossref] [PubMed]
48. Hernández Altemir F. The submental route for endotracheal intubation. A new technique. J Maxillofac Surg 1986;14:64-5. [Crossref] [PubMed]
49. Goh EZ, Loh NHW, Loh JSP. Submental intubation in oral and maxillofacial surgery: a systematic review 1986-2018. Br J Oral Maxillofac Surg 2020;58:43-50. [Crossref] [PubMed]
50. Lim D, Ma BC, Parumo R, et al. Thirty years of submental intubation: a review. Int J Oral Maxillofac Surg 2018;47:1161-5. [Crossref] [PubMed]
51. Ramalingam B, Ebenezer V, Dakir A. Lateral submental intubation in panfacial trauma review of five cases. Biosciences Biotechnology Research Asia 2014;11:901-6.
52. Gadre KS, Waknis PP. Transmylohyoid/Submental intubation: review, analysis, and refinements. J Craniofac Surg 2010;21:516-9. [Crossref] [PubMed]
53. Taglialatela Scafati C, Maio G, Aliberti F, et al. Submento-submandibular intubation: is the subperiosteal passage essential? Experience in 107 consecutive cases. Br J Oral Maxillofac Surg 2006;44:12-4. [Crossref] [PubMed]
54. Hanamoto H, Morimoto Y, Niwa H, et al. A new modification for safer submental orotracheal intubation. J Anesth 2011;25:781-3. [Crossref] [PubMed]
55. Saheb SM, Nath VN, Kumar KP, et al. A novel method using Seldinger's technique for submental intubation in major craniomaxillofacial fractures: A case series. Indian J Anaesth 2014;58:48-50. [Crossref] [PubMed]
56. Jung I, Yoo BH, Ju JY, et al. Novel alternative for submental intubation - A case report. Anesth Pain Med (Seoul) 2020;15:247-50. [Crossref] [PubMed]
57. Saravanan P, Arrowsmith JE. Retrograde submental intubation after faciomaxillary trauma. Anesth Analg 2005;101:1892-3. [Crossref] [PubMed]
58. Arya VK, Kumar A, Makkar SS, et al. Retrograde submental intubation by pharyngeal loop technique in a patient with faciomaxillary trauma and restricted mouth opening. Anesth Analg 2005;100:534-7. [Crossref] [PubMed]
59. Kapoor D, Gupta A, Thapa D, et al. Two point fixation of endotracheal tube in submentotracheal intubation during craniomaxillofacial surgeries-our experience! Anaesthesia, Pain and Intensive Care 2012;16:273-5.
60. Ali S, Athar M, Ahmed SM, et al. A Randomized Control Trial of Awake Oral to Submental Conversion versus Asleep Technique in Maxillofacial Trauma. Ann Maxillofac Surg 2017;7:202-6. [Crossref] [PubMed]
61. Biglioli F, Mortini P, Goisis M, et al. Submental Orotracheal Intubation: An Alternative to Tracheotomy in Transfacial Cranial Base Surgery. Skull Base 2003;13:189-95. [Crossref] [PubMed]
62. Sharma RK, Tuli P, Cyriac C, et al. Submental tracheal intubation in oromaxillofacial surgery. Indian J Plast Surg 2008;41:15-9. [Crossref] [PubMed]
63. de Toledo GL, Bueno SC, Mesquita RA, et al. Complications from submental endotracheal intubation: a prospective study and literature review. Dent Traumatol 2013;29:197-202. [Crossref] [PubMed]
64. Neha S, Karthick KS. Inadvertent strangulation of inflation line of the pilot balloon during submental endotracheal intubation: a rare complication. J Clin Monit Comput 2021;35:449-51. [Crossref] [PubMed]
65. Yoon KB, Choi BH, Chang HS, et al. Management of detachment of pilot balloon during intraoral repositioning of the submental endotracheal tube. Yonsei Med J 2004;45:748-50. [Crossref] [PubMed]
66. Emara TA, El-Anwar MW, Omara TA, et al. Submental intubation versus tracheostomy in maxillofacial fractures. Oral Maxillofac Surg 2019;23:337-41. [Crossref] [PubMed]
67. Schütz P, Hamed HH. Submental intubation versus tracheostomy in maxillofacial trauma patients. J Oral Maxillofac Surg 2008;66:1404-9. [Crossref] [PubMed]
68. Ramalingam B, Prabhu NP, Senthilnathan R. Submental intubation versus tracheostomy in panfacial trauma patients. Research Journal of Pharmaceutical, Biological and Chemical Sciences 2016;7:625-7.
69. Wiles MD. Airway management in patients with suspected or confirmed traumatic spinal cord injury: a narrative review of current evidence. Anaesthesia 2022;77:1120-8.
70. Dutta K, Sriganesh K, Chakrabarti D, et al. Cervical Spine Movement During Awake Orotracheal Intubation With Fiberoptic Scope and McGrath Videolaryngoscope in Patients Undergoing Surgery for Cervical Spine Instability: A Randomized Control Trial. J Neurosurg Anesthesiol 2020;32:249-55. [Crossref] [PubMed]
71. Agarwal A, Mathur P, Singh H, et al. Awake intubation using lightwand in patients with cervical spine injuries: a comparison of nasal and oral routes. J Anaesthesiol Clin Pharmacol 2010;26:19-22.
72. Sut EY, Gunal S, Yazar MA, et al. Comparison of effectiveness of intubation by way of "Gum Elastic Bougie" and "Intubating Laryngeal Mask Airway" in endotracheal intubation of patients with simulated cervical trauma. Rev Bras Anestesiol 2017;67:238-45. [Crossref] [PubMed]
73. King D, Collins-Yoder A. Perioperative Considerations in Patients With Concussion. AANA J 2019;87:97-104.
74. Audu P, Aboagye VO, Trivedi K. Anesthetic Care for the Post-concussive Patient: There Are More Questions Than Answers. Curr Anesthesiol Rep 2020;10:56-60.
75. Abcejo AS, Pasternak JJ. Concussion: a Primer for the Anesthesiologist. Curr Anesthesiol Rep 2018;8:245-51.
76. Milby AH, Halpern CH, Guo W, et al. Prevalence of cervical spinal injury in trauma. Neurosurg Focus 2008;25:E10. [Crossref] [PubMed]
77. Brain Trauma Foundation. J Neurotrauma 2007;24:S55-8. Erratum in: J Neurotrauma 2008;25:276-8. [Crossref] [PubMed]
78. Schaefer SD. Management of acute blunt and penetrating external laryngeal trauma. Laryngoscope 2014;124:233-44. [Crossref] [PubMed]
79. Mercer SJ, Lewis SE, Wilson SJ, et al. Creating airway management guidelines for casualties with penetrating airway injuries. J R Army Med Corps 2010;156:355-60. [Crossref] [PubMed]
80. Harvin JA, Taub EA, Cotton BA, et al. Airway management following repair of cervical tracheal injuries: A retrospective, multicenter study. J Trauma Acute Care Surg 2016;80:366-70; discussion 370-1. [Crossref] [PubMed]
81. Tallon JM, Ahmed JM, Sealy B. Airway management in penetrating neck trauma at a Canadian tertiary trauma centre. CJEM 2007;9:101-4. [Crossref] [PubMed]
82. Randall DR, Rudmik LR, Ball CG, et al. External laryngotracheal trauma: Incidence, airway control, and outcomes in a large Canadian center. Laryngoscope 2014;124:E123-33. [Crossref] [PubMed]
83. Wu JC, Chen HY, Liao CH, et al. Maxillofacial Fractures Associated With Laryngeal Injury: A Craniofacial Surgeon Should be Alert. Ann Plast Surg 2019;82:S72-6. [Crossref] [PubMed]
84. Dillon JK, Christensen B, Fairbanks T, et al. The emergent surgical airway: cricothyrotomy vs. tracheotomy. Int J Oral Maxillofac Surg 2013;42:204-8. [Crossref] [PubMed]
85. Jean YK, Potnuru P, Diez C. Airway Management of Near-Complete Tracheal Transection by Through-the-Wound Intubation: A Case Report. A A Pract 2018;11:312-4. [Crossref] [PubMed]
86. Unal D, Sumak Hazir M. Airway Management in Pediatric Patients With Burn Contractures of the Face and Neck. J Burn Care Res 2022;43:1186-202. [Crossref] [PubMed]
87. Huang RY, Chen SJ, Hsiao YC, et al. Positive signs on physical examination are not always indications for endotracheal tube intubation in patients with facial burn. BMC Emerg Med 2022;22:36. [Crossref] [PubMed]
88. Badulak JH, Schurr M, Sauaia A, et al. Defining the criteria for intubation of the patient with thermal burns. Burns 2018;44:531-8. [Crossref] [PubMed]
89. Gray RM, Rode H. Intra-operative endotracheal tube stabilisation for facial burns. Burns 2010;36:572-5. [Crossref] [PubMed]
90. Enomoto A, Shimoide T, Kinoshita Y, et al. Application of an oral appliance for endotracheal tube fixation in facial burn patients. Br J Oral Maxillofac Surg 2021;59:127-8. [Crossref] [PubMed]
91. Assi P, Quiroga L, Gerold K, et al. Endotracheal Tube Fixation in Patients With Facial Burns, What Are the Options? Eplasty 2018;18:ic19.
92. Davis C. Endotracheal tube fixation to the maxilla in patients with facial burns. Plast Reconstr Surg 2004;113:982-4. [Crossref] [PubMed]
93. Fleissig Y, Rushinek H, Regev E. Intermaxillary fixation screw for endotracheal tube fixation in the edentulous patient with facial burns. Int J Oral Maxillofac Surg 2014;43:1257-8. [Crossref] [PubMed]
94. Kanno T, Mitsugi M, Furuki Y, et al. Endotracheal tube stabilization using an orthodontic skeletal anchor in a patient with facial burns. Int J Oral Maxillofac Surg 2008;37:386-7. [Crossref] [PubMed]
95. Spurrier EJ, Johnston AM. Use of nasogastric tubes in trauma patients--a review. J R Army Med Corps 2008;154:10-3. [Crossref] [PubMed]
96. Al Shetawi AH, Golden L, Turner M. Anesthetic Complication during Maxillofacial Trauma Surgery: A Case Report of Intraoperative Tension Pneumothorax. Craniomaxillofac Trauma Reconstr 2016;9:251-4. [Crossref] [PubMed]
97. Casap N, Alterman M, Lieberman S, et al. Enigma of missing teeth in maxillofacial trauma. J Oral Maxillofac Surg 2011;69:1421-9. [Crossref] [PubMed]
98. Romito JW, Atem FD, Manjunath A, et al. Comparison of Bispectral Index Monitor Data Between Standard Frontal-Temporal Position and Alternative Nasal Dorsum Position in the Intensive Care Unit: A Pilot Study. J Neurosci Nurs 2022;54:30-4. [Crossref] [PubMed]
99. Aziz MF, Brambrink AM, Healy DW, et al. Success of Intubation Rescue Techniques after Failed Direct Laryngoscopy in Adults: A Retrospective Comparative Analysis from the Multicenter Perioperative Outcomes Group. Anesthesiology 2016;125:656-66. [Crossref] [PubMed]
100. Gupta N, Gupta A, Sarma R, et al. Video laryngoscopy vs. direct laryngoscopy for nasotracheal intubation in oromaxillofacial surgery: a systematic review and meta-analysis of randomized controlled trials. Korean J Anesthesiol 2021;74:439-48. [Crossref] [PubMed]
101. Tabrizi R, Dahi M, Moshari MR, et al. Video Laryngoscopy or Macintosh Laryngoscopy: Which One Is More Successful in Patients With Bilateral Mandibular Fractures? J Oral Maxillofac Surg 2018;76:1864-8. [Crossref] [PubMed]