Primary Care Otolaryngology

Chapter 12

applied to the head by someone other than the intubating physician at the time of intubation. The second reason you might not be able to perform oral intubation is massive facial and neck trauma with distortion of land- marks and bleeding.

This patient might have had a lateral C-spine film that showed no C-spine fracture, but at direct laryngoscopy, all you can see is blood and disrupted tissue. This patient would obviously need a sur- gical airway. You would perform a crico- thyrotomy, unless there is concern over a fractured larynx (widened thyroid car- tilage, subcutaneous air [crepitus], neck bruising, hoarseness, coughing up blood) , in which case, a tracheotomy is the procedure of choice. Remember, nor- mal lateral C-spine film does not com- pletely rule out a C-spine fracture. Next, consider breathing and ventilation. If you cannot perform an oral intubation, you can sometimes perform a fiberoptic nasotracheal intubation. In this case, an endotracheal tube is passed through the

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Figure 12.1. Nasal fracture. Note that the bony nasal pyramid has been shifted toward the patient’s left. Most commonly a right- handed individual will strike a patient’s nose and shift the bony pyramid toward the patient’s right. Repair is straight- forward, but should be completed within 5–7 days to ensure optimal outcome.

nose down into the hypopharynx, guided by a fiberoptic endoscope placed through the endotracheal tube. With the endoscope, you can see when the tube approaches and is advanced into the larynx. You must wait until just after an expiration, because the ideal time to push the endoscope through is when the patient breaths in, opening the vocal cords. Once the endoscope is in the trachea, the tube is passed over the scope, and the endoscope is then removed. The advantage of the fiberoptic nasotracheal intubation technique is that the neck is not manipulated at all, so it is still a viable option, even if a C-spine fracture has not been ruled out. Fiberoptic nasotracheal intubation is best performed on an awake patient who is able to sit upright. Tissue collapse makes this procedure more challenging when patients are supine. This technique is not feasible if visualization is obscured by secretions, blood, or swelling. Also, if there is a severe midface injury with possible cribriform plate fracture, passage of a nasogastric or blind nasotracheal tube is contraindicated because the tube may pass into the brain.

Primary Care Otolaryngology