Nasal Intubation

[anbuitachi]

What is your practice on doing nasal intubations in OMFS procedures (eg that needs to wire mouth shut) in patients with significant fractures after trauma? I see a bunch of these patients especially after MVCs.

Orbital fractures, Nasal fractures, sinus fractures. No csf leak but OMFS always want nasal tubes.

It's 'controversial' but a contraindication is significant facial fractures to nasal intubation. However if a patient has significant fractures, what do you do? Tell them no? If not then how long do you wait..?

Other than trach or submental intubation

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[Shimmy8]

I ask them, "You good with nasal? Ok with xyz fractures?" and ask them which side they want it on.

If poly-trauma with multiple other injuries (pelvis, humerus, femur, etc) and expected to have multiple procedures, then trach from the get-go.

 

[vector2]

What is your practice on doing nasal intubations in OMFS procedures (eg that needs to wire mouth shut) in patients with significant fractures after trauma? I see a bunch of these patients especially after MVCs.

Orbital fractures, Nasal fractures, sinus fractures. No csf leak but OMFS always want nasal tubes.

It's 'controversial' but a contraindication is significant facial fractures to nasal intubation. However if a patient has significant fractures, what do you do? Tell them no? If not then how long do you wait..?

Other than trach or submental intubation

I just make sure they're aware of whatever fractures/leforte the pt has and ask if they're still OK with nasal. If they say yes then I place a nasal and document that we discussed it.

 

[anbuitachi]

I ask them, "You good with nasal? Ok with xyz fractures?" and ask them which side they want it on.

If poly-trauma with multiple other injuries (pelvis, humerus, femur, etc) and expected to have multiple procedures, then trach from the get-go.

I just make sure they're aware of whatever fractures/leforte the pt has and ask if they're still OK with nasal. If they say yes then I place a nasal and document that we discussed it.

so you let the surgeon decide? but arent you the one doing the procedure? if anything goes wrong, im guessing responsibility lies with anesthesiologist, and surgeon walks away hands clean

 

[Harpoon1]

so you let the surgeon decide? but arent you the one doing the procedure? if anything goes wrong, im guessing responsibility lies with anesthesiologist, and surgeon walks away hands clean

He gave the most practical, real world response possible. in fact a reasonable person might even say he consulted with and made a decision with an expert of facial bones/fractures. The medico-legal hangwringing response is indicative of a mindset that gets our practice nowhere, imo.

 

[vector2]

so you let the surgeon decide? but arent you the one doing the procedure? if anything goes wrong, im guessing responsibility lies with anesthesiologist, and surgeon walks away hands clean

I mean, any time I have a facial fracture or airway case I look at the CT images and the report myself so I don't get surprised by anything.... but yeah, we have extremely high OMFS volume and I trust the surgeons I work with so I defer to them. Same goes for ENT assuming it's a staff I've worked with before.

And honestly, insisting on avoiding nasal (when you literally know next to nothing about the nuances of facial fractures) while an expert on the nuances of facial fractures is telling you nasal is ok...seems rather asinine. This is not one of those situations where the surgeon has to stay out of your lane. Facial and airway stuff is very much in their lane, too.

 

[Iso4ane]

What is your practice on doing nasal intubations in OMFS procedures (eg that needs to wire mouth shut) in patients with significant fractures after trauma? I see a bunch of these patients especially after MVCs.

Orbital fractures, Nasal fractures, sinus fractures. No csf leak but OMFS always want nasal tubes.

It's 'controversial' but a contraindication is significant facial fractures to nasal intubation. However if a patient has significant fractures, what do you do? Tell them no? If not then how long do you wait..?

Other than trach or submental intubation

Submental Intubation. This is the way.

 

[Arch Guillotti]

I mean, any time I have a facial fracture or airway case I look at the CT images and the report myself so I don't get surprised by anything.... but yeah, we have extremely high OMFS volume and I trust the surgeons I work with so I defer to them. Same goes for ENT assuming it's a staff I've worked with before.

And honestly, insisting on avoiding nasal (when you literally know next to nothing about the nuances of facial fractures) while an expert on the nuances of facial fractures is telling you nasal is ok...seems rather asinine. This is not one of those situations where the surgeon has to stay out of your lane. Facial and airway stuff is very much in their lane, too.

What he said.

 

[anbuitachi]

I mean, any time I have a facial fracture or airway case I look at the CT images and the report myself so I don't get surprised by anything.... but yeah, we have extremely high OMFS volume and I trust the surgeons I work with so I defer to them. Same goes for ENT assuming it's a staff I've worked with before.

And honestly, insisting on avoiding nasal (when you literally know next to nothing about the nuances of facial fractures) while an expert on the nuances of facial fractures is telling you nasal is ok...seems rather asinine. This is not one of those situations where the surgeon has to stay out of your lane. Facial and airway stuff is very much in their lane, too.

yea for sure make sense. just wondering. saw a case the other day, ENT said do oral intubation. but the case is booked under plastic surgery who said nasal intubation is fine.

curious who is the true specialist of this stuff or is it just shared. many other services its very clear cut. neuro for brain stuff, derm for skin, anesthesiology for anesthesia...

but multiple services do these surgeries involving face. plastics, ENT, OMFS. all fix mandibles etc.

 

[anbuitachi]

He gave the most practical, real world response possible. in fact a reasonable person might even say he consulted with and made a decision with an expert of facial bones/fractures. The medico-legal hangwringing response is indicative of a mindset that gets our practice nowhere, imo.

i get it. just reminds me of all those times surgeons will say this case will take 1 hour and 3 hours later they are still operating. or closure is 10 mins, and its 45. or you dont need arterial line for this case, and its 10 hrs with a lot of bleeding.

i spoke to OMFS and he said in his career hes never seen nasal intubation go wrong so its okay. so i guess its anectodal/based on his experience which is valid. but if the books say its a contraindication.... then it becomes a discussion. you dont see one until you see one. this stuff is supposed to be rare

im just saying in the end intubation its my procedure so im responsible and ive seen plenty of times surgeon will throw the anesthesiologist under the bus when things go south. but appreciate everyones input of course

 

[vector2]

yea for sure make sense. just wondering. saw a case the other day, ENT said do oral intubation. but the case is booked under plastic surgery who said nasal intubation is fine.

curious who is the true specialist of this stuff or is it just shared. many other services its very clear cut. neuro for brain stuff, derm for skin, anesthesiology for anesthesia...

but multiple services do these surgeries involving face. plastics, ENT, OMFS. all fix mandibles etc.

I think more important than ENT said X and plastics said Y is 1) which (attending) surgeon is saying what 2) do you know that person and have you worked with them before 3) what is the reasoning behind them either OK'ing or not OK'ing nasal or oral intubation.

Craniofacial polytrauma is sometimes subject to three different specialists coming in to look at three different parts on a patient's head, so the person I would defer to is the one who is actually fixing the jaw/facial/skull base fractures.

 

[Shimmy8]

I mean, any time I have a facial fracture or airway case I look at the CT images and the report myself so I don't get surprised by anything.... but yeah, we have extremely high OMFS volume and I trust the surgeons I work with so I defer to them. Same goes for ENT assuming it's a staff I've worked with before.

And honestly, insisting on avoiding nasal (when you literally know next to nothing about the nuances of facial fractures) while an expert on the nuances of facial fractures is telling you nasal is ok...seems rather asinine. This is not one of those situations where the surgeon has to stay out of your lane. Facial and airway stuff is very much in their lane, too.

This exactly. I’m in a high volume, high acuity OMFS world. They respect my abilities, and I respect their expertise.

 

[anbuitachi]

I think more important than ENT said X and plastics said Y is 1) which (attending) surgeon is saying what 2) do you know that person and have you worked with them before 3) what is the reasoning behind them either OK'ing or not OK'ing nasal or oral intubation.

Craniofacial polytrauma is sometimes subject to three different specialists coming in to look at three different parts on a patient's head, so the person I would defer to is the one who is actually fixing the jaw/facial/skull base fractures.

worked with both services frequently.

ENT said oral because of significant bone fractures in the face. OMFS said nasal okay because no basilar skull fracture. I did some reading and while every source lists basilar skull fracture as a contraindication, some sources list severe facial fractures as one too.

this patient had bilateral comminuted nasal bone fracture. anterior posterior medial lateral bilateral maxillary sinus fracture. and left inferior orbital bone fracture. ethmoid sinuses opaque probably due to blood. the patient has racoon eyes bilaterally. we ended up doing a nasal on the right side, without the orbital fracture and it went fine... but was very gentle with it. if resistance i wouldve just told them we are doing oral tube.

my experience here is when ENT/plastics does face bone cases, they are way more cool with oral intubation and will work around it unless its close to impossible. OMFS will almost always want a nasal intubation

 

[vector2]

worked with both services frequently.

ENT said oral because of significant bone fractures in the face. OMFS said nasal okay because no basilar skull fracture. I did some reading and while every source lists basilar skull fracture as a contraindication, some sources list severe facial fractures as one too.

this patient had bilateral comminuted nasal bone fracture. anterior posterior medial lateral bilateral maxillary sinus fracture. and left inferior orbital bone fracture. ethmoid sinuses opaque probably due to blood. the patient has racoon eyes bilaterally. we ended up doing a nasal on the right side, without the orbital fracture and it went fine... but was very gentle with it. if resistance i wouldve just told them we are doing oral tube.

my experience here is when ENT/plastics does face bone cases, they are way more cool with oral intubation and will work around it unless its close to impossible. OMFS will almost always want a nasal intubation

I would be asking what exactly omfs needs a nasal tube for given that fracture pattern. No mandible or tmj fractures too?

 

[coffeebythelake]

worked with both services frequently.

ENT said oral because of significant bone fractures in the face. OMFS said nasal okay because no basilar skull fracture. I did some reading and while every source lists basilar skull fracture as a contraindication, some sources list severe facial fractures as one too.

this patient had bilateral comminuted nasal bone fracture. anterior posterior medial lateral bilateral maxillary sinus fracture. and left inferior orbital bone fracture. ethmoid sinuses opaque probably due to blood. the patient has racoon eyes bilaterally. we ended up doing a nasal on the right side, without the orbital fracture and it went fine... but was very gentle with it. if resistance i wouldve just told them we are doing oral tube.

my experience here is when ENT/plastics does face bone cases, they are way more cool with oral intubation and will work around it unless its close to impossible. OMFS will almost always want a nasal intubation

How are you intubating this? In the setting of mid face fractures without an absolute contraindication. Asleep nasal fiberoptic?

 

[vector2]

How are you intubating this? In the setting of mid face fractures without an absolute contraindication. Asleep nasal fiberoptic?

In this case I'd do either asleep nasal FOI, or put a red rubber on the end of the nasal tube, feed it through the nose into the oropharynx and then pull the red rubber out through the mouth after using it as a guide to feed to the tip of the nasal tube into the back of the throat.

 

[deleted875186]

depends on the quality of the surgeon, generally ENT surgeons much better and would trust them, but probably my own anecdotal experience.

 

[nimbus]

depends on the quality of the surgeon, generally ENT surgeons much better and would trust them, but probably my own anecdotal experience.

For facial fractures, opposite is true at my institution. Trauma center with high volume of facial fractures and OMFS>plastics>ENT.

 

[anbuitachi]

I would be asking what exactly omfs needs a nasal tube for given that fracture pattern. No mandible or tmj fractures too?

there are mandible fractures

 

[vector2]

there are mandible fractures

I've had cases like this and we did the facial fxs first with an oral, gave a day or two for the swelling to calm down, and then came back with omfs for the mandible and did nasal. You said in your case the guy had comminuted nasal fxs so I dunno how they'd fix that with a nasal tube in place anyway

 

[anbuitachi]

I've had cases like this and we did the facial fxs first with an oral, gave a day or two for the swelling to calm down, and then came back with omfs for the mandible and did nasal. You said in your case the guy had comminuted nasal fxs so I dunno how they'd fix that with a nasal tube in place anyway

they not touching the nose. only fixing mandible

 

[vector2]

they not touching the nose. only fixing mandible

Your story is a little hard to follow. Is any other service (not just omfs) consulted on and/or doing anything about the other facial fxs? Cause if ENT/plastics is the consulting service on the leforte/nasal, even if those fxs are non-op I'd want them to OK the nasal intubation so we're not directly violating whatever nasal/sinus precaution recs they put in their note.

 

[Iso4ane]

Submental was designed for this, your face is messed up enough to need jaw fixation/wires, and can’t do nasal because of basiliar skull fracture, but you’re not concussed and don’t foresee the need for prolonged intubation. It’s a small-ish window but it does happen, and I’ve seen it a few times.

 

[Maverikk]

Can someone on here who works with omfs a lot tell me what is their specialty? I know this sounds bad and I don’t mean it too but I’ve worked at a few hospitals and it seems like they have the widest scope of practice.
One trauma place I worked at they did facial fractures, albeit only the ones that ent could pawn off to them. And they were scary bad to work with, a lot of bad stories in the icu I worked in. They mostly did outpatient private pay stuff and covered call there.
The other place the omfs people did neck and oral cancer, 10-18 hr neck dissections, flaps, people referred them there from all over. Stuff I was kind of surprised they were doing but I’m totally unfamiliar with their specialty. Do they go to both medical school and dental school? Do they do a general surgery residency?

 

[vector2]

Can someone on here who works with omfs a lot tell me what is their specialty? I know this sounds bad and I don’t mean it too but I’ve worked at a few hospitals and it seems like they have the widest scope of practice.
One trauma place I worked at they did facial fractures, albeit only the ones that ent could pawn off to them. And they were scary bad to work with, a lot of bad stories in the icu I worked in. They mostly did outpatient private pay stuff and covered call there.
The other place the omfs people did neck and oral cancer, 10-18 hr neck dissections, flaps, people referred them there from all over. Stuff I was kind of surprised they were doing but I’m totally unfamiliar with their specialty. Do they go to both medical school and dental school? Do they do a general surgery residency?

Their typical scope is the full gamut of dental surgery and surgery on the bones of the face. Head and neck is a fellowship that omfs can do after residency (just like ENT) which is why you see some of them doing neck dissections and flaps. They do dental school and then apply for omfs residency which includes getting their MD during the residency.

 

[2Fast2Des]

Their typical scope is the full gamut of dental surgery and surgery on the bones of the face. Head and neck is a fellowship that omfs can do after residency (just like ENT) which is why you see some of them doing neck dissections and flaps. They do dental school and then apply for omfs residency which includes getting their MD during the residency.

Some do MD after dental school, and some just do OMFS residency without doing MD. I did an OMFS rotation in med school and from what I gathered - 4 years dental, 1 year OMFS internship, then 3rd and 4th year med school (have to take the step exams as well I believe), and then finish out the 3 or 4 years OMFS residency. For those doing DDS\DMD + MD + OMFS route is a long and expensive road, wonder what their pay is because their loans make ours look silly. I knew an OMFS resident doing the MD route with 700k loans and he had like 3 years to go...

 

[abolt18]

Some do MD after dental school, and some just do OMFS residency without doing MD. I did an OMFS rotation in med school and from what I gathered - 4 years dental, 1 year OMFS internship, then 3rd and 4th year med school (have to take the step exams as well I believe), and then finish out the 3 or 4 years OMFS residency. For those doing DDS\DMD + MD + OMFS route is a long and expensive road, wonder what their pay is because their loans make ours look silly. I knew an OMFS resident doing the MD route with 700k loans and he had like 3 years to go...

OMFS guys at our training program frequently moonlight as dentists on the weekend and make an extra $2-4K on a Saturday. We interact with them a lot because they do 5 months of anesthesia.

I have talked with several as they were graduating. Pay can be anywhere from 300s in academics to easy 7 figures in PP. One was going to a PP with all outpatient stuff where he'd make 800 while on partner track, but after partner should expect about $1.3M for 3-4 days/week.

Can be very very lucrative.

 

[propadope]

i get it. just reminds me of all those times surgeons will say this case will take 1 hour and 3 hours later they are still operating. or closure is 10 mins, and its 45. or you dont need arterial line for this case, and its 10 hrs with a lot of bleeding.

i spoke to OMFS and he said in his career hes never seen nasal intubation go wrong so its okay. so i guess its anectodal/based on his experience which is valid. but if the books say its a contraindication.... then it becomes a discussion. you dont see one until you see one. this stuff is supposed to be rare

im just saying in the end intubation its my procedure so im responsible and ive seen plenty of times surgeon will throw the anesthesiologist under the bus when things go south. but appreciate everyones input of course

Nasal intubation CAN go wrong. Its quite possible to not be able to pass the tube nasally and epistaxis is always a risk.

Could always do oral intubation right off the bat and then from there you can attempt nasal and/or submental/trach

 

[anbuitachi]

Some do MD after dental school, and some just do OMFS residency without doing MD. I did an OMFS rotation in med school and from what I gathered - 4 years dental, 1 year OMFS internship, then 3rd and 4th year med school (have to take the step exams as well I believe), and then finish out the 3 or 4 years OMFS residency. For those doing DDS\DMD + MD + OMFS route is a long and expensive road, wonder what their pay is because their loans make ours look silly. I knew an OMFS resident doing the MD route with 700k loans and he had like 3 years to go...

OMFS guys at our training program frequently moonlight as dentists on the weekend and make an extra $2-4K on a Saturday. We interact with them a lot because they do 5 months of anesthesia.

I have talked with several as they were graduating. Pay can be anywhere from 300s in academics to easy 7 figures in PP. One was going to a PP with all outpatient stuff where he'd make 800 while on partner track, but after partner should expect about $1.3M for 3-4 days/week.

Can be very very lucrative.

thats when you apply for PSLF. by the time you finish training, loans almost forgiven. just work in a qualified area for a couple years and boom your 800k loans is gone. then go to PP and make 7 figs

its a good gig if you care about $$. much better than neuro or CT surgery IMO. the hours during training and after are MUCH MUCH BETTER

 

[2Fast2Des]

thats when you apply for PSLF. by the time you finish training, loans almost forgiven. just work in a qualified area for a couple years and boom your 800k loans is gone. then go to PP and make 7 figs

its a good gig if you care about $$. much better than neuro or CT surgery IMO. the hours during training and after are MUCH MUCH BETTER

True... There's that option, just gotta stomach the academic pay for those 2 years then

 

[nimbus]

It’s good to be an oral surgeon in a country where few people have wisdom teeth.

 

[C.elegans]

Can someone on here who works with omfs a lot tell me what is their specialty? I know this sounds bad and I don’t mean it too but I’ve worked at a few hospitals and it seems like they have the widest scope of practice.
One trauma place I worked at they did facial fractures, albeit only the ones that ent could pawn off to them. And they were scary bad to work with, a lot of bad stories in the icu I worked in. They mostly did outpatient private pay stuff and covered call there.
The other place the omfs people did neck and oral cancer, 10-18 hr neck dissections, flaps, people referred them there from all over. Stuff I was kind of surprised they were doing but I’m totally unfamiliar with their specialty. Do they go to both medical school and dental school? Do they do a general surgery residency?

OMFS scope is a point of much confusion among physicians in the US. Physicians from the UK and Europe are more familiar because OMFS is largely a medical specialty (requiring MD only) in countries like Spain and Italy, or a specialty that requires both a medical and dental degree (UK, Germany, Australia come to mind). In the US, it is considered a specialty of dentistry with around half of current trainees opting to go to medical school for around 2 years to receive a MD on top of their residency training of 4 years while the other half forego the MD and practice under their DDS/DMD only.

Scope of practice can vary wildly between institutions. This is because there is significant overlap in scope between ENT, OMFS, and Plastics in certain areas, and what each specialty does in a particular institution usually depends on which department started doing them first. Taking this in to account, OMFS scope, with variations depending on fellowship training/geography/provider preference, is generally considered the following:

- Oral and dental surgery (dental implants, wisdom teeth, bone grafts, oral and facial biopsies)
- Facial trauma and head and neck infections (Fractures of frontal sinus, NOE, ZMC, orbit, leforts, mandible etc, soft tissue laceration repair)
- Salivary gland surgery (parotidectomies, sialoendoscopy, submandibular gland excisions, etc)
- Benign and malignant pathology of the head and neck (odontogenic tumors, cancer of the tongue/mouth/face)
- Microvascular reconstruction of the head and neck (ALT, radial forearm, fibula, scapula flaps)
- Craniofacial anomalies (cleft lip and palate, distraction osteogenesis, fronto-orbital advancements etc)
- Orthognathic surgery also known as corrective jaw surgery for bite deformities
- TMJ surgery (total joint replacements, arthroscopy, etc)
- Aesthetic Facial surgery (facelifts, rhinoplasties, facial feminization surgery, chin implants)

Aesthetic facial surgery, head and neck oncology and microvascular reconstruction, and pediatric craniofacial surgery are considered areas where a 1-2 year fellowship is necessary for an OMFS to practice in. The rest are considered core scope that any competent OMFS trained at a reasonable program should be able to do comfortably. Hope this helps clear things up.

 

[702]

Can someone on here who works with omfs a lot tell me what is their specialty? I know this sounds bad and I don’t mean it too but I’ve worked at a few hospitals and it seems like they have the widest scope of practice.
One trauma place I worked at they did facial fractures, albeit only the ones that ent could pawn off to them. And they were scary bad to work with, a lot of bad stories in the icu I worked in. They mostly did outpatient private pay stuff and covered call there.
The other place the omfs people did neck and oral cancer, 10-18 hr neck dissections, flaps, people referred them there from all over. Stuff I was kind of surprised they were doing but I’m totally unfamiliar with their specialty. Do they go to both medical school and dental school? Do they do a general surgery residency?

Why were they scary bad to work with?

 

[IMGASMD]

Why were they scary bad to work with?

You must be new here. There was a whole thing about a year or two ago…..
basically when you think you’re jack of all trades, you’re master of none. When you really “believe” you can do “sedation” as well as anesthesiologists because you’ve observed hundreds of cases under another attending, who may not have rescue airways in years…… and you direct a dental tech instead of nurse at minimum to monitor and fetch dental stuff. With all that, you truly believe that you cannot and will not harm a patient, that’s why.

 

[nimbus]

You must be new here. There was a whole thing about a year or two ago…..
basically when you think you’re jack of all trades, you’re master of none. When you really “believe” you can do “sedation” as well as anesthesiologists because you’ve observed hundreds of cases under another attending, who may not have rescue airways in years…… and you direct a dental tech instead of nurse at minimum to monitor and fetch dental stuff. With all that, you truly believe that you cannot and will not harm a patient, that’s why.

I think he’s replying to a post that said OMFS was bad at facial fractures. In my experience, they are very good at facial fractures. At our place, ENT won’t touch facial fractures. It’s almost exclusively OMFS and rarely plastics. OMFS is ortho of the face!