Anesthetic concerns of external maxillary distraction osteogenesis

External maxillary distractions present additional anesthetic concerns to the existing complexity of the patient with craniofacial disorder. The distraction hardware is rigidly fixed to the cranium and projects in the frontofacial midline, thus limiting oronasal airway access.

A review of 16 patients (10 male, 6 female) having external maxillary distraction was done. Patients with patent tracheostomies were excluded. In all cases, the same type of external distraction device was used (R.E.D., K.L.S. Martin, Jacksonville, FL, USA). Perioperative records were reviewed for medical history; operative diagnosis, presence of airway disease, tracheostomy, laryngoscopy grade, use of fiberoptic bronchoscope, procedure, operative time, use of intraoperative steroid, day of postoperative extubation, and need for reintubation were documented.

The study group was subdivided into two diagnostic categories: those with syndromic craniosynostosis (n = 9) and those with cleft lip/palate (CLP) (n = 7). Patients in the craniosynostotic group had grade 1 laryngoscopy views, with the exception of a single patient with Crouzon syndrome who had a grade 3 view. This was the only patient who required fiberoptic intubation. One patient with Apert syndrome required reintubation (48 hours after surgery); successful extubation was done 96 hours later. In the cleft lip/palate group, all patients had grade 1 laryngoscopic views, except one with a grade 3 view; no patient required fiberoptic intubation. Six of the seven patients were extubated immediately after surgery, with one patient extubated the next day. No patient experienced failure of extubation.

External maxillary distraction minimally affects anesthetic management provided certain safeguards are observed. The vertical bar can be left attached to the cranial portion of the distractor, or it can be removed for extubation or reintubation. Removal of the vertical bar allows unobstructed direct laryngoscopy. This emphasizes the importance for the emergent availability of the appropriate screwdrivers and wire cutters to remove the vertical bar and trained personnel to perform the removal.