Safety of Intubation Methods in Patients With LeFort Pattern Facial Trauma

Choosing an airway for operative fixation of LeFort fractures involves a complex risk assessment. Tracheostomy can result in significant morbidity such as bleeding, accidental decannulation, infection, and scarring, whereas nasotracheal intubation (NTI) is often avoided due to its theoretical association with intracranial advancement in cases of skull base injury. In this retrospective cohort study, complication rates were compared between tracheostomy, NTI, and orotracheal intubation (OTI) in adults undergoing surgical repair of LeFort I-III fractures at a tertiary academic center between 2018 and 2023. Operating room airway method, evidence of skull base fracture, complications, and reoperations were recorded. Equivalence testing compared mean complications per patient and multivariable regression identified predictors of reintervention. Sixty patients were included: 20 NTI, 18 OTI, and 22 tracheostomies. Skull base disruption occurred in 35% of patients. Of those, 68% were given tracheostomies and 10% NTI. Nineteen patients (32%) experienced ≥1 complication, and 9 events (15%) were related to airway method (bleeding from the airway, malocclusion, or need for hardware removal). Mean complications per patient were equivalent for NTI and tracheostomy (0.50 versus 0.54; P=0.019), even when isolating the higher severity LeFort II and III injuries (0.45 versus 0.56; P=0.040). However, tracheostomy alone predicted a reintervention requirement (OR 2.3, 95% CI 1.1-4.8; P=0.025). Thus, NTI achieved a complication profile equivalent to tracheostomy while avoiding its higher reoperation rate and scar burden.