J Korean Assoc Oral Maxillofac Surg.  2016 Jun;42(3):151-156. 10.5125/jkaoms.2016.42.3.151.

Submental intubation: alternative short-term airway management in maxillofacial trauma

• Kumar RR
• Vyloppilli S
• Sayd S
• Thangavelu A
• Joseph B
• Ahsan A

• KMID: 2309257
• DOI: http://doi.org/10.5125/jkaoms.2016.42.3.151

Abstract

OBJECTIVES
To assess submental route intubation as an alternative technique to a tracheostomy in the management of the airway in cranio-maxillofacial trauma, along with an assessment of its morbidity and complications.
MATERIALS AND METHODS
Submental intubation was performed in 17 patients who had maxillofacial panfacial trauma and management was done under general anesthesia during a period of one year from 2013 to 2014 at Departments of Oral and Maxillofacial Surgery and Dentistry, the Malankara Orthodox Syrian Church Medical College, Kochi, India.
RESULTS
In all 17 cases, the technique of submental intubation was found to be simple and reliable. Hypertrophic scars were noted in three cases, orocutaneous fistula and mucocele in one case each. All these complications were managed comfortably without significant morbidity to the patient.
CONCLUSION
Submental intubation is a good technique that can be used regularly in the management of the airway in cranio-maxillofacial trauma, but with some manageable complications.

Keyword

General anesthesia; Oral intubation; Submental intubation; Tracheostomy; Maxillofacial trauma

MeSH Terms

Airway Management*
Anesthesia, General
Cicatrix, Hypertrophic
Dentistry
Fistula
Humans
India
Intubation*
Mucocele
Surgery, Oral
Tracheostomy

Figure

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  Fig. 1 Making of incision for submental intubation.

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  Fig. 2 Placement of hemostat.

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  Fig. 3 Placement of intraoral incision and use of hemostat for creation of continuity through the extraoral incision.

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  Fig. 4 Grasping pilot tube through the intraoral incision.

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  Fig. 5 Grasping endotracheal tube and pulling it out through the submental region.

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  Fig. 6 Stabilising endotracheal tube with suture.

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  Fig. 7 Mucocele formation in the postoperative period on the floor of the mouth.

Reference

1. Shetty PM, Yadav SK, Upadya M. Submental intubation in patients with panfacial fractures: a prospective study. Indian J Anaesth. 2011; 55:299–304. PMID: 21808409.

2. Markowitz BL, Manson PN. Panfacial fractures: organization of treatment. Clin Plast Surg. 1989; 16:105–114. PMID: 2924486.

3. Shumrick KA, Kersten RC, Kulwin DR, Sinha PK, Smith TL. Extended access/internal approaches for the management of facial trauma. Arch Otolaryngol Head Neck Surg. 1992; 118:1105–1112. PMID: 1389061.

4. Phero JC, Weaver JM, Peskin RM. Anesthesia for maxillofacial/mandibular trauma. Anesthesiol Clin North Am. 1993; 11:509–523.

5. Hernández Altemir F. The submental route for endotracheal intubation. A new technique. J Maxillofac Surg. 1986; 14:64–65. PMID: 3456416.

6. Castling B, Telfer M, Avery BS. Complications of tracheostomy in major head and neck cancer surgery; a retrospective study of 60 consecutive cases. Br J Oral Maxillofac Surg. 1994; 32:3–5. PMID: 8136336.

7. Halfpenny W, McGurk M. Analysis of tracheostomy-associated morbidity after operations for head and neck cancer. Br J Oral Maxillofac Surg. 2000; 38:509–512. PMID: 11010784.

8. Alberti PW. Tracheotomy versus intubation. A 19th century controversy. Ann Otol Rhinol Laryngol. 1984; 93:333–337. PMID: 6380376.

9. Muhsin WW, Rendell-Baker L. The principles of thoracic anaesthesia, past and present. Oxford: Blackwell Scientific Publications;1953. p. 44.

10. Coe TR, Human M. The peri-operative complications of nasal intubation: a comparison of nostril side. Anaesthesia. 2001; 56:447–450. PMID: 11350331.

11. Sanuki T, Hirokane M, Kotani J. Epistaxis during nasotracheal intubation: a comparison of nostril sides. J Oral Maxillofac Surg. 2010; 68:618–621. PMID: 19931965.

12. Seltzer AP. Complications of nasotracheal intubation. J Natl Med Assoc. 1969; 61:415–416. PMID: 5346059.

13. Chandu A, Gibson NS, Smith AC. An unusual complication of naso-tracheal intubation. Int J Oral Maxillofac Surg. 2000; 29:395. PMID: 11071248.

14. Choudhuri AH, Bhatnagar S, Mishra S. Epistaxis after nasotracheal intubation in oral cancer surgeries: a comparison between fibreoptic intubation and conventional technique. Indian J Anaesth. 2006; 50:275–278.

15. Amygdalou A, Dimopoulos G, Moukas M, Katsanos C, Katagi A, Mandragos C, et al. Immediate post-operative effects of tracheotomy on respiratory function during mechanical ventilation. Crit Care. 2004; 8:R243–R247. PMID: 15312224.

16. Mort TC. Emergency tracheal intubation: complications associated with repeated laryngoscopic attempts. Anesth Analg. 2004; 99:607–613. PMID: 15271750.

17. Sise MJ, Shackford SR, Cruickshank JC, Murphy G, Fridlund PH. Cricothyroidotomy for long-term tracheal access. A prospective analysis of morbidity and mortality in 76 patients. Ann Surg. 1984; 200:13–17. PMID: 6732322.

18. Martinez-Lage JL, Eslava JM, Cebrecos AI, Marcos O. Retromolar intubation. J Oral Maxillofac Surg. 1998; 56:302–305. PMID: 9496840.

19. González-Garcia R, Rodríguez-Campo FJ, Naval-Gías L, Sastre-Pérez J. Oral to nasal endotracheal tube exchange following reconstructive surgery of the oral cavity by means of vascularized free flaps. J Oral Maxillofac Surg. 2005; 63:1249–1250. PMID: 16094603.

20. Anwer HM, Zeitoun IM, Shehata EA. Submandibular approach for tracheal intubation in patients with panfacial fractures. Br J Anaesth. 2007; 98:835–840. PMID: 17459905.

21. Adeyemo WL, Ogunlewe MO, Desalu I, Akanmu ON, Ladeinde AL. Submental/transmylohyoid intubation in maxillofacial surgery: report of two cases. Niger J Clin Pract. 2011; 14:98–101. PMID: 21494002.

22. Bögi I, Incze F. Submental introduction of tracheal tube in endotracheal anesthesia. (Modified tracheal intubation method for cases of simultaneous maxillofacial injuries and osteotomies). Fogorv Sz. 1996; 89:3–6. PMID: 8713614.

23. Taglialatela Scafati C. Mucoceles as a complication of submandibular intubation. J Craniomaxillofac Surg. 2004; 32:335. PMID: 15458678.

24. Stranc MF, Skoracki R. A complication of submandibular intubation in a panfacial fracture patient. J Craniomaxillofac Surg. 2001; 29:174–176. PMID: 11465257.

25. Nayan S, Kotrashetti SM, Singh R, Mandlik G, Keswani E, Shevale V. Submental approach for oral endotracheal intubation in maxillofacial trauma: a prospective study. Heal Talk. 2013; 5:26–27.

26. Ramsey CA, Dhaliwal SS. Retrograde and submental intubation. Atlas Oral Maxillofac Surg Clin North Am. 2010; 18:61–68. PMID: 20176327.

27. Green JD, Moore UJ. A modification of sub-mental intubation. Br J Anaesth. 1996; 77:789–791. PMID: 9014636.

28. Nyárády Z, Sári F, Olasz L, Nyárády J. Submental endotracheal intubation in concurrent orthognathic surgery: a technical note. J Craniomaxillofac Surg. 2006; 34:362–365. PMID: 16860564.

29. Mahmood S, Lello GE. Oral endotracheal intubation: median submental (retrogenial) approach. J Oral Maxillofac Surg. 2002; 60:473–474. PMID: 11928115.

30. Lima SM Jr, Asprino L, Moreira RW, de Moraes M. A retrospective analysis of submental intubation in maxillofacial trauma patients. J Oral Maxillofac Surg. 2011; 69:2001–2005. PMID: 21367502.