Does submental intubation technique show an edge over percutaneous tracheostomy? A prospective study in complex oromaxillofacial surgery

Abstract

Background: Complex oromaxillofacial fractures pose unique challenge for securing the airway. Techniques other than conventional tracheostomy and orotracheal intubation need to be explored to overcome shortcomings associated with conventional methods. This study compares median approach of submental intubation with percutaneous tracheostomy with respect to procedure time, time for extubation/decannulation, length of stay in intensive care unit and complications encountered. Aims: To evaluate procedure time, time for extubation/decannulation, length of stay in intensive care unit and complications for two techniques of airway management in oromaxillofacial surgeries.Settings and Design: Institutional, prospective study.Materials and methods: This prospective study included 25 patients who sustained oromaxillofacial fracture operated under general anesthesia from August 2008 to December 2009. In 15 patients, submental intubation and in 10 patients percutaneous tracheostomy technique were adopted. Complex oromaxillofacial fractures included Lefort 1 and 2, nose, ethmoid and orbit, maxilla and mandible. Airway technique of submental intubation and percutaneous tracheostomy were attempted on the basis of interincisor gap. The procedure time for the two techniques, the time for extubation/decannulation and the length of stay in intensive care unit were evaluated statistically.Statistical analysis used: unpaired ‘t’ test. Results: Of the 25 patients, there were 12 males, 3 females and 8 males,2 females in the submental intubation and percutaneous tracheostomy group respectively. All patients belonged to ASA status 1 and 2. The first successful attempt achieved for submental intubation group and percutaneous tracheostomy group was 93% and 90% respectively. The mean time to perform the submental intubation procedure was 5.27 + 0.72(mean + standard deviation) minutes and 21.72 + 2.04 minutes for percutaneous tracheostomy group. The mean time for extubation was 4.73 + 8.18 days in submental intubation group and 23.3 + 5.25 days for decanulation in percutaneous tracheostomy group. The average length of stay in intensive care unit postoperatively were 6.73 + 8.18 days in submental intubation group and 25.8 + 6.81 days for percutaneous tracheostomy group. Theperformance time, the time for extubation/decannulation and the length of stay in intensive care unit were statistically highly significant for the two groups. Complications encountered in the two groups were recorded. Conclusions: Both, submental intubation and percutaneous tracheostomy can secure the airway in complex oromaxillofacial fracture reduction surgery. Both techniques allow uninterrupted surgical access to the operative field. Although submental intubation technique gives an imperceptible scar which has aesthetically greater acceptance compared to functionally challenging and unsightly tracheostoma which pose an enormous stress to the patient. The complications associated with tracheostomy are at times difficult to manage even in expert hands. Though submental intubation is easily performed, the selection of a particular technique should take into consideration factors other than preoperative airway assessment.