Submandibular approach for tracheal intubation of maxillofacial fracture patient

Abstract

Introduction: Airway management of facial trauma patients remains a challenge for anaesthesiologists. Alternatives are needed for patients who are unable to perform the nasotracheal or orotracheal intubation commonly used in general anaesthesia for dental surgery. However, if prolonged maintenance of airway or ventilation is not needed, tracheostomy is not an appropriate alternative. Objectives/Aims: We report a case of submandibular intubation using sterile disposable camera cable drape (Sani-sleeve®) to minimise the injury caused by surgical intubation. CASE REPORT: The patient was diagnosed with LeFort II fracture (both), LeFort III fracture (Lt.), Infraorbital wall fracture, maxillary anterior alveolar fracture, maxillary sinus anterior wall fracture, and lower lip laceration due to facial trauma. The nasotracheal and orotracheal intubation were impossible. Therefore, we decided to perform submandibular intubation to reduce the sequelae of invasive tracheostomy. Then awake fibreoptic orotracheal intubation was performed successfully with 7.5 mm sized reinforced tube. After confirming the success of orotracheal intubation, submandibular approach for tracheal intubation was started. Submandibular incision (2 cm) was performed on two fingers away from the right mandibular border. We made a tunnel by blunt dissection with Kelly forceps and dissecting scissors to right oral cavity floor. The Sani-sleeve® (Camera cable drape) was passed with Kelly forceps through a tunnel from extraoral to intraoral space. Another 7.5 mm sized reinforce tube was passed into the Sani-sleeve® to dilate the space which the intubated tube would pass. After confirming that space was created, the intubated tube was repositioned to extraoral space through the Sani-sleeve® tunnel and fixed. At the end of the surgery, the submandibular intubated tube was repositioned again to the oral cavity. Conclusion: This case suggests that submental or submandibular intubation can be an appropriate alternative to the tracheostomy.