Submental Orotracheal Intubation-A Technique for Airway Management in Severe Facial Trauma.

Abstract

Severe facialandanterior skull base traumapresentparticular challengestothesurgeonandanesthesiologist.Avarietyofmethodshave beendescribed forairwaymanagement incasesofpanfacial trauma; however, the literature is equivocal on the ideal technique. In 1986, Hernandez Altemir1 described a technique that exteriorized an oralendotracheal tubethrougha floor-of-mouth and submental incision. Submental orotracheal intubation (SMOTI) avoids the risks, morbidity,andhindranceassociatedwithnasotracheal intubation,orotracheal intubation, or tracheostomy. SMOTI secures the endotracheal tubeandprovidesuninhibitedaccesstocraniofacial injuries.We present a step-by-stepdescriptionwith aVideoof SMOTI toprovide surgeonsaclear andconcise referencewhenmanaging theairway in patients with severe facial trauma. The intraoperative photographs and Video depicting this technique are taken from the case of a 15year-old male who sustained left-sided LeFort III, right-sided LeFort II, naso-orbito-ethmoid, and skull base fractures with cerebrospinal fluid leak (Figure 1). The patient is placed under standard general anesthesia using a spiral metal embedded endotracheal tube (Mallinckrodt Medical Inc). The sealed circuit connector on the reinforced tube is removedwith heavy scissors. A universal connector from a standard endotracheal tube, typically 1 full size smaller, is attached to the reinforced tube. The submental crease ismarked in themidline (Figure2A), and local anestheticwith epinephrine is injected subcutaneously. Local anesthetic is also injected along the midline floor of mouth, anterior to the sublingual caruncle. The skinof theneckandchinareprepared using povidone iodine solution, and the oral cavity is rinsed with chlorhexidine gluconate solution. Cheek retractors and bite blocks arepositioned to improvevisualizationof the floorofmouth. A 15-blade scalpel is used to make a 1.0to 1.5-cm midline incision along the submental skin crease. A scalpel is used to make a 1to 1.5-cm horizontal incision in the anterior floor-of-mouth mucosa (Figure 2B). Theperiosteumof the lingual cortex should not be violated. Care should be taken to position this incision anterior to the sublingual papillae toavoid trauma to the submandibular glandoutflow tracts. A large curved clamp is advanced from the submental incision through the floor-of-mouth incision (Figure 2C). The subcutaneousandmuscular layersare traversedbluntlycoursing the lingual cortex of themandibular symphysis. The endotracheal tube is secured manually, and the universal circuit connector is removed.Thepilotballoon isdeflatedandpassed through the tunnel using the clamp. The tube is extracted through the submental incision. The connector is reconnected to the tube, and anesthesia circuit is reestablished (Figure 2D). After confirmation of correct tracheal position by anesthesiology, the tube is secured to submental skin with a 2-0 silk suture and the surgery proceeds as planned (Figure 2E). At theconclusionof the surgery, extubation isperformed in the reverseorder.After removingthesubmental securementsuture, the deflated pilot balloon is passed into the oral cavity. The connector is removed, and the endotracheal tube is passed into the oral cavity. The connector is reattached, and the anesthesia circuit is reestablished.The floor-of-mouth incisioncanbeapproximatedwith5-0 chromic gut suture or can be left to heal by granulation. The submental incision is repairedwith 5-0nylon sutures (Figure 2F). If the patient requirespostoperativemaxillomandibular fixation, the tube can be placed in a retromolar position.With the teeth in occlusion, guidingelasticbandsor fixationwiresmaybeappliedtothearchbars, followed by extubation if appropriate. SMOTI is an excellent alternative to nasotracheal and orotracheal intubationandtracheostomy inpatientswithsevere facial fractures with or without skull base fractures. It is a secure and effective technique that provides full access to craniofacial injuries.2,3 In patientswith anterior skull base fractures, nasotracheal intubation can be safely be performedwith a fiber-optic endoscope by an anesthesiologist or otolaryngologist to avoid intracranial complications. Both nasotracheal and retromolar orotracheal tubepositionVideo at jamafacialplasticsurgery.com