Submental Incision Research Articles

Submental intubation: A solution for anesthetic dilemma in mid- and panfacial fractures

Introduction: Faciomaxillary injuries are very common following trauma, specifically following road traffic accidents. Many a time, those injured present with panfacial fractures. Such patients need urgent surgical attention for stabilization and fixation of the fractures. Materials and Method: The patient is intubated by oral route in the conventional manner with an armored tracheal tube as the first step. This tube is taken out externally via a mucosal incision in the floor of mouth and submental incision and connected with the ventilator. The cuff is inflated and the tube is secured with the suture with the skin. The skin and the mucosal incisions are closed. Discussion: Securing the endotracheal tube during the operation for patients with panfacial fracture without coming in the way of oral procedure always poses a problem for the anesthetist. Fracture of the base of the skull or the naso-orbital ethmoid complex excludes the option of nasal intubation, while oral intubation would prevent the surgeon from obtaining a proper occlusion. In these circumstances, submental intubation is a simple and safe procedure that can be carried out. However, if a patient needs prolonged intubation even after surgery due to upper respiratory obstruction, tracheostomy remains the procedure of choice. Conclusion: Submental intubation is helpful in allowing the surgeon to operate intraorally and ensure proper dental occlusion in patients with panfacial fractures.

Adjustable Minimally Invasive Hyoid Myotomy and Suspension with Uvulopalatopharyngoplasty for the Treatment of Obstructive Sleep Apnea

Objectives: Examine the efficacy of minimally invasive hyoid myotomy and mandibular suspension with adjustable tensioning for hypopharyngeal obstruction in conjunction with uvulopalatopharyngoplasty in the surgical treatment of obstructive sleep apnea. Methods: Retrospective chart review in a private practice. Twenty consecutive patients with multilevel obstructive sleep apnea over a 12-month period were included. Patients underwent hyoid myotomy and suspension and uvulopalatopharyngoplasty with or without tonsillectomy either staged or performed at the same time for those patients who had not undergone uvulopalatopharyngoplasty previously. The hyoid was suspended to the posterior surface of the mandible using the Siesta Encore system and desired tension set through a single small submental incision. Patients underwent clinical examination and sleep study prior to surgery and approximately 3 months postoperatively. The primary outcome was a successful surgical result, defined as respiratory distress index lower than 20, and 50% or greater decline in respiratory distress index, and no oxygen desaturations below 85% on the postoperative sleep study. Results: Nineteen (95%) of 20 patients achieved a successful outcome. The average preoperative respiratory disturbance index (RDI) was 52.7. The average postoperative RDI was 11.8 ( P < .005). The average preoperative body mass index was 27.3. The average decrease in the RDI was 78%. All patients in the study reported clinical improvement of symptoms. There were 2 minor wound complications and no major complications. Conclusions: For patients with multilevel obstructive sleep apnea, minimally-invasive mandibular hyoid suspension appears to be highly efficacious for the treatment of hypopharyngeal airway obstruction when performed in conjunction with uvulopalatopharyngoplasty.

Submental intubation in oral maxillofacial surgery

Background: Oral and maxillofacial surgical procedures present a unique set of problems for both the anaesthesists and the surgeons. Simultaneous access to the oral or nasal cavities and dental occlusion is required for the surgical treatment of some craniofacial deformities. Generally, airway is maintained by orotracheal or nasotracheal intubation and some instances by tracheostomy however, nasotracheal intubation is contraindicated in skull base or midface fracture. Tracheostomy has inherent complications ranging from surgical emphysema to disfiguration where as orotracheal route prevents free access to oral cavity. In these circumstances, submento-tracheal intubation may provide a better option to overcome these problems.
 Objective: The aim of this study was to evaluate outcome of conversion of orotracheal route to submentotracheal route for surgical correction of maxillofacial trauma & deformity and time required to change from oral to submental route, accidental extubation, postoperative complications, and the healing of intraoral and submental scars were evaluated.
 Patients and Methods:
 Method: A total of 23 patients were selected from maxillofacial department of BSMMU and other institutions from December 2007 to March 2011 to use this technique. After standard orotracheal intubation, a 2 cm incision was made lateral to the midline in the submentum and a blunt dissection opposite to the skin incision on the lingual aspect of the mandible provides access to the floor of the mouth, the orotracheal tube is disconnected and pulled through the floor of the mouth then to the submental incision, the tube is then sutured to the skin. Surgery was completed without interference from flexometallic endotracheal tube. Following surgery the sequence is reversed and the patients extubated in the conventional manner.
 Results The technique was used in 13 patients with multiple facial fractures & 10 patients with facial deformity. The mean age of the group was 30 (20-50) years .The submental orotracheal intubation was completed successfully in all patients. No accidental extubations or tube injuries occurred. The mean time required for intubation was 6 minutes. All patients were extubated in the operating theatre. The intraoral and submental accesses healed with minimal scarring in all patients .There were no incidence of intra- or postoperative complications related to submental intubation.
 Conclusions Submental intubation is a simple, safe, and predictable approach without significant morbidity that facilated safe airway and enhances meticulous surgical procedure of fractured skull base and midface.
 JBSA 2012; 25(1): 21-27

Calvarial Onlay Graft and Submental Incision in Treatment of Atrophic Edentulous Mandibles

The aim of this study was to test our approach based on the use of calvarial graft and extraoral approach, in treatment of severe mandibular atrophies with implant surgery and prosthetic rehabilitation. We selected 6 patients, 4 females and 2 males, completely edentulous with a severe mandibular atrophy (class VI Cawood and Howell classification). Mean age of patients was 63 years, ranging from 60 to 67 years. Mandibles were reconstructed with a submental incision with calvarial bone graft harvested from parietal area. After a mean of 4.2 months, each patient received 4 implants, and after a mean of 4.67 months, implants were loaded. No complications occurred in donor site or on the mandible, and all patients recovered well. No extraoral scar occurred. A total of 25 implants were inserted, and, with exception of an early failure and successive replacement, all implants were osseointegrated at successive visits. After 1-year follow-up, our analysis showed 100% implants survival and correct fit and success of prosthetic rehabilitation. Results of this study showed an uneventful recovery for all patients with our approach and reduced healing time of bone graft. So extraoral approach with submental incision and calvarial graft is a reliable method in reconstruction of atrophic mandibles, and staged implant surgery is suggested.

Comparison of two point versus one point fixation techniques in submentotracheal intubation during craniomaxillofacial surgeries—a pilot study

Background and objectives: Airway management in the craniomaxillofacial trauma surgery may require some modifications of the standard intubation techniques. Submental endotracheal intubation may serve as an effective and safe alternative route in these conditions. In standard technique of submentotracheal intubation, the tube is fixed extra orally at the submental incision site with sutures to prevent displacement of the tube during the surgical intervention. But still it leaves a possibility of accidental extubation during the conversion of orotracheal to submental route and vice versa.

Endoscope-assisted concurrent resection of thyroglossal duct cysts and benign thyroid nodules via a small submental incisions

The objective of this study was to evaluate the technique of endoscope-assisted concurrent resection of thyroglossal duct cysts and benign thyroid nodules via a small submental incision. Endoscope-assisted thyroglossal duct cyst excision and subtotal thyroidectomy were performed via a small submental incision in six patients with thyroglossal duct cysts and benign nodular thyroid lesions. The thyroglossal duct cysts and thyroid lesions were completely excised. The incisions were 3-4cm in length, and the mean operation time was 84±11min. The mean volume of blood loss was 19±5mL. Postoperative pathological examination findings confirmed the diagnosis of thyroglossal duct cyst in all patients. The thyroid lesions were nodular goiter in three patients and thyroid adenoma in three patients. No postoperative complications such as hematoma, pharyngeal fistula, hypocalcemia, recurrent laryngeal nerve paralysis, or dysphagia were observed. No changes in the planned surgical procedure were required, and no recurrent lesions were detected during follow-up. In conclusion, patients with thyroglossal duct cysts and benign thyroid lesions can be treated by endoscopic excision via a small submental incision, thereby avoiding large neck incisions and resulting in better postoperative cosmetic outcomes.

A simple procedure to facilitate chin implants placement via submental approach

In order to facilitate chin implants placement by submental incision, the use of two threads is described. They are separately passed through the extremities of the implant and inserted into the previously created subperiosteal pocket using a grooved guide. Once the landmarks of dissection have been reached, the tip of the needle exits through the skin just a few centimetres laterally to the augmentation area and, only by pulling the free ends of the threads, the implant can easily be inserted into the pocket and the sutures cut and removed. This procedure was successfully performed in 79 patients of both sexes presenting with deficiencies in the sagittal dimension at the pogonion and in width, laterally to the symphysis. Therefore, in the authors' opinion, the before-described technique could be a useful tool that facial plastic surgeons can employ to facilitate alloplastic chin implants placement, by minimising the invasiveness of the procedure, reducing the operative time, and greatly improving the aesthetic result, without sacrificing the safety of the operation.

Submental route of endotracheal intubation;a better solution in cases of multifacial fractures

Complex maxillofacial surgeries have always been a challenge for anaesthesiologists, where oral cavity is the main field of surgery and dental occlusion is a prerequisite. In such conditions, anaesthesiologists opt for nasotracheal intubation. Some patients however may require simultaneous free nasal field where nasal fracture and cerebrospinal fluid leak may contraindicate nasotracheal intubation. Tracheostomy has long been the sole answer to these problems. Here submental approach for tracheal intubation can be an apt alternative. In this approach the endotracheal tube is introduced along a diverted route through the floor of mouth via a tunnel made in the submental region. We opted for this technique in four patients posted for fixing facial bones, requiring both nasal and oral fields and the results have been satisfying. In two patients we used one tube method. In the other two patients, we used double tube method where another tube was brought intraoral through submental incision and the first tube was replaced. This technique avoided the need for tracheostomy and provided a safe airway without causing significant morbidity. Thus submental approach for tracheal intubtion can be a better solution to various problems arising in cases of complex maxillofacial surgeries. We also found that double tube method was safer and even easier than one tube method for submental intubation. DOI: http://dx.doi.org/10.4038/slja.v20i2.3524 Sri Lankan Journal of Anaesthesiology.2012:20(2);100-103

Transmylohoid/Submental Endotracheal Intubation in Pan-facial Trauma: A Paradigm Shift in Airway Management with Prospective Study of 35 Cases

The present study was planned to assess the efficacy, utility and complications of transmylohoid intubation in facial polytrauma patients, by setting and design: prospective study. This study was conducted between May 2008 and May 2011 and 35 patients of facial polytrauma were included irrespective of sex, caste and religion. All the selected 35 patients were male and the age of patients ranged between 15 to 45years (mean age 31years). All the patients were intubated with transmylohoid, orotracheal intubation using an armoured endotracheal tube (ETT). Average time to perform transmylohoid intubation was 15.51+1.85min (mean+standarad deviation). Average time for drawing the ETT transmylohoid from the submental incision was 49.7+24.8s. Mean duration for which the ETT was kept indwelling was 0.37+1.03days. Accidental extubation of ETT was noted in two patients. Minor post operative complications like swelling in the submental area (2 patient), dehiscence of the submental incision (2 patient) and minor infection at the site of submental incision (3 patients) were noticed, which were found to be statistically insignificant. The transmylohoid intubation allowed simultaneous reduction and fixation of all the facial fractures and intraoperative control of dental occlusion without interference from the tube during the surgery without interfering in the maintenance of the anesthesia and air way.

Closed Platysmotomy: A New Procedure for the Treatment of Platysma Bands Without Skin Dissection

Platysma muscular bands are present during the aging period, generally starting in the second half of the fourth decade of life in both sexes. One or two bands along the anterior segment of the neck are the most frequent, with varied extensions and appearances. The literature records different techniques for solving the problem of platysma bands. All the methods involve submental incision, cutaneous dissection, and various tactics for eliminating the action of the platysma bands. This report aims to describe a procedure for deactivating these bands using a percutaneous approach that eliminates the need for submental, cutaneous incision and dissection. This technique involves the use of a steel wire loop that encircles the platysma band and is connected to a device known as the platysmotome through two puncture holes in the skin. Three to six sections along each band eliminate the platysma band, leaving no visible marks on the skin. This method is indicated as an isolated procedure for patients with visible platysma bands and no skin flaccidity, patients with recurring bands after face-lifting and no cervical skin flaccidity, patients who have bands with little cervical skin flaccidity but do not care to undergo face-lifting, and patients who undergo face-lifts for platysma bands that include closed platysmotomy and tightening of the platysma by lateral suture. The described technique is a method specifically designed for deactivation of the platysma bands that can be used both in isolation and in conjunction with face-lifting. Because this method avoids submental, cervical incision and dissection, it is a less invasive technique for “deleting” the bands, whether applied alone or in association with face-lifting. From May 2008 to November 2009 (19 months), 61 patients underwent surgery for the correction of platysma bands via percutaneous myotomy. Among them, the first 11 patients received postoperative follow-up evaluation ranging from 8 to 17 months.

Submental intubation in patients with panfacial fractures: A prospective study

Submental intubation is an interesting alternative to tracheostomy, especially when short-term postoperative control of airway is desirable with the presence of undisturbed access to oral as well as nasal airways and a good dental occlusion. Submental intubation with midline incision has been used in 10 cases from October 2008 to March 2010 in the Department of Oral and Maxillofacial Surgery, Manipal College of Dental Sciences, Mangalore. All patients had fractures of the jaws disturbing the dental occlusion associated with fracture of the base of the skull, or/and a displaced nasal bone fracture. After standard orotracheal intubation, a passage was created by blunt dissection with a haemostat clamp through the floor of the mouth in the submental area. The proximal end of the orotracheal tube was pulled through the submental incision. Surgery was completed without interference from the endotracheal tube. At the end of surgery, the tube was pulled back to the usual oral route. There were no perioperative complications related to the submental intubation procedure. Average duration of the procedure was less than 6 minutes. Submental intubation is a simple technique associated with low rates of morbidity. It is an attractive alternative to tracheotomy in the surgical management of selected cases of panfacial trauma.

Modified Deep Plane Rhytidectomy with a Lateral Approach to the Neck: An Alternative to Submental Incision and Dissection

A "composite" type subplatysmal dissection with lateral advancement of the platysma-skin flap to lift the neck during rhytidectomy has been advocated by several authors. However, the limited subplatysmal dissection described in these techniques restricts the degree of mobilization of the flap. Therefore, most investigators rely on supraplatysmal dissection and medial plication of the platysma to achieve satisfactory cervical contours, especially in patients with difficult necks. To allow for greater mobilization of composite neck flaps, the senior author (T.A.M.) extends the subplatysmal dissection to incorporate release of cervical retaining ligaments. The dissection is carried medially to just beyond the region defined by the inferomedial portion of the parotid gland, and inferiorly to where the superficial musculoaponeurotic system-platysma layer and greater auricular nerve cross the posterior border of the sternocleidomastoid muscle. Dissection of the composite flap is followed by use of fine cannula submental liposuction. Experience with 742 rhytidectomies performed over a 10-year period indicates that this operation can be completed safely with satisfactory results and a low incidence of complications. The use of a submental incision and medial platysma plication can be avoided almost entirely. Identification and release of the cervical retaining ligaments permits significant platysma-skin flap mobilization. When complemented with submental liposuction, complete cervical rejuvenation can be achieved without need for medial platysma plication. The full integration of the neck and facial plane of dissection results in a very even tension and a natural appearance, even in repeated face lifts.

Discussion: Modified Deep Plane Rhytidectomy with a Lateral Approach to the Neck: An Alternative to Submental Incision and Dissection

Discussion: Modified Deep Plane Rhytidectomy with a Lateral Approach to the Neck: An Alternative to Submental Incision and Dissection

Basket Submandibular Gland Suspension

Correction of a ptotic submandibular gland is a considerable challenge in neck rejuvenation. The procedures available to treat this condition either provide only short-term success or carry perceived risk of significant postoperative morbidities. The authors describe a new technique, basket submandibular gland suspension, for the effective long-term treatment of submandibular fullness. The ptotic gland is accessed through a submental incision or combined submental and rhytidectomy incision. The gland is protected in a piece of deep temporal fascia or superficial musculoaponeurotic system graft. Two Mitek fixation sutures are placed at each corner of the fascia and secured to the medial surface of the mandible after passing through a small portion of glandular tissue to create a basket-like structure that lifts and suspends the gland. Nineteen submandibular glands were suspended on 10 patients. The average follow-up was 1.8 years. Six patients (11 glands) experienced a complete elimination of bilateral submandibular fullness, whereas three patients had minimal residual fullness. One patient with a hypertrophic gland required resection after 1 year due to residual ptosis. None of the patients developed dryness of the mouth; loss of taste; or difficulties with phonation, articulation, or swallowing. One patient required removal of the suspension sutures due to infection. One patient developed temporary paresthesia along the lingual nerve distribution. One patient noted a palpable Mitek anchor on one side, which was removed without subsequent adverse outcome. Basket submandibular gland suspension produces effective long-term results for the elimination of submandibular fullness in patients who have normal sized, ptotic glands.

Submental tracheal intubation in oromaxillofacial surgery

Background:Oromaxillofacial surgical procedures present a unique set of problems both for the surgeon and for the anesthesist. Achieving dental occlusion is one of the fundamental aims of most oromaxillofacial procedures. Oral intubation precludes this surgical prerequisite of checking dental occlusion. Having the tube in the field of surgery is often disturbing for the surgeon too, especially in the patient for whom skull base surgery is planned. Nasotracheal intubation is usually contraindicated in the presence of nasal bone fractures seen either in isolation or as a component of Le Fort fractures. We utilized submental endotracheal intubation in such situations and the experience has been very satisfying.Materials and Methods:The technique has been used in 20 patients with maxillofacial injuries and those requiring Le Fort I approach with or without maxillary swing for skull base tumors. Initial oral intubation is done with a flexo-metallic tube. A small 1.5 cm incision is given in the submental region and a blunt tunnel is created in the floor of the mouth staying close to the lingual surface of mandible and a small opening is made in the mucosa. The tracheal end of tube is stabilized with Magil′s forceps, and the proximal end is brought out through submental incision by using a blunt hemostat taking care not to injure the pilot balloon. At the end of procedure extubation is done through submental location only.Results:The technique of submental intubation was used in a series of twenty patients from January 2005 to date. There were fifteen male patients and five female patients with a mean age of twenty seven years (range 10 to 52). Seven patients had Le Fort I osteotomy as part of the approach for skull base surgery. Twelve patients had midfacial fractures at the Le Fort II level, of which 8 patients in addition had naso-ethomoidal fractures and 10 patients an associated fracture mandible. Twelve patients were extubated in the theatre. Eight patients had delayed extubation in the post-operative ward between 1 and 3 days postoperatively.Conclusion:In conclusion, the submental intubation technique has proved to be a simple solution for many a difficult problem one would encounter during oromaxillofacial surgical procedures. It provides a safe and reliable route for the endotracheal tube during intubation while staying clear of the surgical field and permitting the checking of the dental occlusion, all without causing any significant morbidity for the patient. Its usefulness both in the emergency setting and for elective procedures has been proved. The simplicity of the technique with no specialized equipment or technical expertise required makes it especially advantageous. This technique therefore, when used in appropriate cases, allows both the surgeon and the anesthetist deliver a better quality of patient care.

Submental tracheal intubation in oromaxillofacial surgery

ABSTRACT Background: oromaxillofacial surgical procedures present a unique set of problems both for the surgeon and for the anesthesist. achieving dental occlusion is one of the fundamental aims of most oromaxillofacial procedures. oral intubation precludes this surgical prerequisite of checking dental occlusion. having the tube in the field of surgery is often disturbing for the surgeon too, especially in the patient for whom skull base surgery is planned. nasotracheal intubation is usually contraindicated in the presence of nasal bone fractures seen either in isolation or as a component of le fort fractures. we utilized submental endotracheal intubation in such situations and the experience has been very satisfying.materials and methods: the technique has been used in 20 patients with maxillofacial injuries and those requiring le fort i approach with or without maxillary swing for skull base tumors. initial oral intubation is done with a flexo-metallic tube. a small 1.5 cm incision is given in the submental region and a blunt tunnel is created in the floor of the mouth staying close to the lingual surface of mandible and a small opening is made in the mucosa. the tracheal end of tube is stabilized with magil′s forceps, and the proximal end is brought out through submental incision by using a blunt hemostat taking care not to injure the pilot balloon. at the end of procedure extubation is done through submental location only.results: the technique of submental intubation was used in a series of twenty patients from january 2005 to date. there were fifteen male patients and five female patients with a mean age of twenty seven years (range 10 to 52). seven patients had le fort i osteotomy as part of the approach for skull base surgery. twelve patients had midfacial fractures at the le fort ii level, of which 8 patients in addition had naso-ethomoidal fractures and 10 patients an associated fracture mandible. twelve patients were extubated in the theatre. eight patients had delayed extubation in the post-operative ward between 1 and 3 days postoperatively.conclusion: in conclusion, the submental intubation technique has proved to be a simple solution for many a difficult problem one would encounter during oromaxillofacial surgical procedures. it provides a safe and reliable route for the endotracheal tube during intubation while staying clear of the surgical field and permitting the checking of the dental occlusion, all without causing any significant morbidity for the patient. its usefulness both in the emergency setting and for elective procedures has been proved. the simplicity of the technique with no specialized equipment or technical expertise required makes it especially advantageous. this technique therefore, when used in appropriate cases, allows both the surgeon and the anesthetist deliver a better quality of patient care.

Chin Surgery V: Treatment of the Long, Nonprojecting Chin

Correction of the long, nonprojecting chin requires both vertical reduction and sagittal augmentation. Wedge excision-based therapy reduces chin height and allows for advancement of the distal segment, but it is associated with at least a 10 percent incidence of mental nerve injury. The authors propose two innovative ways to correct the long, nonprojecting chin. There are two approaches, intraoral and extraoral. With the intraoral approach, following a gingivobuccal incision, a single horizontally oblique osteotomy is made at least 6 mm beneath the mental nerve foramina. The vertically long genial segment is freed and the posterior edge is contoured with a side-cutting burr. The contoured jumping genial segment is secured to the mandible with countersunk screws and contoured in situ to preserve the lower 8 to 10 mm. With the extraoral approach, following a submental incision, the anterior and posterior surfaces of the symphysis are cleared (a double-armed suture is placed through the posterior musculature). A reciprocating saw is used to remove the lower border of the symphysis to reduce the vertical excess. The tagged musculature is resuspended, and a tapered, textured implant is secured to the new symphysis. Aesthetic outcomes using these two techniques were good and there were no complications. Representative patients, operated on by the senior author, illustrate these techniques. Both the intraoral one-cut in situ contoured jumping genioplasty and the extraoral vertical reduction/sagittal augmentation genioplasty reduce excess chin height, control sagittal advancement, provide pogonion projection, and avoid the risks of a standard wedge. Both techniques provide custom projection at the lower pole of the new symphysis.

Infected dermoid cyst of the tongue with a sinus tract to the submental skin

Objectives : We report a case of a teratoid type dermoid cyst of the tongue with a sinus tract to the submental skin. Study design : Case report. Methods : We present a 3-month-old infant with a dermoid cyst of the tongue with a sinus tract to the submental skin and review of the literature on dermoid cysts of the tongue. Results : This rare case presented as an enlarging tongue mass and difficulty feeding. A midline submental skin pinpoint discharge revealed to be a sinus tract connecting the cyst to the skin. Complete excision of the cyst and sinus tract through midline ventral tongue and submental incisions was performed. Conclusion : Although dermoid cysts of the tongue are rare they should be part of the differential diagnosis of tongue masses and presence of a sinus tract should be considered in such cases.

Augmentation Mentoplasty with Diced High-Density Porous Polyethylene

Augmentation mentoplasty is a common procedure, applied especially in conjunction with rhinoplasty. Although various materials have been used for this procedure, diced high-density porous polyethylene (Medpor) has not been used so far. The purpose of this study was to evaluate the use of diced high-density porous polyethylene in chin augmentation. A subperiosteal pocket is prepared through submental incision. A high-density porous polyethylene block is diced into 1 x 1.5-mm pieces, to be placed into the subperiosteal pocket as much as needed by wrapping into oxidized cellulose (Surgicel). Immediately after the incision is closed, shaping with external massage is performed and an external bandage is applied. This procedure was performed in 20 patients, in addition to rhinoplasty, with a mean follow-up of 14 months (range, 8 to 20 months). Five to 14 mm of augmentation was achieved. There were no complications, except for early seroma formation in three patients, which required aspiration by syringe. It is easy to give shape to diced high-density porous polyethylene by means of massage 3 weeks after surgery. Diced high-density porous polyethylene in augmentation mentoplasty is cheap, easy to insert, and moldable by external massage, and has flexibility in conforming to the shape of the mandible. It also avoids all the disadvantages of monobloc implants, allowing postoperative ingrowth of fibrous tissues, precluding late displacement, and giving a natural feel to the reconstructed area.

Submental intubation for cancrum oris: a case report

Cancrum oris (Noma) is a devastating gangrenous disease that leads to severe tissue destruction in the face. We describe the anesthetic management of a 12-year-old girl with cancrum oris sequelae in a Rural Secondary level Hospital in Central India (Padhar Hospital). She presented with a large defect in her upper lip on the left side that extended into the columella and the floor of the left nostril. She was scheduled to undergo reconstructive surgery and the surgeons planned to use an Abbé flap based on the lower lip. For this, access to both the mouth and the nose was required. We considered a tracheostomy but decided to attempt the submental route for orotracheal intubation. Following intravenous induction the patient's trachea was intubated with a cuffed oral tracheal tube. This was passed through the submental incision and then reconnected. The surgery proceeded uneventfully and the patient was extubated before transfer. She made a satisfactory recovery and the submental scar healed without complication or scarring. We describe briefly the features of cancrum oris and review the technique of submental intubation (described in adults with midfacial trauma). The use of submental intubation in children and for cancrum oris sequelae has not been previously reported.