Submental Intubation Research Articles

Submental/submandibular intubation: a journey from past to future.

In 1986, Altemir published the first article on submental intubation as an alternative to tracheostomy for managing difficult airways. This review provides an overview of submental/submandibular intubation, covering its development, techniques, and clinical outcomes. Initially devised to address difficult airways in oral and maxillofacial surgery, the technique has since evolved. Recent advancements include focused surgical incisions, ultrasound-guided imaging, and the use of improved procedural tools like the Seldinger technique. Clinical trials have demonstrated that submental/submandibular intubation is generally more efficient and quicker than tracheostomy in trauma patients. One of its key advantages is the absence of visible scarring, along with a less invasive recovery process. However, the technique has some limitations, including risks of infection, bleeding, and scarring, which require further investigation to optimize its application. While submental/submandibular intubation remains a valuable method for managing difficult airways, ongoing refinement and evaluation are necessary to maximize its clinical utility. This technique presents an excellent alternative in specific surgical scenarios and offers a simplified solution where other intubation methods may be unfeasible.

Anesthetist's Perception Towards Submental Intubation: A Questionnaire Study.

Submental intubation allows for the passage of an endotracheal tube through the anterior floor of the oral cavity. This allows for adequate surgical access to the regions of the mouth and the nasal pyramid with minimal to no hindrance in airflow to the lungs. To explore the perception of an anaesthetist regarding the submental intubation. A questionnaire‑based prospective randomized analysis was formatted and carried out in Odisha, India, between 20 Jan 2023 and 20 may 2023. A self-structured questionnaire consisting of 16 questions was distributed to the anaesthetists of the medical colleges in Odisha. Out of 97, 42 (43%) male and 45 (46%) female were familiar with the submental infiltration technique. Among the participants, 56% females and 43% males have performed and assisted in a submental intubation procedure. None of them encountered any complications or adverse events related to submental intubation (p = 0.0001). Out of all, 20% females and 19% males were very confident in performing submental intubation. Submental intubation is a simple, safe, quick, and relatively harmless alternative to tracheostomy for securing the airway in selected patients with craniofacial trauma. Familiarity with the submental intubation technique will help the anaesthetists to avoid tracheostomy in selected patients with craniofacial trauma who do not require long-term mechanical ventilation. But, this procedure is technique sensitive as well.

Unlocking the Potential of Submental Intubation - Redefining Airway Management in Craniomaxillofacial Trauma Patients

Study Design Submental intubation is and underutilized alternative to traditional techniques of intubation. Complications associated can indeed deter surgeons and anesthesiologist from performing it. Surgeons may opt for submental intubation if they believe that its advantages outweigh the potential risks of the procedure. Identifying the reasons of complications and implementing of proper strategies to address them can help mitigate risks. Objective This study aims to compare and analyze the complications experienced during and after submental intubation to comment on its safety, efficacy. Revisiting literature, will help us to comment on diagnosis in trauma and associated perioperative and intraoperative complication with it. It will also help us deduce most preferred way of performing submental intubation and various methods to manage complications. Methods Submental intubation in patients experiencing craniofacial trauma was reviewed retrospectively for 9 years from January 2015 to August 2023. Common diagnosis sites were analyzed for perioperative and postoperative complications. Results It was found that there were no much complications faced perioperatively and also notes methods used for management of complications. Most commonly encountered postoperative complication was scar. Literature of past years was reviewed, during process we also came out with novel method for safe extubation for which we have got copyright from Government of India. Conclusions Submental intubation is a safe and efficient intraoperative airway management technique for patients with craniomaxillofacial injuries when there is concurrent facial trauma. This study findings would underscore the safety and efficacy of SEI, making it a promising unparalleled method of airway management worth considering.

Submental Intubation in a Case of Panfacial Fractures in a Paediatric Patient: A Case Report

Maxillofacial fractures can pose a challenge to the anaesthesiologist especially in securing the airway. The oral route of endotracheal intubation is unsuitable in surgical treatment requiring intraoperative maxillomandibular fixation and temporary occlusion of teeth. The nasal route may also pose a problem or may be contraindicated. Tracheostomy is an alternative, though it has a high likelihood of complications. Submental intubation offers an easy, rapid, and efficient substitute for oral and nasal tracheal intubation or tracheostomy in such patients. It does not interfere with the surgical field, provides simultaneous access to the nasal and oral airways, good dental occlusion with minimal morbidity.

Submental intubation as an alternative to tracheostomy in severe craniofacial trauma: A case report

El presente trabajo describe el manejo de la vía aérea mediante abordaje submentoniano en un paciente con traumatismo craneofacial grave diagnósticado de fractura LeFort III. El caso se presentó en sesión multidisciplinar para decidir el manejo de la vía aérea intraoperatoria entre traqueostomía o intubación submentoniana. Se decidió la segunda para evitar complicaciones asociadas a la traqueostomía. Tras proceder a la intubación orotraqueal dormido con fibrobronscoscopio, se realiza abordaje submentoniano paramedial. Una vez establecida la fijación intermaxilar se procedió a la osteosíntesis de las fracturas. Finalizada la cirugía se reconvirtió la intubación submentoniana a orotraqueal. Dada la extensa inflamación de la base de la boca se decidió mantener intubado las siguientes 12 horas, procediendo entonces a la extubación sin complicaciones. La intubación submentoniana es una opción segura y efectiva en el manejo de pacientes con fracturas maxilofaciales complejas, evitando así la necesidad de una traqueostomía y sus riesgos asociados.

Management of Maxillofacial Injuries with Palatal Fracture

Maxillofacial injuries, especially palatal fractures, often result from high-energy trauma, posing a challenging treatment. Achieving good occlusion is crucial, particularly when palatal fractures are associated with Le Fort fractures. While tracheostomy has traditionally been the airway management option, submental intubation serves as an alternative. The objective of this report is to illustrate a case of palatal fractures associated with Le Fort fractures in a 12-year-old female following a motorbike accident. She was admitted to dr. Cipto Mangunkusumo Hospital with Le Fort I and II fractures and palatal fractures. The treatment plan included submental intubation, the application of wire and arch bars, and the use of plates and screws. The patient experienced a good recovery without complications. Compared to submental intubation, tracheostomy requires a significantly longer time and often necessitates scar revision. No significant difference was observed in post-operative occlusal stability between intra-arch wire and mini-plate. In conclusion, limited direct comparisons exist between submental intubation, tracheostomy, intra-arch wire, and miniplate for palatal stabilization. Submental intubation is a faster and less complication-prone alternative to tracheostomy in maxillofacial surgical procedures. However, evidence regarding the superiority of intra-arch wire or mini plate for palate stabilization remains inconclusive.

Anesthetic Management of Difficult Airway Due to Maxillofacial Trauma in a Pregnant Patient Requiring Submental Intubation: A Case Report

: Managing a patient with maxillofacial trauma poses significant challenges, and when the patient is pregnant, these challenges are further heightened for an anesthesiologist. The optimal strategy to aid trauma patients is to provide immediate care, which includes managing the airway both in the pre-hospital setting and with advanced interventions within the critical first hour post-trauma, often referred to as the "golden hour." In this report, we detail the case of a twenty-week pregnant patient with maxillofacial trauma, which was successfully managed by a multidisciplinary team at our trauma center. This article outlines the initial assessment and management upon arrival, intraoperative anesthetic procedures, and postoperative critical care provided to the patient. It also examines the factors contributing to airway management challenges and discusses the most effective strategies involving airway devices, maneuvers, and techniques that proved beneficial in handling difficult traumatic airways.

Airway Management in Pan Facial Fracture: An Outcome Analysis of Elective Tracheostomy and Submental Endotracheal Intubation

Background and Aims. Pan facial fractures are complex and often requiring complex airway management. Elective tracheostomy (ET) and submental endotracheal intubation (SEI) are the two major techniques for airway management. The aim of this article is to compare the management outcome between these techniques. Methods. This study was done in a tertiary care hospital from Jan 2019 to Dec 2019. Data were retrieved for all patients from hospital admission-discharge reports, operation room records, follow-up notes, and clinical photograph records which was recorded prospectively after ethical clearance. Total 38 patients were included in the study after the exclusion criteria into two groups: submental endotracheal intubation (SEI) and elective tracheostomy (ET). Demographic data, intraoperative time (IOT), length of hospital stay (LOHS), postoperative pain score at three and seven days, and Vancouver Scar Score (VSS) at 4 and 12 weeks was compared between the two groups. Results. SEI consisted of 23 patients (60%) while ET had 15 (40%) patients. The mean age was 32.77±8.24 years in the SEI and 29.36±7.32 years in the ET. The IOT in SEI was 15.36±1.53 min and 24.60±1.40 min in the ET which was statistically significant (p = 0.00001). The LOHS was 11±3.87 days in SEI and 25.2±3.88 days in ET (p = 0.0001). The mean VSS at 4 and 12 weeks for SEI were moderate and mild respectively and for the ET was moderate and mild respectively. Both were statistically significant with a p = 0.003 and p = 0.006. Conclusion. Submental intubation is a safe airway management technique in pan facial fracture. It provides the surgeon with an excellent operative field for achieving the proper dental occlusion. Both short- and long-term outcomes are better compared to the alternative airway method of elective tracheostomy.

Use of Griggs forceps for submental intubation: A modification of Seldinger's technique.

Use of Griggs forceps for submental intubation: A modification of Seldinger's technique.

An innovative method of pilot balloon capping for submental intubation.

An innovative method of pilot balloon capping for submental intubation.

Submental intubation in complex maxillofacial trauma: Pilot balloon protection

AimsThis study aims to describe our refined technique of submental intubation to avoid the recorded intraoperative complications related to tube passage and pilot balloon rupture. Case seriesThis is a retrospective case series of 21 patients with complex maxillofacial trauma who underwent submental intubation from January 2019 to January 2023. All the patients underwent to the same procedure with a new technique of pilot balloon protection: the pilot balloon was not deflated because, once the connector was removed, only the tube was curved and passed through the incision extraorally while the cuff remained inflated. The wire of the pilot balloon was passed behind the last tooth so as not to interfere with the maxillary-mandibular fixation, remaining extraorally under the anesthetist's view. DiscussionOnly 2 patients (9.5%) reported complications related to submental intubation: in particular a patient (4.8%) reported oral floor infection, and in another patient (4.8%) an unesthetic skin scar was observed. No patients reported intraoperative complications related to the procedure. ConclusionThe technique of pilot balloon protection that we have proposed seems to be effective in reducing the intraoperative complications related to the passage of the pilot balloon, such as rupture, damage or early extubation.

Submental intubation in patients with maxillofacial fractures: case report and literature review

Background: Conventional orotracheal and nasotracheal intubation can be challenging in patients requiring fixation of fractures of the maxillofacial skeleton. The proximity of the surgical site for maxillofacial procedures to the airway predisposes patients with maxillofacial pathologies to anaesthetic complications like dislodged endotracheal (ET) tubes and inadvertent extubation. The need for maxillomandibular fixation (MMF) as part of fracture management precludes the use of orotracheal intubation. In patients with nasal bone fractures, nasotracheal intubation may not be feasible, and the complications associated with tracheostomy make it a last resort for securing access to the airway. The purpose of this article is to highlight the usefulness of submental intubation in the management of patients with maxillofacial fractures.Case presentation: We present our initial experience with the submental route of intubation and illustrate the procedure with a case of a patient with midface fractures successfully managed using submental intubation. A literature review of alternative airway routes to conventional orotracheal and nasotracheal intubation is also included.Discussion: Edentulous spaces, retromolar intubation, submental intubation, submandibular intubation, and tracheostomy have been used as alternatives to conventional endotracheal intubation. Each route has its associated advantages, disadvantages, and limitations.The submental approach is fast, easy to learn, and associated with minimal complications.Conclusion:Submental intubation is a safe option for airway management in patients with maxillofacial fractures.

53. Submental intubation in orthognathic surgery: A 17 year experience

53. Submental intubation in orthognathic surgery: A 17 year experience

P074 Revisiting the role of submental intubation (SMI) in oral and maxillofacial surgery

P074 Revisiting the role of submental intubation (SMI) in oral and maxillofacial surgery

P121 Use of custom silicone putty device for nasal tube stabilisation in orthognathic surgery to minimise alterations in nasio-labial angle, inter-alar width, and nasal septa distortion, as an alternative to submental intubation

P121 Use of custom silicone putty device for nasal tube stabilisation in orthognathic surgery to minimise alterations in nasio-labial angle, inter-alar width, and nasal septa distortion, as an alternative to submental intubation

Submental intubation for orthognathic surgery in a patient with a history of pharyngeal flap construction: A case report

AbstractBackgroundSubmental intubation is an airway management technique wherein an endotracheal tube is guided through incisions in the floor of the mouth and the submental skin after normal orotracheal intubation.Case presentationA 20‐year‐old man with a history of pharyngeal flap construction for a cleft palate was planned for orthognathic surgery. Preoperative nasopharyngoscopy showed that the space lateral to the flap was too narrow for nasotracheal intubation; then submental intubation was performed. No intra‐ or postoperative complications were observed.ConclusionSubmental intubation is a useful alternative to tracheotomy in patients with difficulty in nasotracheal intubation during surgeries requiring occlusal confirmation.

Maksillofasiyal cerrahiden sonra gelişen postoperatif bulantı kusma için risk faktörleri

Aim: The aim of this study was to determine the risk factors for postoperative nausea and vomiting (PONV) in maxillofacial surgery and contribute to its prevention. 
 
 Methods: 93 patients (42 female, 51 male) who underwent maxillofacial surgery under general anesthesia were included in the study. No postoperative rescue antiemetic medications were given to patients. One investigator recorded patient-related anesthesia-related and surgery-related variables. The nausea and pain were evaluated postoperatively by means of Visual Analogue Scale. Total number of vomiting in the first 24 hours after surgery and number of days of hospital stay were recorded. 
 
 Results: The risk factors most associated with postoperative nausea and vomiting were found to be female sex, increased bleeding, submental intubation, prolonged operation time, and postoperative pain. No significant relationship was found between smoking, age, BMI, receiving GA for the first time and PONV in context of maxillofacial surgery.
 
 Conclusion: Given its prevalence and significant consequences, prevention of postoperative nausea and vomiting is an important consideration. It may be useful to take preoperative and postoperative precautions in patients with one or more risk factors.

Motorcycle accidents and high energy midface fractures: a critical review and illustrative case

Accidents involving motorcycle riders often result in maxillofacial injuries and fractures to the midfacial skeleton are common injuries in patients who sustain high-energy trauma to their face. Objective: The aims of this study were to perform a review of the relationship between motorcycle accidents and high energy trauma resulting in midface fractures and to report the case of a motorcycle accident victim who developed a complex fracture pattern of the midface structures. Case report: A 33 year-old man, victim of a motorcycle accident and developed a complex fracture of the midfacial skeleton is reported. Surgical planning included submental intubation using a nasofibroscope and several approaches were performed to the arrangement of the midface fractures. Results/ Discussion: The rates of facial fractures caused by motorcycle accidents tend to increase, especially in developing countries. This increase is also associated with the use of motorcycles for commercial purposes. Young men are the group most involved in this type of accident. The use of helmets is related to lower morbidity in high energy trauma and facial injuries. Conclusion: Fracture patterns involving the midfacial skeleton are directly related to high-energy traumas such as those caused by motorcycle accidents. Prevention campaigns should be encouraged to reduce the high rates of facial injuries among motorcyclists.

Submental Intubation: A Valuable Technique for Airway Management in Complex Head and Maxillofacial Trauma: A Case Report

Submental Intubation: A Valuable Technique for Airway Management in Complex Head and Maxillofacial Trauma: A Case Report

Ultrasound-guided seldinger technique-assisted submental intubation for panfacial trauma-walking off the beaten path.

After introduction of ultrasound, there is paradigm shift towards under vision performance of procedures in anaesthesia. Blind puncture and dissection of submental space may lead to vascular injury and injury to salivary glands. We describe the ultrasound guided Seldinger technique assisted submental intubation for panfacial trauma. Modified ultrasound guided Seldinger technique for submental intubation in 10 patients, who were posted for open reduction and fixation of panfacial fractures. Total procedural time, peri-procedural complications such as bleeding, dislodgment of tube, desaturation and postoperative complications such as injury to sublingual glands/submandibular glands, hematoma, cheloid or hypertrophic scar formation or skin site infection were noted. The mean time to perform submental intubation was 8.9 ± 0.94 minutes (range, 8-11 minutes). Only one patient had minor bleeding during procedure which was stopped after local application of pressure. All patients had a clean scar with no formation of cheloid or hypertrophic scar in the postoperative follow up. Ultrasound assisted submental intubation increases safety of the procedure in patients presenting with maxilla-facial trauma.