Submental Intubation Research Articles

Submental intubation: experience with 30 cases

IntroductionWhen a patient has multiple injuries, involving serious fractures in the maxillofacial region and base of skull, a tracheostomy is often performed to approach the different affected facial thirds simultaneously. Submental intubation offers an alternative to this type of airway management, involving a decreased risk for the patient due to its safety and versatility in treating nasal fractures and re-establishment of dental occlusion. MaterialsA total of 30 patients with different degrees of involvement of the facial thirds (superior, middle and inferior) were treated by our team, performing a submental intubation to maintain the airway. These fractures affected nasal bones and dental occlusion. ResultsIn all cases we accomplished an adequate reduction of nasal fractures and obtained an accurate dental occlusion, with no incidents during or after this intubation. ConclusionsSubmental intubation is a good alternative to treat multiple injury patients who have nasal and oral cavities involvement, avoiding the use of tracheostomy in cases that do not need it.

USE OF THE RING‑ADAIR‑ELWYN (RAE) TUBE AS AN ALTERNATIVE FOR FLEXIBLE REINFORCED ARMORED TUBE FOR SUBMANDIBULAR APPROACH FOR ENDOTRACHEAL INTUBATION TO AVOID SURGICAL INTERRUPTION IN PATIENTS WITH PANFACIAL FRACTURES

Background: Maxillofacil and dental surgery are challenges for the anesthetist, because the surgical procedures are just around the upper airway. So, the corner stone in the maxillofacial surgical patients is the patient safety during and after operation. Previous studies recommended the use of reinforced armored tube for submandibular tracheal intubation in maxillofacial surgical patients. The current study tested the RAE tube as an alternative technique to armored tube in the submandibular route for tracheal intubation in maxillofacial surgical patients. Objectives: The study aimed to compare the RAE tube as an alternative to flexible reinforced armored tube in submental endotracheal intubation in maxillofacial surgery. Methods: A total of thirty patients had undergone submental intubation for management of maxillofacial surgical procedures. The submandibular intubation by RAE tube was chosen in 15 patients as an alternative for flexible armored tube in another 15 patients when the oral and nasal intubation was not suitable and not safe for the surgical procedure. We excluded from the start the patient that required prolonged assisted ventilation because the tracheostomy is the preferred choice for all. Results: From November 2013 to November 2014, thirty patients with traumatic panfacial fractures were admitted to the Plastic Surgery and Burn Department at Al-Azhar University Hospitals within the subspeciality of Maxillofacial Surgery. Endotracheal oral intubation by laryngoscope was successful in all patients of the studied groups. No statistical difference was recorded between the studied groups as regard the time of intubation (9-13min), and no recorded intraoperative or postoperative major complications. Both types of the tube provided secured airway and an uninterrupted surgical access to the oral and nasal cavity. Also, it carried an access for good hemostasis and allowed intraoperative control of dental occlusion. The technique was found to be easy and convenient with uneventful intraoperative and postoperative periods. The technique was satisfactory to the surgeon, the anesthetist, the patients and the relatives. Conclusions: Submandibular tracheal intubation by RAE tube is an effective and useful technique for airway control in maxillofacial surgery. It can be used as a good alternative to reinforced armored tube in maxillofacial surgical patients.

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.

Submental intubation in maxillofacial trauma patients: A review of literature

Submental intubation is a simple, safe, low morbidity technique for operative airway management in maxillofacial trauma patients, when there are fractures involving the nasal region and concomitant dental occlusal disturbances.Severe maxillofacial injuries usually require intraoperative intermaxillary fixation to achieve optimum reduction of fractures and access to the nasal pyramid. Thus herein, we review certain articles pertaining to submental intubation, its anatomic relevance, technique, indications, contraindications, and modifications in this technique.

Facing the airway challenges in maxillofacial trauma: A retrospective review of 288 cases at a level i trauma center.

Background:Maxillofacial trauma is an apt example of a difficult airway. The anesthesiologist faces challenges in their management at every step from airway access to maintenance of anesthesia and extubation and postoperative care.Methods:A retrospective study was done of 288 patients undergoing surgery for maxillofacial trauma over a period of five years. Demographic data, detailed airway assessment and the method of airway access were noted. Trauma scores, mechanism of injury, duration of hospital stay, requirement of ventilator support were also recorded. Complications encountered during perioperative anaesthetic management were noted.Results:259 (89.93%) of the patients were male and 188 (62.85%) were in the 21-40 year range. 97.57% of the cases were operated electively. 206 (71.53%) patients were injured in motor vehicular accidents. 175 (60.76%) had other associated injuries. Mean Glasgow coma scale score (GCS), injury severity score (ISS) and revised trauma score (RTS) were 14.18, 14.8 and 12, respectively. Surgery was performed almost nine days following injury. The mean duration of hospitalization was 16 days. ICU admission was required in 22 patients with mean duration of ICU stay being two days. Majority of patients had difficult airway. 240 (83.33%) patients were intubated in the operating room and fibreoptic guided intubation was done in 159 (55.21%) patients. Submental intubation was done in 45 (14.93%) cases.Conclusions:Maxillofacial injuries present a complex challenge to the anaesthesiologist. The fibreoptic bronchoscope is the main weapon available in our arsenal. The submental technique scores over the time-honored tracheostomy. Communication between the anaesthesiologist and the surgeon must be given paramount importance.

Retromolar intubation: A better alternative to submental intubation or tracheostomy for dental occlusion by intermaxillary fixation.

Retromolar intubation: A better alternative to submental intubation or tracheostomy for dental occlusion by intermaxillary fixation.

English

Anaesthesia for panfacial fracture reduction is a challenge to anaesthetist. Oral and nasal intubation makes good reduction difficult for the surgeon. Tracheostomy carries high risk. Submental intubation would be the better alternative for short term airway management. Using flexible broncoscope makes even difficult intubations successful.

Intubación submental: experiencia con 30 casos

IntroductionWhen a patient has multiple injuries, involving serious fractures in the maxillofacial region and base of skull, a tracheostomy is often performed to approach the different affected facial thirds simultaneously. Submental intubation offers an alternative to this type of airway management, involving a decreased risk for the patient due to its safety and versatility in treating nasal fractures and re-establishment of dental occlusion. MaterialsA total of 30 patients with different degrees of involvement of the facial thirds (superior, middle and inferior) were treated by our team, performing a submental intubation to maintain the airway. These fractures affected nasal bones and dental occlusion. ResultsIn all cases we accomplished an adequate reduction of nasal fractures and obtained an accurate dental occlusion, with no incidents during or after this intubation. ConclusionsSubmental intubation is a good alternative to treat multiple injury patients who have nasal and oral cavities involvement, avoiding the use of tracheostomy in cases that do not need it.

Sub-mental Intubation in Oral and Maxillofacial Trauma Patients.

Oral and maxillofacial surgical procedures present a unique set of problems for both the surgeon and the anesthesiologist as achieving dental occlusion is one of the most important aims of the treatment. Sub-mental intubation is a reliable and safe method of alternative airway management in maxillofacial surgery. This article presents the technique of sub-mental intubation along with a brief comparison with other techniques.

Intubation sub-mentale chez un patient victime d’un traumatisme maxillo-facial

Maxillo-facial traumas are frequent and most often occur in young patients. Naso-tracheal or orotracheal intubation may be contraindicated in case of combined occlusal fracture and nasal or ethmoido-nasal fracture. This study was carried out a clinical case of a patient treated at the Lille University Hospital for a maxillofacial trauma associating fracture of nose and maxilla. The purpose was to assess the reliability of submental intubation as an alternative to tracheotomy. Submental intubation is a reliable single and safe technique allowing an one-stage surgical treatment in case of complex association of fractures without using tracheotomy. Its use should be implemented on a larger scale.

Lateral Submental Intubation in Panfacial Trauma Review of Five Cases

Maintaining the airway while operating panfacial trauma patients is very crucial and important. Panfacial trauma may include cranial fractures, nasal fractures along with maxillomandibular fractures. The conventional oroendotracheal intubation is contraindicated since the tube will hinder the maxillomandibular fixation by wiring or while reducing and stabilising the fractured segments. Nasoendotracheal intubation is also not a choice of intubation since the nasal fractures are also present in a panfacial fracture. Even it can cause meningitis or the tube can be passed intracranially in patients with frontobasillar fractures. Only option for maintaining the airway remained complex procedures like tracheostomy or cricothyrotomy until 1986 when a Spanish maxillofacial surgeon named Francisco Hernandez Altemir invented an alternate way known as submental intubation for airway maintainance after intubation. In submental intubation at first the normal orotracheal intubation is done followed by which an incision is placed at the submental region and blunt dissection is made through which the tube is passed from iside to outside and then reconnected. Its an excellent method of intubation for panfacial trauma since it does not interfere with the treatment or surgical procedures and at the same time complicated procedures like tracheostomy. Several modifications are available for the submental intubation. Five cases of maxillomandibular fractures along with nasal fractures are operated successfully while using the lateral submental intubation approach for maintaining the airway.

Assessment of the Efficacy of Submental Intubation in the Management of Midfacial and Panfacial Trauma Patients.

Securing an airway in maxillofacial injuries remains a challenge and is an important objective on the part of a maxillofacial surgeon to thoroughly understand its management. The aim of this study was to evaluate the efficacy and complications of submental intubation in the management of midfacial/panfacial trauma patients where oro-endotracheal or naso-endotracheal intubation is contraindicated and tracheostomy can be avoided. Twenty patients with maxillofacial injuries were selected for submental intubation who were admitted in Kamineni Hospital, Narketpally, Nalgonda during a 2year period (2010-2012). The parameters used to assess the efficacy were; restoration of the occlusion, duration of the surgery, presence of scar, presence of infection, damage to vital structures or any post-operative salivary fistula. Submental intubation allowed reduction and fixation of all fractures without the interference of the tube during surgical procedure in all of the patients. There were no intra-operative complications and none of the patients required post-operative ventilation. There were no significant post-operative complications. However, in one of the cases (case 4) infection of submental wound was seen and in another case (case 11) salivary fistula was formed. Both the cases were appropriately managed without any difficulty. The submental scar was well accepted by all the patients. Submental intubation is a safe and extremely useful procedure in severe maxillofacial injuries. It presents a low incidence of operative and post operative complications. It allows both the surgeon and the anaesthetist to deliver a better quality of patient care.

Midline Submental Intubation Might Be the Preferred Alternative to Oral and Nasal Intubation in Elective Oral and Craniomaxillofacial Surgery When Indicated

No consensus exists to date regarding the best method of controlling the airway for oral or craniomaxillofacial surgery when orotracheal and nasotracheal intubations are unsuccessful or contraindicated. The most commonly used method of tracheostomy has been associated with a high degree of morbidity. Therefore, the present study was conducted to determine the indications, safety, efficacy, time required, drawbacks, complications, and costs of the midline submental intubation (SMI) approach in elective oral and craniomaxillofacial surgical procedures. A retrospective case series study was used to evaluate the surgical, financial, and photographic records of all patients who had undergone oral or craniomaxillofacial operations at Sharda University School of Dental Sciences, Greater Noida, from April 2006 to March 2014. The indications, drawbacks, time required for the procedure, ability to provide a secure airway, intra- and postoperative complications, and additional costs associated with SMI were analyzed. Of the 2,823 patients treated, the present study included 120 patients (97 men and 23 women, aged 19 to 60 years). The average time required for SMI was 10 ± 2 minutes. No episode of intraoperative oxygen desaturation was noted. One intraoperative complication, an injury to the ventral surface of the tongue, was encountered. Two patients developed infection at the skin incision site. No significant additional cost was incurred with the use of SMI. SMI has been successfully used in elective oral and craniomaxillofacial surgical procedures for which oral and nasal intubations were either not indicated or not possible. The advantages include a quick procedure, insignificant complications, the ability to provide a stable airway, and no added costs, making SMI a quick, safe, efficient, and cost-effective alternative in such cases.

Intubation techniques: preferences of maxillofacial trauma surgeons.

To evaluate the clinical outcomes of alternative techniques of intubation in patients sustaining maxillofacial injuries, where nasotracheal intubation (NTI) is best avoided. Alternative techniques to standard naso-tracheal intubation like submental intubation, orotracheal intubation-retrotuberosity/retromolar and missing dentition were used and variables of clinical outcome recorded. Submental intubation provides an unobstructed intraoral surgical field, avoids intraoperative and postoperative complications of tracheostomy, and overcomes the disadvantages of NTI. In our experience with submental intubation (6 cases), we only had complication related to tube apparatus like damage to pilot balloon. With retrotuberosity intubation (5 cases) we did not encounter any complications and the only limitations were bulbous maxillary tuberosity. Retromolar intubation (4 cases) a safe noninvasive technique has disadvantages like tube interference within the surgical field and not feasible in case of limited retromolar space. Orotracheal-missing dentition intubation (4 cases) is of great advantage i.e. it can be used in cases where NTI is contraindicated, no specialized skill required, no added cost, avoids the need for tracheostomy, no extra-oral procedures required and does not interfere with occlusion/MMF; with disadvantage of occasional tube interference within the surgical field. Preferred techniques of securing an airway like orotracheal, nasotracheal may not always be applicable, thus a trauma surgeon-anesthesist team should always have alternative techniques in their armamentarium to reduce the morbidity associated with these patients without interference with occlusion, which is prime goal in jaw fracture reduction. We have used these techniques in a country with limited resources and found them equally effective and convenient to use.

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

Submental endotracheal intubation in patient with panfacial fracture: a useful alternative to tracheostomy

Submental intubation is a simple safe and useful technique for air way management during maxillofacial surgery when both nasal and oral tracheal intubation are deemed unsuitable. This technique offers an optimal operating field and an opportunity to check the dental occlusion. It avoids the need for tracheostomy and its consequent morbidity. We present a case of multiple facial fractures where we avoided tracheostomy by the use of submental endotracheal intubation. DOI: http://dx.doi.org/10.3329/jbsa.v26i1.19818 Journal of Bangladesh Society of Anaesthesiologists 2013; 26(1): 54-57

Combating nasal septum deviation in le fort 1 orthognathic surgery complications, with submental intubation.

Orthognathic Le Fort 1 osteotomy, a surgical procedure performed to correct the aesthetics of mid face. Some of the complications of this surgery are hemorrhage, loss of sensation due to facial nerve damage, nasal septum deviation leading to crooked nose and snoring. Nasal septum deviation is the most common complication and one of the most noticeable complications that is developed during the Le Fort 1 osteotomy. To ascertain that Submental Intubation in Orthognathic Le Fort 1 Osteotomy combats Nasal septum Deviation. Medical records and clinical data of 32 patients who underwent orthognathic Le Fort 1 Osteotomy under submental orotracheal intubation were analyzed to understand if nasal septum deviation and other complications of Le Fort 1 Osteotomy occurred in such cases based on 6 parameters. No complications of nasal septum deviation or other complications that's associated with orthognathic Le Fort 1 Osteotomy were found in the 32 cases that were analyzed. The surgeon needs to have a non-obtrusive nasal canal so as to determine the extent to which the nasal septum needs to be reduced so that it does not cause nasal septum deviation post the procedure. Submental oratracheal intubation provides the surgeon with an excellent view of the operating field, enough space for intra oral manipulation of the bone and septum for intra oral operation and control of dental occlusion. Submental intubation is a better method of intubation during Le Fort 1 osteotomy as it does not cause nasal septum deviation or other associated complications.

Evaluation of submental approach for oro-endotracheal intubation in maxillofacial trauma

Introduction: In maxillofacial injuries, a choice has often to be made between different ways of intubation when surgical access to fractured nasal bone and simultaneous establishment of occlusion are required. We report our experience with submental intubation in the airway management of complex maxillofacial trauma patients and complication associated with it. The aim is to evaluate the outcome of airway management in patients with complex maxillofacial trauma by submental intubation. Materials and Methods: Fifteen cases reporting to the Department of Oral and Maxillofacial Surgery of a tertiary care hospital, with multiple facial trauma from September 2011 to September 2013 were selected for study. Median submental intubation was performed. Follow-up during hospitalization for wound associated complication and 3 months postoperatively was done. Results: At the end of the procedure, all 15 patients were extubated without any complications. Postoperatively, only one patient presented with superficial infection of the submental wound. Conclusion: Submental endotracheal intubation is a simple technique with very low morbidity and can be used as an alternative to tracheostomy in selected cases of maxillofacial trauma.

Airway management in maxillofacial trauma: do we really need tracheostomy/submental intubation.

There are various techniques available for airway management in patients with maxillofacial trauma. Patients with panfacial injuries may need surgical airway access like submental intubation or tracheostomy, which have their associated problems. We have been managing these types of cases by a novel technique, i.e, intraoperative change of nasotracheal to orotracheal intubation. To review our experience about various techniques for the airway management in patient with maxillofacial trauma. To analyse the possibility of using nasotracheal intubation and intraoperative change of nasotracheal to orotracheal intubation in panfacial fractures. In a tertiary care centre four hundred eighty seven patients of maxillofacial injuries, operated over a period of 2 years were reviewed in relation to age, sex, mode of injury, type of facial fractures, methods of airway management and their associated complications. Young patients with male predominance is the most common affected population. Panfacial fracture is the most common type of injury (39.83%) among facial fractures. Airway was managed with intraoperative change of nasotracheal to orotracheal intubation in 33.05% of the patients whereas submental intubation or tracheostomy was done in 8.62% of the patients. Nasal route for endotracheal intubation is not a contraindication in the presence of nasal fractures, base of skull fractures and CSF leak. By changing the nasotracheal intubation to orotracheal intubation intraoperatively in cases panfacial fractures, most of the tracheostomies and submental intubations can be avoided.

A novel method using Seldinger′s technique for submental intubation in major craniomaxillofacial fractures: A case series

Airway management is a challenge to anesthesiologists particularly in maxillofacial surgeries. The oral tracheal tube is unsuitable because it interferes with the surgical field and prevents dental occlusion. Nasotracheal intubation may not always be possible due to structural deformity or trauma to the nasal bones. Tracheostomy and submental intubation have their drawbacks. To overcome these shortcomings we used Percutaneous Dilatational Tracheostomy Kit (PDTK) to modify the technique of submental intubation. Serial dilatations were performed over the guide wire before passing the tracheal tube by submental route, using the PDT kit in four patients. Submental intubation could be achieved in all the four cases with this technique and there were no associated complications. Seldinger's technique is a simple and easy technique with minimal bleeding, imperceptible scar, and more importantly anesthesiologists feel more comfortable because of their familiarity with the Seldinger technique.