Submental Intubation Technique Research Articles

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.

AB094. SOH23ABS_067. Revisiting the role of submental intubation in maxillofacial trauma cases

Background: Airway management in maxillofacial trauma cases can prove particularly challenging as often the conventional methods of intubation are unsuitable. Standard orotracheal intubation may be a hinderance to the surgeon who may need to perform intra-operative maxillomandibular fixation. Nasotracheal intubation, a commonly used alternative is often not appropriate either particularly if there is a nasal fracture or base of skull fracture present. Clear communication between the anaesthetist and surgeon is paramount for successful intubation as both parties are forced to share the same working space. In these types of trauma cases Submental Intubation provides an excellent choice for airway securement. The Submental Intubation technique as an alternative method of airway management was first described in 1986 by Hernandez Altemir. It is a safe and effective method of intubation with a low risk of morbidity. It provides access to maxillofacial fractures without interference from an anaesthetic tube enabling maxillomandibular fixation and access to naso-orbito-ethmoid fractures. It avoids the need for tracheostomy which has many reported complications including post-op bleeding, surgical emphysema, tracheostomy site infections, nerve injury, tracheal stenosis, poor scar aesthetics, tracheoarterial fistula and death. Submental intubation has no associated major complications when compared to tracheostomy.

A Prospective, Randomized Comparison of the Classical Altemir's Method With the Newer Seldinger's Technique of Submental Intubation.

Submental intubation performed using the classical Altemir's technique is a well-accepted, safe technique for providing optimal operating field to the maxillofacial surgeon, in cases where either nasotracheal or orotracheal intubation is impossible. We propose a new, percutaneous Seldinger's technique of submental intubation as an interesting alternative to the classical Altemir's technique, wherein a percutaneous dilatational tracheostomy kit is used to dilate the submental tract, instead of bluntly dissecting it. We hypothesized that Seldinger's technique would be associated with reduced procedure time and minimal scar formation in patients with maxillofacial fractures. We enrolled 60 patients scheduled to undergo maxillofacial injury fixation under general anesthesia. After consent, the cohort was randomly allocated to undergo submental intubation by either the classical Altemir's technique or Seldinger's technique. As our primary objective, we noted the time taken to complete the procedure of submental intubation. Our secondary objectives were the components of primary outcome, such as disconnection/apnea time, bleeding, and technical difficulties during the procedure. We also observed for complications such as presence of salivary fistula/infection at hospital discharge and scar characteristics at 1- and 3-month follow-up. The median time for performing submental intubation in the Seldinger group was significantly lower than that in the Altemir group (170.5 [136.5-256.0] seconds vs 220.0 [205.5-289.0] seconds; P value, .040). The median disconnection time was also significantly lower in the Seldinger group (12.0 [10.8-20.0] seconds vs 19.0 [15.0-23.0] seconds; P value, .036). Furthermore, significant bleeding was absent in nearly 53.8% of the study participants in the Seldinger group as compared to 25.9% in the Altemir group. At follow-up, there was no evidence of differences in scar characteristics between the 2 groups. Seldinger's technique is associated with shorter procedure time and reduced apnea time due to easier and better tract formation, thus minimizing the effort required to exteriorize the endotracheal tube. Furthermore, as dilation reduces tissue damage, Seldinger's technique is associated with significantly less procedural bleeding. Thus, Seldinger's technique can be safe, easy, and faster to perform compared with the classical Altemir's technique of submental intubation in patients with maxillofacial trauma.

Comparison among the Intubation Techniques Employed in the Course of Management of Pan-Facial Trauma

Objective: To find the best method of intubation in patients sustaining pan-facial trauma by comparing the pros and cons of each technique. Materials and methods: Three different types of intubation techniques (nasotracheal intubation, orotracheal intubation, and sub-mental intubation) were considered in this study. The study population involves 9 patients who have undergone treatment for pan-facial trauma under general anesthesia (3 patients per technique) and the variables of clinical outcome of each group were recorded. Results: Nasal intubation is the most common and safest method of intubation. However, it can’t be used in some types of pan-facial trauma. In cases like these, oral intubation is not preferred. As it severely compromises maxillofacial repair because of interference with the placement of intermaxillary fixation [3](IMF), which is used to establish the patient s occlusion in the intraoperative period. Submental intubation is an alternative with minimal risk to tracheostomy when orotracheal or nasotracheal intubation is not appropriate. The submental intubation technique gave an uninterrupted surgical field, unobstructed airway, ease of gaining occlusion in general anesthesia, less intraoperative and postoperative complications and it overcomes the disadvantages of both nasotracheal and orotracheal intubation. Conclusion: Preferred techniques of securing an airway are orotracheal, nasotracheal intubation. However these techniques may not always be applicable, thus a trauma surgeon-anesthetist team should always have alternative techniques in their armamentarium which secures the patient's airways without interfering with occlusion, to gain at most postoperative esthetic and functional results.

A Simple and Reliable Submental Intubation Technique for Maxillofacial Fractures.

In 1986, Altemir first reported the use of submental intubation to avoid tracheotomy in patients with panfacial and midfacial fractures for whom intermaxillary fixation is necessary, but orotracheal and nasotracheal intubations are not recommended. This novel technique allowed intraoperative access to perform dental occlusion and reconstruction of the nasal pyramid in patients with skull base fractures. Herein, we describe a refined technique based on Altemir's original procedure. Seven male patients with panfacial fractures underwent submental intubation using our refined technique. The technique was developed after encountering a technical error with Altemir's original procedure. In this new technique, we employed a 2-0 silk suture guide to allow the passage of both the endotracheal and cuff-inflation tubes through the same tunnel created from the oral cavity to the submental area. The success rate of the refined technique was 100%, and there were no intraoperative or postoperative complications. There was 20 seconds of ventilation outage time in total. Endotracheal and cuff-inflation tubes were easily and quickly passed through the same submental tunnel. Our refined technique is simple, easy, safe, fast, inexpensive, and does not require specific materials. Submental scars were smaller and relatively inconspicuous in this study, compared to those reportedly associated with other modified techniques.

Intubación submentoniana: una alternativa útil para cirugía ortognática en pacientes con malformaciones craneofaciales. Informe de caso

IntroductionSubmental intubation is a simple, fast and safe alternative associated with low morbidity rates as compared against tracheostomy. It is suitable for patients with nose obstruction due to craniomaxillofacial malformation. Case report (clinical findings and therapeutic intervention)The goal of this study is to do a literature review of the procedure and a clinical case presentation of a patient with severe hypoplasia of the middle third of the face that as a consequence of the characteristics of the patient's malformation required submental intubation for surgical treatment. ConclusionThe submental intubation technique is an excellent choice for orthognathic surgery in patients with facial malformations and airway problems.

Submental intubation: A useful alternative for orthognathic surgery in patients with craniofacial malformations. Case report

IntroductionSubmental intubation is a simple, fast and safe alternative associated with low morbidity rates as compared against tracheostomy. It is suitable for patients with nose obstruction due to craniomaxillofacial malformation. Case report (clinical findings and therapeutic intervention)The goal of this study is to do a literature review of the procedure and a clinical case presentation of a patient with severe midface hypoplasia that as a consequence of the characteristics of the patient's malformation required submental intubation for surgical treatment. ConclusionThe submental intubation technique is an excellent choice for orthognathic surgery in patients with facial malformations and airway problems.

Submental intubation: alternative short-term airway management in maxillofacial trauma

ObjectivesTo assess submental route intubation as an alternative technique to a tracheostomy in the management of the airway in cranio-maxillofacial trauma, along with an assessment of its morbidity and complications.Materials and MethodsSubmental intubation was performed in 17 patients who had maxillofacial panfacial trauma and management was done under general anesthesia during a period of one year from 2013 to 2014 at Departments of Oral and Maxillofacial Surgery and Dentistry, the Malankara Orthodox Syrian Church Medical College, Kochi, India.ResultsIn all 17 cases, the technique of submental intubation was found to be simple and reliable. Hypertrophic scars were noted in three cases, orocutaneous fistula and mucocele in one case each. All these complications were managed comfortably without significant morbidity to the patient.ConclusionSubmental intubation is a good technique that can be used regularly in the management of the airway in cranio-maxillofacial trauma, but with some manageable complications.

Evaluation of safety and usefulness of submental intubation in panfacial trauma surgery.

ObjectivesSubmental intubation has been advocated as an alternative to classical tracheostomy for certain indicated panfacial trauma surgeries. Surgeons should have various options for airway management in maxillofacial trauma patients. Most maxillofacial injuries involve occlusal derangements, which might require intraoperative occlusal corrections; hence, orotracheal intubation is not ideal. Maxillofacial surgeons generally prefer nasotracheal intubation; however, in cases with concomitant skull base fracture or nasal bone fracture, nasotracheal intubation might not be suitable; in these situations, tracheostomy is typically performed. However, the possible complications of tracheostomy are well known. Due to trauma situations and to avoid the complications of tracheostomy, submental intubation would be an ideal alternative procedure in selected maxillofacial trauma surgery patients. This study aimed to evaluate the safety and usefulness of a submental intubation technique for panfacial trauma surgery. Moreover, we intended to share our experience of submental intubation and to recommend this simple, safe procedure for certain panfacial trauma surgeries.Materials and MethodsIn five panfacial trauma patients, we performed submental intubation for airway management; the mean time required for the procedure was only eight minutes.ResultsWe were able to execute this procedure safely in a short time without any intraoperative or postoperative complications.ConclusionSubmental intubation is a safe and simple technique for airway management in indicated panfacial trauma surgery patients.

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.

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.

Submental intubation for airway management of patients with complex caniomaxillofacial injuries: Our experience.

Context:There is paucity of data regarding the role of submental intubation (SI) in the airway management of patients with craniomaxillofacial trauma from India.Aims:To study the characteristics of patients presenting with craniomaxillofacial injuries requiring submental intubation, the duration of SI procedure and complications of this technique.Settings and Design:Tertiary level, teaching institute, retrospective, observational study.Materials and Methods:Forty patients requiring submental intubation between June, 2007 and December, 2009. The primary outcome measure was the time required for submental intubation defined as starting from the completion of the orotracheal intubation to the fixation of the submental tube. The secondary outcome measures included characteristics of patients with craniomaxillofacial injuries, intraoperative and postoperative complications of the SI technique.Statistical Analysis Used:Data are presented as mean± standard deviation and frequency and percentages, where relevant.Results:Most of the patients were young (average age = 35.15 ± 12.02 years), males (75%) and sustained craniomaxillofacial injuries due to road traffic accidents (85%). The 40 patients included in this audit had 56 injuries recorded at the time of admission including, orthopedic injuries in 65% and head injuries in 55% of patients. The mean time required for completion of SI was 8.90 min. The complications observed included, intraoperative tube migration, development of extra oral fistula, and sialocele, in one patient each.Conclusions: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 anesthesiologist to avoid tracheostomy in selected patients with craniofacial trauma who do not require long-term mechanical ventilation.

Submental intubation: our experience

Airway management for patients who suffered midfacial fractures is complicated. In maxillofacial injuries, a choice has often to be made between different ways of intubation when surgical access to both the nasal and oral cavities is necessary. Submental intubation technique is an alternative to nasoendotracheal intubation and tracheostomy in the management of patients with severe midfacial fractures. This procedure is simple to do and has a low morbidity. Submental intubation-paramedian technique has been used in 15 cases from May 2005-April 2007 in Hosmat Hospital, Bangalore. All patients had fractures disturbing the dental occlusion plus either an associated fracture of the skull base or a displaced nasal fracture. Average duration of procedure was 7 minutes. Average duration of tube in vitro after surgery was 20 hours. There were 2 postoperative complications of tube obstruction which were successfully managed. Submental intubation demands certain technical skills but it is simple, rapid and may avoid tracheostomy in selected patients.

Submental intubation in panfacial injuries: our experience

Panfacial fractures present a unique set of problems to the anaesthesiologist and surgeon. Airway management in panfacial fractures is still a challenge to the anaesthesiologist as all modalities available such as orotracheal intubation, nasotracheal intubation, tracheostomy, etc., have their own advantages and disadvantages. When all the conventional modalities to secure airway seem unsuitable then submental route offers an excellent alternative to manage airway in such patients. Here we describe our experience with submental intubation technique in 10 patients with panfacial injuries over a period of two years.

Does submental intubation technique show an edge over percutaneous tracheostomy? A prospective study in complex oromaxillofacial surgery

Background: Complex oromaxillofacial fractures pose unique challenge for securing the airway. Techniques other than conventional tracheostomy and orotracheal intubation need to be explored to overcome shortcomings associated with conventional methods. This study compares median approach of submental intubation with percutaneous tracheostomy with respect to procedure time, time for extubation/decannulation, length of stay in intensive care unit and complications encountered. Aims: To evaluate procedure time, time for extubation/decannulation, length of stay in intensive care unit and complications for two techniques of airway management in oromaxillofacial surgeries.Settings and Design: Institutional, prospective study.Materials and methods: This prospective study included 25 patients who sustained oromaxillofacial fracture operated under general anesthesia from August 2008 to December 2009. In 15 patients, submental intubation and in 10 patients percutaneous tracheostomy technique were adopted. Complex oromaxillofacial fractures included Lefort 1 and 2, nose, ethmoid and orbit, maxilla and mandible. Airway technique of submental intubation and percutaneous tracheostomy were attempted on the basis of interincisor gap. The procedure time for the two techniques, the time for extubation/decannulation and the length of stay in intensive care unit were evaluated statistically.Statistical analysis used: unpaired ‘t’ test. Results: Of the 25 patients, there were 12 males, 3 females and 8 males,2 females in the submental intubation and percutaneous tracheostomy group respectively. All patients belonged to ASA status 1 and 2. The first successful attempt achieved for submental intubation group and percutaneous tracheostomy group was 93% and 90% respectively. The mean time to perform the submental intubation procedure was 5.27 + 0.72(mean + standard deviation) minutes and 21.72 + 2.04 minutes for percutaneous tracheostomy group. The mean time for extubation was 4.73 + 8.18 days in submental intubation group and 23.3 + 5.25 days for decanulation in percutaneous tracheostomy group. The average length of stay in intensive care unit postoperatively were 6.73 + 8.18 days in submental intubation group and 25.8 + 6.81 days for percutaneous tracheostomy group. Theperformance time, the time for extubation/decannulation and the length of stay in intensive care unit were statistically highly significant for the two groups. Complications encountered in the two groups were recorded. Conclusions: Both, submental intubation and percutaneous tracheostomy can secure the airway in complex oromaxillofacial fracture reduction surgery. Both techniques allow uninterrupted surgical access to the operative field. Although submental intubation technique gives an imperceptible scar which has aesthetically greater acceptance compared to functionally challenging and unsightly tracheostoma which pose an enormous stress to the patient. The complications associated with tracheostomy are at times difficult to manage even in expert hands. Though submental intubation is easily performed, the selection of a particular technique should take into consideration factors other than preoperative airway assessment.

An alternative anaesthetic and surgical technique of submental intubation

An alternative anaesthetic and surgical technique of submental intubation

Submental Intubation Versus Tracheostomy in Maxillofacial Trauma Patients

To evaluate the indications and outcomes of airway management by submental intubation or tracheostomy in patients with maxillofacial trauma, and to describe the technique of submental intubation in detail and discuss its latest refinements. Of 356 patients admitted from January 2004 through September 2007 with maxillofacial trauma, 222 were operated on under general anesthesia. Eight patients underwent urgent or elective tracheostomy; 8 patients underwent submental intubation. Seven patients with submental intubation were extubated at the end of the procedure. One patient received elective tracheostomy 3 days later. We did not encounter any complications in the tracheostomy group, while 1 case of slight damage to the endotracheal tube occurred in the submental intubation group. Submental endotracheal intubation is a simple technique with very low morbidity and can replace tracheostomy in selected cases of maxillofacial trauma without indication for prolonged ventilation support.

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.

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.