Rapid protocol distraction with rhBMP-2 allows distraction of the hypoplastic mandible to class III occlusion during the initial operation and avoids the latency and distraction phases of standard mandibular distraction. This case series demonstrates the safety and effectiveness of rapid distraction in neonates with Pierre Robin syndrome. Larger studies and long-term follow-up are necessary; however, this study suggests that rapid protocol distraction with rhBMP-2 is effective in neonates with Pierre Robin syndrome.

A irway management in patients with facial trauma requiring operative intervention can present a unique challenge to both the anesthesiologist and the surgeon. Submental intubation (SI) has been described as an alternative to nasoendotracheal intubation when oral endotrachel intubation is contraindicated. Contraindications to nasotracheal intubation include basal skull fractures, which have lead to intracranial malposition of nasopharyngeal airway (1,2).The present case report highlights the successful implementation of an alternative approach first described in 1986 by Hernandez Altemir (3). SI offers an alternative to tracheostomy in patients requiring an isolated operation for facial reconstruction. In addition, submental intubation can be performed in less than 5 min (4) and few complications, such as superficial wound infection (4) and mucocele formation (5), have been reported. No cases of injury to the structures of the floor of the mouth, associated glands or hemorrhage have been reported (4). The present case report describes the use of the SI in the setting of facial trauma where nasotracheal intubation was unable to be obtained. Case presentationAn 18-year-old woman presented to the emergency department after suffering a fall from the second story window of her house. On presentation, she was able to protect her airway and did not require intubation. She was admitted for observation and pain management due to her comminuted left mandibular fracture and bilateral displaced condylar fractures.On hospital day 3 she was taken to the operating room for repair of her facial fractures. Her respiratory status had been stable throughout her hospital stay and, thus, she was never intubated before her operative intervention. The patient was to be nasally intubated because she required access to her oral cavity during the procedure and maxillary mandibular fixation postoperatively. The anesthesia staff attempted multiple times to perform nasoendotracheal intubation and were unsuccessful. Fibre optic assistance was also attempted; however, the anesthesia staff did not feel that the patient could be intubated safely. The trauma surgeon was called into the room to perform a tracheotomy to provide an airway for the patient; however, before tracheotomy it was decided to attempt to perform a SI.The patient was intubated initially via standard oral endotracheal intubation technique and this was converted to a SI by the surgical team. A spiral armored endotracheal tube was used. Then, a 1.5 cm incision was made immediately to the right of the midline in the floor of the mouth and blunt dissection was done through the submental region Submental intubation (SI) has been proposed as an alternative to nasoendotracheal intubation when oral endotracheal intubation is contraindicated. In patients who require intubation for maxillofacial reconstruction, this is an alternative to a traditional tracheostomy. The present case report presents an 18-year-old woman who suffered a comminuted mandibular fracture. Two days after her acci...

Submental intubation (SI) has been proposed as an alternative to nasoendotracheal intubation when oral endotracheal intubation is contraindicated. In patients who require intubation for maxillofacial reconstruction, this is an alternative to a traditional tracheostomy. The present case report presents an 18-year-old woman who suffered a comminuted mandibular fracture. Two days after her accident, she was taken to the operating room for open reduction with internal fixation of her mandible; however, the anesthesia staff was unable to nasally intubate the patient. A SI was performed. The procedure was completed without complications and the surgery accomplished with the SI. The patient was able to avoid a tracheostomy for an isolated operation. SI avoids the dangers of nasoendotracheal intubation in patients with midfacial fractures and avoids complications related to tracheostomy. Thus, SI may serve as an alternative to tracheostomy in patients without other medical conditions and indications for long-term intubation.