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.

A study of submental intubation for anaesthesia in patients with faciomaxillary injuries

“…9,13,19,32,37,39 In present study, in one case there was infection of the submental wound on fourth day postoperatively which was treated with broad spectrum antibiotics and chlorhexidine mouth washes.…”

“…This may lead to increased chance of endotracheal tube disconnection, displacement, endobronchial migration and accidental extubation. 30,32,[35][36][37] Two cases of endobronchial migration of the tube during the surgical procedure were noted. This was recognised by changes in the end tidal carbon dioxide (ETCO 2 ) wave forms along with decrease in saturation to 96% intraoperatively.…”

Submental intubation: a literature review

“…The most common indication for submental intubation was trauma (N = 721) in 86% of the reported cases followed by elective facial osteotomy (N = 100) in 12% of patients 1,2,4,6,[9][10][11]13,15,17,[19][20][21][22][25][26][27][28][31][32][33][34][35][36][37][39][40][41][42][43][44][45][49][50][51][52]54 . Transmaxillary cranial base tumour access (N = 18) comprised 2% of patients 13 .…”

Efficacy and complications of submental tracheal intubation compared with tracheostomy in maxillofacial trauma patients

“…Reported complications include accidental extubation (17,18), detachment of the pilot balloon (19) or its damage during externalization (20), damage to the cuff of the tracheal tube (15), skin infection (15,21), scar formation (22), tube dislodgement (17), lingual nerve paresthesia, venous bleeding (23), salivary fistula (21,24), and mucocele formation (25). In the present study, minor complications included dislodgement, skin infection, and scar formation.…”

“…Scar formation after submental tracheal intubation is by far less visible than the scar after a tracheostomy. The previously reported serious complications associated with this technique included accidental extubation (17,18) or difficulty with the pilot balloon (19) or the cuff of the tracheal tube (15) when the tube was being pulled through the submental incision. With this technique, difficulty in withdrawing the tube through the submental tunnel for any reason could result in prolonged apnea time.…”