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LETTER TO EDITOR
Year : 2019  |  Volume : 2  |  Issue : 1  |  Page : 52-53

Submental intubation: Does it still find a place in modern era


1 Department of Anaesthesiology and Critical Care, Heritage Institute of Medical Sciences, Varanasi, UP, India
2 Department of Anaesthesiology and Critical Care, Ram Manohar Lohia Institute of Medical Sciences, Lucknow, UP, India

Date of Web Publication25-Apr-2019

Correspondence Address:
Dr. Pradeepika Gangwar
D-45 Royal Residency, Mahmoorganj, Varanasi, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ARWY.ARWY_13_18

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How to cite this article:
Gangwar P, Giri M. Submental intubation: Does it still find a place in modern era. Airway 2019;2:52-3

How to cite this URL:
Gangwar P, Giri M. Submental intubation: Does it still find a place in modern era. Airway [serial online] 2019 [cited 2019 Jun 17];2:52-3. Available from: http://www.arwy.org/text.asp?2019/2/1/52/257046



Maxillofacial trauma involving nasal and skull bone fracture present a unique situation to the anaesthesiologist for securing a safe airway. Blind nasal intubation is contraindicated and oral intubation may neither be feasible nor desirable. Surgical airway by either cricothyroidotomy or tracheostomy remains the options for airway access. These procedures subject the patient to the risk of iatrogenic complications such as laryngeal injury, tracheoesophageal fistula, tracheal stenosis and scarring.[1],[2] The submental route may be a useful alternative in such cases.[3] It provides better access to the surgical field and is associated with fewer complications as compared with a tracheostomy.[4]

A 26-year-old 70 kg male, a victim of road traffic accident with a history of bleeding from the ear and nose, was scheduled for maxillofacial reconstructive surgery. Neurological, cardiovascular and respiratory systemic examinations were normal. Non-contrast computed tomography of the head showed bilateral fracture of maxillary, mandibular and nasal bones. Mouth opening was restricted to two fingers probably due to pain. Routine blood investigations were within the normal limits. Patient was accepted for surgery with the plan to perform submental intubation.

The patient was kept nil by mouth for 8 h before surgery. In the operating room, standard monitors such as electrocardiogram, blood pressure and pulse oximeter were applied. Premedication was given with intravenous (IV) glycopyrrolate 0.2 mg, midazolam 2 mg and fentanyl 140 μg. The patient was induced with propofol 2 mg/kg IV. After confirmation of adequacy of mask ventilation, rocuronium 1 mg/kg IV was given. Following conventional laryngoscopy, the trachea was intubated with an 8.0 mm ID cuffed flexometallic endotracheal tube (ETT). To convert oral intubation into the submental route, sterile painting and draping were done over the chin and mouth. A transverse 2 cm long midline incision was made at the inferior border of the mandible. With the aid of a haemostat, a tract was created in the floor of mouth by dissecting subcutaneous tissue, muscles and mucosa. After entering the floor of mouth, an incision was made parallel to the gingival margin. After administering 100% oxygen for 3 min, the breathing circuit was briefly disconnected and the connector removed. The pilot balloon, followed by ETT, was brought out through the incision. The connector was reconnected to the ETT and the breathing circuit was reattached. The ETT was secured to the skin [Figure 1]. Anaesthesia was maintained with isoflurane (1–1.3 MAC) in an oxygen-air mixture (FIO2 0.4) and intermittent boluses of rocuronium. Intraoperatively, interdental wiring of the maxilla and mandible was done to ensure proper alignment. After completion of surgery that lasted for 4 hours, residual neuromuscular blockade was antagonised with neostigmine 0.04 mg/kg IV and glycopyrrolate 0.01 mg/kg IV. The patient was extubated awake in the operating room after complete recovery with availability of difficult airway cart, wire cutter and tracheostomy set. Skin incision was closed under the effect of 2% lignocaine infiltration. The patient was observed for 2 h in a high dependency unit until he had an uneventful recovery.
Figure 1: Submental intubation

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Though retromolar intubation is an alternative to submental intubation for securing the airway in patients with complex maxillofacial trauma, it does have some disadvantages such as the risk of dislodgement of ETT and compromised surgical sterility. In our patient, the retromolar space was not adequate for accommodating the ETT while still retaining the ability to occlude the maxilla and mandible during surgery. In view of lower morbidities, submental endotracheal intubation technique is an alternative to nasotracheal intubation and tracheostomy in patients with multiple facial fractures undergoing reconstructive surgeries.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his image and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Acknowledgement

The authors would like to thank Dr Vikash Singh.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Caubi AF, Vasconcelos BC, Vasconcellos RJ, de Morais HH, Rocha NS. Submental intubation in oral maxillofacial surgery: Review of the literature and analysis of 13 cases. Med Oral Patol Oral Cir Bucal 2008;13:E197-200.  Back to cited text no. 1
    
2.
Anwer HM, Zeitoun IM, Shehata EA. Submandibular approach for tracheal intubation in patients with panfacial fractures. Br J Anaesth 2007;98:835-40.  Back to cited text no. 2
    
3.
Amin M, Dill-Russell P, Manisali M, Lee R, Sinton I. Facial fractures and submental tracheal intubation. Anaesthesia 2002;57:1195-9.  Back to cited text no. 3
    
4.
Hernández Altemir F. The submental route for endotracheal intubation. A new technique. J Maxillofac Surg 1986;14:64-5.  Back to cited text no. 4
    


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