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Year : 2019  |  Volume : 2  |  Issue : 1  |  Page : 41-44

Anaesthetic management of panfacial injury using submental endotracheal intubation

Department of Anaesthesiology, BJ Medical College, Civil Hospital, Ahmedabad, Gujarat, India

Date of Web Publication25-Apr-2019

Correspondence Address:
Dr. Mahendrabhai Gautam Vaishali
9, Rangdarshan Society, Near Tirupati Society, Radhaswami Road, Ranip, Ahmedabad - 382 480, Gujarat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ARWY.ARWY_4_19

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Hernandez first described the submental route for endotracheal intubation in 1986 as a valuable alternative to tracheostomy for maxillofacial procedures. Over a 5-year period, we have successfully managed 25 patients of panfacial trauma using the submental route of endotracheal intubation without facing significant adverse outcomes. Submental intubation is contraindicated in patients suffering from neurological deficits who may require prolonged ventilation postoperatively. However, patients who require ventilation for short procedures may be managed using the submental route for endotracheal intubation without significant perioperative comorbidities.

Keywords: Difficult airway, panfacial trauma, submental intubation

How to cite this article:
Vaishali MG, Pushkar VD. Anaesthetic management of panfacial injury using submental endotracheal intubation. Airway 2019;2:41-4

How to cite this URL:
Vaishali MG, Pushkar VD. Anaesthetic management of panfacial injury using submental endotracheal intubation. Airway [serial online] 2019 [cited 2023 Sep 21];2:41-4. Available from: https://www.arwy.org/text.asp?2019/2/1/41/257050

  Introduction Top

Road traffic accidents are the most common cause for maxillofacial injuries.[1] Most of these patients with maxillofacial injuries require surgical reduction.[2] In the majority of cases, there are six specific situations associated with maxillofacial trauma which can adversely affect the airway.[3]

  1. Posterior inferior displacement of a fractured maxilla parallel to the inclined plane of the base of the skull may block the nasopharyngeal airway
  2. A bilateral fracture of the anterior mandible may cause the fractured symphysis and the tongue to slide posteriorly and block the oropharynx in the supine patient
  3. Fractured or exfoliated teeth, bone fragments, vomitus, blood and secretions as well as foreign bodies such as dentures, debris and shrapnel may block the airway anywhere along the oropharynx and larynx
  4. Haemorrhage from distinct vessels in open wounds or severe nasal bleeding from complex blood supply of the nose may also contribute to airway obstruction
  5. Soft-tissue swelling and oedema because of trauma to the head and neck may cause delayed airway compromise
  6. Trauma of the larynx and trachea may cause swelling and displacement of structures such as the epiglottis, arytenoid cartilages and vocal cords, thereby increasing the risk of cervical airway obstruction.

Securing the airway to provide anaesthesia during these surgeries is a challenge as the anaesthesiologist must share the airway with the surgeon. A conventional surgical airway such as a tracheostomy can always be used, but it could be associated with life-threatening complications.[4],[5],[6],[7]

Submental endotracheal intubation has been described as a useful alternative to tracheostomy with minimal complications in these circumstances.[8],[9],[10],[11] Nasotracheal intubation is not recommended in the presence of a panfacial fracture, cervical spine injury, skull base fracture with or without cerebrospinal fluid rhinorrhoea, systemic coagulation disorders, distorted nasal anatomy and when nasal packing is indicated.[12] Nasotracheal intubation may be impossible as deformity or fracture of nasal bones, cribriform plate of the ethmoid or naso-orbital ethmoid complex is often associated. Potential complications of nasotracheal intubation are mucosal dissection, injury to adenoids, meningitis, sepsis, sinusitis, epistaxis, dislodgement of bony fragments and obstruction of the tube by the distorted airway anatomy or rarely intracranial intubation. In 1983, Bonfils first documented the use of the retromolar space for endotracheal intubation. Patients with Le Fort II fracture having both occlusive changes and disruption of nasal architecture are potential candidates for retromolar intubation.[13] Retromolar intubation is a comparatively less invasive and time-efficient technique, but the retromolar space should be adequately big to accommodate the endotracheal tube.

Contraindications for submental intubation include patient refusal, bleeding diathesis, laryngotracheal disruption, infection at the proposed site, long-term airway maintenance and history of keloid formation.[14],[15]

Procedure for submental intubation

In 1986, Hernandez described the technique of submental intubation. It consisted of passing the endotracheal tube through the anterior floor of the mouth to allow free intraoperative access to dental occlusion and to the nasal pyramid without endangering patients with skull base trauma. To perform submental endotracheal intubation, the patient is first intubated orally using a flexometallic endotracheal tube of internal diameter 7.5–8.5 mm.[9],[16],[17] A 1.5-cm skin crease incision is made in the submental region, just medial to the lower border of the mandible, approximately one-third of the way from the symphysis to the angle of the mandible. A closed medium-sized artery forceps is then introduced into the submental incision, and blunt dissection is carried out towards the floor of the mouth. The muscular layers, namely platysma and mylohyoid muscles, are traversed using a curved artery forceps that is always kept in close contact with the lingual cortex of the mandible. The mouth is opened and the tongue is elevated in a posterosuperior direction with a tongue depressor, exposing the ventral surface of tongue and floor of mouth. The universal connector is removed, and the pilot cuff is deflated and pulled out through the path made by the artery forceps. The artery forceps is then quickly reinserted through the submental incision to grasp the machine end of the flexometallic tube which is also pulled out through the same path created in the floor of the mouth. The connector is then reattached, the cuff is reinflated and the tracheal tube is reconnected to the breathing circuit. The position of the tracheal tube is checked using capnography and chest auscultation. A careful note is made of the distance marking on the tube at the skin exit site. The tube is then secured to the skin of the submental region with a heavy (2/0) black silk suture [Figure 1]. The surgeon then proceeds with the scheduled surgical procedure. At the end of the surgical procedure, anaesthesia is discontinued, and all patients are converted back to the oral route of intubation and the submental incision is sutured.
Figure 1: Submental tube anchored in place by a 2/0 black silk suture

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[Table 1] shows the demographics of 25 patients and details of submental intubation including complications. With the exception of 2 patients in whom the saturation dropped to 95%, all other patients maintained their saturation at 100%. Eight patients had complications as noted. In one patient, while changing the tube from submental to orotracheal route, the patient was accidentally extubated before reversal of anaesthesia but was immediately intubated with oral tube without any complication or fall in saturation. Complications associated with submental intubation have included superficial wound infection, orocutaneous fistula, tracheal tube compression and increased airway pressure.[18] Damage to or dislodgement of endotracheal tube, entrapment of pilot balloon, accidental extubation, venous bleed and mucocoele have also been reported.
Table 1: Patient demographics (n=25) and details of submental intubation including complications

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  Discussion Top

This technique provides a secure airway while at the same time allowing an unobstructed surgical field for adequate reduction and fixation of midface and panfacial fractures. Submental tracheal intubation also avoids the potential complications associated with nasal intubation and tracheostomy and obviates the need for a tube change during the operation.

Dangers of nasotracheal intubation in the presence of midfacial and skull base fractures, epistaxis and trauma to the pharynx are avoided. Early complications associated with tracheostomy including bleeding, subcutaneous or mediastinal emphysema, cardiac arrest caused by stimulation of the vagus nerve, post-hypercapnic shock due to sudden lowering of the carbon dioxide level (in obstructed airway) and air embolism and late complications such as recurrent laryngeal nerve damage and laryngeal or tracheal stricture and tracheo-oesophageal fistula are avoided. A common complication that occurred in five of our patients was the formation of a double track while passing the artery forceps through the floor of mouth to pull out the tube. This caused the pilot balloon and cuff inflating channel to get entrapped, resulting in inability to inflate the cuff. In these patients, we had to pass the tube back into the mouth and then after proper dissection, converting again to the submental route. In one patient, we had to convert twice to the orotracheal route, and we succeeded in the third attempt with proper placement of both tube and cuff. After facing this problem repeatedly in our initial ten cases, we came to the conclusion that the artery forceps should remain closed while within the floor of mouth and should be opened only when it comes out through the floor of mouth. The opened artery forceps should then be sequentially used to bring out the cuff-inflating tube first followed by the endotracheal tube.

  Conclusion Top

Submental tracheal intubation is a useful alternative for airway management in selected patients with complex craniomaxillofacial injuries. It has a low morbidity and avoids some of the complications associated with nasal intubation and tracheostomy, while allowing unimpeded surgical access to the oral cavity and midface. It also avoids the need for a tube change halfway through the operation if an oral tracheal tube was used initially. Effective communication is essential, however, between the surgical and anaesthesia teams to minimise any potential complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Drugs and equipment were provided to the hospital by the Gujarat State Government.

Conflicts of interest

There are no conflicts of interest.

  References Top

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Barak M, Bahouth H, Leiser Y, Abu El-Naaj I. Airway management of the patient with maxillofacial trauma: Review of the literature and suggested clinical approach. Biomed Res Int 2015;2015:724032.  Back to cited text no. 3
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  [Figure 1]

  [Table 1]


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