Retrograde submental intubation assisted with direct video laryngoscopy in maxillofacial trauma: technical note and case report / Intubación submentoniana retrógrada asistida con videolaringoscopía en trauma maxilofacial: nota técnica y reporte de caso

The management of a difficult airway is one of the biggest challenges of perioperative anesthesia management. The maxillofacial trauma can cause serious disturbances of the soft and hard tissues of the anatomical components of the upper airway and often with little external evidence of deformity. The submental intubation is a procedure that was reported to avoid tracheostomy and allow for the concomitant restoration of occlusion and reduction of facial fractures in patients with craniomaxillofacial trauma ineligibles for nasotracheal intubation. We described a modification of the original technique by performing a retrograde submental intubation assisted by direct laryngoscope video in a maxillofacial trauma patient with restricted mouth opening. In addition, the surgical anatomy of the technique is detailed described.

El manejo de una vía aérea difícil es uno de los mayores desafíos del manejo anestésico perioperatorio. El trauma maxilofacial puede causar serias alteraciones a los tejidos blandos y duros de la vía aérea superior, y muchas veces con pequeña evidencia externa de deformidad. La intubación submentoniana es un procedimiento que fue reportado para evitar la traqueostomía y permitir la concomitante restauración de la oclusión para la reducción de fracturas faciales en pacientes donde la intubación nasotraqueal está contraindicada. Describimos una modificación de la técnica original, realizando una intubación submentoniana retrógrada asistida con videolaringoscopio en un paciente de trauma maxilofacial con apertura de la cavidad disminuida. Adicionalmente se describe detalladamente la anatomía quirúrgica de la técnica.

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

OBJECTIVES: To 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 METHODS: Submental 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. RESULTS: In 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. CONCLUSION: Submental 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.

Submental Intubation in Panfacial Trauma Patient: A Case Report

Submental Intubation with Reinforced Tube for Intubating Laryngeal Mask Airway

Submental endotracheal intubation is a simple and secure alternative to either nasoendotracheal intubation or a tracheostomy in the airway management of maxillofacial trauma. However, a submental endotracheal intubation is quite difficult to manage if adverse events such as a tube obstruction, accidental extubation, or a leaking cuff with the endotracheal tube in the submental route occur, which could endanger the patient. This paper describes the use of a LMA-Fastrach (TM) ETT in the submental endotracheal intubation of patients suffering from maxillofacial trauma. One of the patients was a 16-year-old male, and the other was a 19-year-old male. They were scheduled for an open reduction and internal fixation of the maxillofacial fracture including naso-orbital-ethmoidal (NOE) complex, and a zygomaticomaxillary complex fracture. A submental intubation with a LMA-Fastrach (TM) ETT was performed in both cases, and the operation proceeded without any difficulties. These cases show that the use of the LMA- Fastrach (TM) ETT can improve the safety and efficacy of submental endotracheal intubation. This is because the LMA- Fastrach (TM) ETT has a freely detachable connector, and is flexible enough to keep the patency despite the acute angle of airway.

Management of Detachment of Pilot Balloon During Intraoral Repositioning of the Submental Endotracheal Tube

Submental endotracheal intubation for surgery was used as an alternative to nasotracheal intubation in patients with craniomaxillofacial injury. Generally extubation was performed in the operation room by pulling the tube through the submental incision site. When extubation is not indicated, intraoral indwelling is preferred to submental intubation. We report a case of a 35-year-old male patient with multiple facial bone fractures. At the end of the surgery, we noticed the oropharyngeal edema, and so the submental intubation was converted into a standard orotracheal intubation. During that procedure, the pilot balloon was accidentally detached from the endotracheal tube. The situation was managed by cutting a pilot tube from a new, unused endotracheal tube and connecting it to the intubated tube using a needle connector.

A clinical consideration of submental intubation at oral and maxillofacial surgery

Submental Orotracheal Intubation for Maxillofacial Surgery: A case report / 대한마취과학회지

Airway management for patients who have suffered multiple facial fractures and skull base fractures is complicated. Nasal intubation can interfere with centralization and stabilization of nasal fractures and may lead to cranial intubation. Restoring the dental occlusion by means of intraoperative maxillo- mandibular fixation is a prerequisite to the corrrect anatomical reduction of multiple facial fractures. This fixation precludes oral endotracheal intubation. In the past, it has been overcome by a tracheostomy. Complications of a tracheostomy include infection, hemorrhage, subcutaneous emphysema, pneumothorax, pneumomediastinum, recurrent laryngeal nerve damage, tracheal stenosis, and tracheoesophageal fistula. The technique of submental intubation was originally described by Altemir. This technique provide secure airway, an unobstructed intraoral airway field. and allows maxillomandibular fixation while avoiding the drawbacks and complications of naso-endotracheal intubation or tracheostomy. With this technique, the multiple facial fractures were corrected successfully.

Submental Intubation with a Reinforced Tube for an Intubating Laryngeal Mask Airway (ILMA) / 대한마취과학회지

Nasotracheal intubation, when performed after craniomaxillofacial trauma, may result in the passage of the tube into the cranium, causing significant brain damage. Orotracheal intubation may be preferred, but interferes with the placement of intermaxillary fixation. To avoid these problems, a tracheostomy may be an alternative but it carries significant morbidity. The submental route for endotracheal intubation has been proposed as an alternative to a tracheostomy in the surgical management of craniomaxillofacial trauma. Ideally, this maneuver is performed by using a reinforced tube. Unfortunately, however, some reinforced tracheal tubes are manufactured with nondetachable connectors. Removing them forcefully may be possible, but they will then stay dangerously loose after reconnection. We report a case in which a standard oral Ring-Adair-Elwyn (RAE) tube and reinforced tube for ILMA was used so not to be loose after the reconnection.