|Year : 2014 | Volume
| Issue : 1 | Page : 27-32
Evaluation of submental approach for oro-endotracheal intubation in maxillofacial trauma
Kunal Pravin Kothari, Sanjay S Rao, Shridar D Baliga
Department of Oral and Maxillofacial Surgery, KLE VK Institute of Dental Sciences, Belgaum, Karnataka, India
|Date of Web Publication||2-Jul-2014|
Kunal Pravin Kothari
Department of Oral and Maxillofacial Surgery, KLE VK Institute of Dental Sciences, JNMC Campus, Nehru Nagar, Belgaum - 590 010, Karnataka
Source of Support: None, Conflict of Interest: None
Introduction: In maxillofacial injuries, a choice has often to be made between different ways of intubation when surgical access to fractured nasal bone and simultaneous establishment of occlusion are required. We report our experience with submental intubation in the airway management of complex maxillofacial trauma patients and complication associated with it. The aim is to evaluate the outcome of airway management in patients with complex maxillofacial trauma by submental intubation.
Materials and Methods: Fifteen cases reporting to the Department of Oral and Maxillofacial Surgery of a tertiary care hospital, with multiple facial trauma from September 2011 to September 2013 were selected for study. Median submental intubation was performed. Follow-up during hospitalization for wound associated complication and 3 months postoperatively was done.
Results: At the end of the procedure, all 15 patients were extubated without any complications. Postoperatively, only one patient presented with superficial infection of the submental wound.
Conclusion: Submental endotracheal intubation is a simple technique with very low morbidity and can be used as an alternative to tracheostomy in selected cases of maxillofacial trauma.
Keywords: Submental endotracheal intubation, tracheostomy, maxillofacial trauma
|How to cite this article:|
Kothari KP, Rao SS, Baliga SD. Evaluation of submental approach for oro-endotracheal intubation in maxillofacial trauma
. Indian J Health Sci Biomed Res 2014;7:27-32
|How to cite this URL:|
Kothari KP, Rao SS, Baliga SD. Evaluation of submental approach for oro-endotracheal intubation in maxillofacial trauma
. Indian J Health Sci Biomed Res [serial online] 2014 [cited 2020 Jan 27];7:27-32. Available from: http://www.ijournalhs.org/text.asp?2014/7/1/27/135030
| Introduction|| |
Trauma is one of the most serious health care problems faced in today's world.  India too, has been observing an alarming increase in high impact trauma, resulting in multiple maxillofacial as well as other orthopedic injuries. ,
In maxillofacial surgery, general anesthesia is usually administered via the oral or nasal routes.
In patients with severe maxillofacial trauma involving multiple bones, both oral and nasal routes of intubation become difficult, while, nasal route may even give rise to number of complication such as cranial intubation, trauma to the pharynx, sinusitis, etc., ,
The alternative to orotracheal intubation significantly impedes maneuvers for reduction and stabilization of jaws, which often require intermaxillary fixation. As a result, some specialists consider tracheostomy as preferred route for airway management. ,
However, in spite of its widespread application tracheostomy is accompanied by severe morbidity such as subcutaneous emphysema, pneumomediastinum pneumothorax, tracheal stenosis, injury to recurrent laryngeal nerve etc. ,,,,
Despite being one of the most common surgical procedures, tracheostomy has a 14-45% complication rate documented in literature and its use should be judiciously considered. 
The other options include blind and retrograde intubations which share the same limitation as of naso or oro tracheal intubation. The submental intubation was hence developed to overcome difficulties encountered during the established methods of intubation. Its advantages include that it is simple procedure with low morbidity. ,
Altemir gave the technique of submental intubation as an alternative airway to orotracheal/nasotracheal intubation and tracheostomy in 1986. ,
Hence, with the intention of making all maxillofacial surgical procedures including nasoethmodial complex involved surgeries easier and to avoid tracheostomy, the submental route is the preferred method of endotracheal intubation.
| Materials and Methods|| |
Fifteen cases reporting to the Department of Oral and Maxillofacial Surgery, KLE's, Dr. Prabhakar Kore Hospital, Belgaum with multiple facial trauma were selected for study.
Pretext proforma was used for data collection for each patient.
Criteria for selection of patient
- Multiple craniomaxillofacial traumatic injuries
- Tube interference with surgical intra-oral manipulation and maxilllomandibular fixation.
- Long-term airway management and maintenance if required
- Patients with severe neurologic damage or major thoracic trauma.
The procedure with its advantages, disadvantages and possible complication were explained to the patients. Written informed consent was obtained from the patients or their close relatives.
Orotracheal intubation was accomplished and the tube was secured temporarily with help of tissue plaster. Surgical skin preparation of the perioral and submental region was performed with savlon and betadine and draped with sterile towels.
The midline of face and chin was marked with skin marking pencil. The proposed line of incision in submental crease was marked, approximately 1-1.5 cm in length, or slightly greater than the diameter of tube. Surgical site was infiltrated with local anesthetic solution containing 2% lignocaine with 1:80,000 adrenaline.
Skin and subcutaneous connective tissue were incised in median submental region. The muscular layers, that is, platysma and mylohyoid muscles were traversed using curved artery forceps that was always kept in close contact with the lingual cortex of the mandible.
Mouth was opened and tongue elevated in superio-posterior direction with tongue depressor, exposing ventral surface of tongue and floor of mouth. A strict midline plane was maintained.
The curved artery forceps was then used to bluntly breach the mylohyoid muscle and forcep was readily passed into oral cavity using a palpating finger as a guide.
With the curved hemostat, the armored tube cuff was passed extra-orally. Then, the armored tube was disconnected and connector was removed. The tube was grasped by hemostat and delivered through submental incision and reattached to anesthetic equipment.
The tube was secured to the skin of submental region with 1.0 black silk suture. The proposed surgical procedure was accomplished and at termination of surgical procedure endotracheal tube (ETT) was passed back intra-orally in the reverse order (first the tube, then the tube cuff) through submental incision into mouth and secured back to anesthetic equipment [Figure 1].
Now closure was done in layers with 3.0 vicryl suture and skin closure with 4.0 ethylon suture of submental wound and the intra-oral incision left to heal secondarily [Figure 2].
Extubation was done normally through oral route.
Follow-up during hospitalization for wound associated complication and 3 months postoperatively done for scar evaluation.
| Results|| |
A total of 15 patients reported with multiple facial fractures to Department of Oral and Maxillofacial Surgery, K.L.E's, Dr. Prabhakar kore hospital, Belgaum from 2011 to 2013 as shown in [Table 1].
All patients were male, with age ranged from 19 to 59 years.
The etiology of fractures in 14 patients was road traffic accidents and was fall from height in one.
All patients had severe midface fractures, while 10 patients had associated mandibular fracture. Among mandibular fractures seven had parasymphysis, two symphysis and one body fracture. All patients were treated with open reduction and internal fixation for various fractures.
Intra-operative maxillomandibular fixation was accomplished in all the cases. A good reduction and fixation was achieved in all patients.
No intra-operative complication was noted.
There were no episodes of arterial desaturation while converting oral intubation to submental intubation and vice versa. Care was taken not to damage pilot balloon and ETT connector could be easily removed and reattached firmly.
During the procedure, no difficulty was encountered in passing the tube through the floor of mouth.
Fourteen patients showed good postoperative healing without complication. One patient developed infection at submental wound during hospital stay.
Patients were followed-up during hospital stay and after period of 3 months which showed undectable scar in submental region. All fracture sites had healed well and excellent esthetics were achieved. The submental scar was imperceptible in all patients except on close observation with neck hyper-extended [Figure 3].
| Discussion|| |
Road traffic accidents have been the most frequent cause of facial fractures. Studies in the last decade have shown that road traffic accidents are the most common cause of injuries in India. , Severe facial injuries are dealt under general anesthesia.  General anesthesia is administered by nasal or oral ETT for the management of maxillofacial trauma. The method of orotracheal intubation significantly impedes any maneuvers for reduction and stabilization of jaws, which often require the placement of intermaxillary fixation. In most fractures, this is an essential guide to optimal fracture reduction and fixation. , An alternative of orotracheal intubation is nasoendotracheal intubation.
Several recent publications have dealt with the dangers of nasoendotracheal intubation in the presence of midfacial and basilar skull fractures. , Lefort II and III facial fractures which involve the cribriform plates pose the greatest potential for untoward effects from nasoendotracheal intubation. Among the complications are cranial intubation, epistaxis, and trauma to the pharynx, pressure necrosis of the external nares, otitis media, and avulsion of turbinate bones, sepsis and inability to pass a tube through the nasal passage. ,
Zmyslowski stated basilar skull fractures to be a contraindication to nasotracheal intubation, because of the potential for passage of the tracheal tube into the cranial vault. He also pointed out trauma to the pharynx or adenoid tonsils to be a potential complication of nasotracheal intubation in addition to the ones already mentioned above. These potential complications in patients with Lefort II and III as well as nasoethmoidal complex fractures have been raised as relative contraindications to nasoendotracheal intubation for acute airway management in this group of patients. 
Consequently, some specialists consider tracheostomy as the preferred route for airway management. ,, However, tracheostomy may be accompanied by severe morbidity such as infection, hemorrhage, subcutaneous emphysema, pneumothorax, pneumomediastinum, recurrent laryngeal nerve damage, tracheal stenosis, disruption of posterior tracheal wall and tracheoesophageal fistula ,,, blockage of tracheostomy cannula, tracheitis, cellulitis, pulmonary atelectasis, tracheocutaneous fistula, stomal and respiratory tract infection, tracheal stenosis, tracheal erosions, dysphagia, problems with decanulation, excessive scarring and requires careful surgical and perioperative management.  Tracheostomy may also result in severe bleeding and cardiac arrest secondary to hypoxia. Mark stated that major operative bleeding occurs in approximately 5% of patients undergoing standard tracheostomy. 
Ayesha gave advantages of sub-mental technique over tracheostomy:
- Early extubation after operation
- Avoiding the cumbersome task of postoperative tracheostomy tube care
- Avoidance of possible known complications of tracheostomy tube. 
There have been several attempts to achieve short term airway management, including retromolar intubation and laterosubmental intubation. ,, Petr Schutz described retromolar intubation without this additional surgical intervention, which is consider objectionable, is feasible only rarely and in short, uncomplicated procedures. In patients with multiple facial fractures, the presence of the oral tube is awkward and there is always a risk of dislodgment, especially if a change in head position is required during surgery. 
The laterosubmental approach for endotracheal intubation first described by Altemir in (1986), offered a safe alternative to tracheostomy when it is difficult or impossible to perform oral or nasotracheal intubation. This technique was introduced with the intention of avoiding tracheostomy and making surgical work easier in chosen cases, thus removing the possibility of the tubes interfering with the oral and maxillofacial territory. The possible complications of this technique are:
- Infection in the floor of the mouth
- Risk of submental fistulae and anomalous scars occurring if submental intubation is excessively prolonged
- Damage to important structures of the floor of the mouth. 
MacInnis and Baig found this technique less than satisfactory due to bleeding, difficult tube passage and sublingual gland involvement. They modified the technique to utilize a strict midline approach. They performed 15 midline submental intubation procedures: Fourteen cases of craniomaxillofacial trauma and one elective maxillofacial reconstruction case. No complications with surgical procedure, anesthesia or postoperative recovery period were encountered. Postoperative esthetic complaints have not occurred. Submental scarring was undetectable in all cases except upon close inspection with the chin hyper-extended. 
A review of literature reveals that the Altemir's original technique which has been modified can be divided into anatomical and anesthetic modifications. 
Anatomical modification includes the variation in path of exit of the ETT. MacInnis and Baig found the laterosubmental approach was less satisfactory because of difficulty in tube passage, bleeding, and sublingual gland injury and thus preferred the submental incision in the midline. However, the midline approach can traumatize the Wharton's duct, interfere with attachment of the genioglossus and geniohyoid muscles. 
Anesthetic modifications have been given by Green and Moore the first secured the airway with orotracheal intubation, then passed the reinforced ETT through the submental wound into the oral cavity and substituted the reinforced tube in place of the conventional oral tube after withdrawal of the oral tube.  Laryngeal mask can be used with the technique in patients with laryngeal trauma, unstable cervical fracture, and in voice professionals. 
A careful analysis of the anatomy of the anterior floor of the mouth indicated that, if a strict midline approach to submental intubation was adhered to, all major anatomical structures including Whartons duct, lingual nerves and sublingual glands could be avoided. Moreover, there is minimal vascularity in the midline as opposed to the hemorrhage encountered in the lateral sulcus approach. , According to Gadre and Kushte remaining in contact with the lingual cortex of the mandible, the protection of lingual nerve, the submandibular duct, and mandibular branch of the facial nerve is guaranteed. Furthermore remaining anterior to the masseter muscle guarantees protection to the facial artery.  Same findings were noted in our study.
Christophe made some technical points, making the procedure easier, need to be emphasized: In order to facilitate passage of the tube through the floor of the mouth, it is advisable to disconnect. The simplest way is to use a Mallinckrodt tube (Safety-Flex, Mallinckrodt Medical, Athlone, Ireland) where the connection tube is removed from its setting before it is passed through. This connection tube has then to be replaced, by another with a bigger diameter to avoid air leaks. Another possibility is to use a tube of the Fastrach system (The Laryngeal Mask Company Ltd., Henley on Thames, Oxon, UK) where the connection tubes are detachable. 
As the passage of the tube is done in two stages (the tube cuff and then the tube itself) one must take care not to create two tracks. This would lead to difficulties in positioning the tube during the operation and to its blockage during extubation. 
We treated 15 cases of panfacial trauma using submental intubation of which all were followed-up at the end of 3 months. All the cases healed without complications. Infection of submental wound was noted in one case postoperatively during hospital stay. The wound was cleaned twice a day with hydrogen peroxide and saline and then with betadine. The healing was achieved within 4-5 days. The submental scarring in all the cases was imperceptible except upon close observation with neck hyper-extended. The intra-oral wound healed atraumatically in all the cases. All the patients were extubated in the immediate, postoperative period. Hence, the effects on long term airway support were not judged.
| Conclusion|| |
Analyzing the results obtained from this study the following conclusions were made.
- According to the literature and our own experience, submental endotracheal intubation is a simple technique with low morbidity
- The technique with no specialized equipment or technical expertise required gives unique advantage over other techniques used to avoid tracheostomy
- It combines the advantages of the nasotracheal intubation and orotracheal intubation by allowing access to the interdental occlusion and nasal pyramid, respectively
- It presents a low incidence of operative and postoperative complications and eliminates the risks and side effects of tracheostomy. Thus, it can be used as an alternative to tracheostomy in selected cases of maxillofacial trauma, where nasotracheal and orotracheal intubation is impossible or contraindicated and long-term ventilation support is not required.
Hence, it is concluded that the submental intubation is a simple, safe, and effective technique of intubation in cases of maxillofacial trauma.
| References|| |
|1.||Vincent RL, Shepherd JP. Maxillofacial Injuries. 2 nd ed., Vol. 2. Edinburgh: Churchill Livingstone; 1994. p. 1053. |
|2.||Marya CM, Ashok K, Kottrashetti SM. Maxillofacial injuries and changing treatment modalities. Indian J Oral Maxillofac Surg 1997;12:25-28. |
|3.||Gordon NC, Tolstunov L. Submental approach to oroendotracheal intubation in patients with midfacial fractures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;79:269-72. |
|4.||Shenoi RS, Badjate SJ, Budhraja NJ. Submental orotracheal intubation: Our experience and review. Ann Maxillofac Surg 2011;1:37-41. |
|5.||Green JD, Moore UJ. A modification of sub-mental intubation. Br J Anaesth 1996;77:789-91. |
|6.||Crysdale WS, Forte V. Posterior tracheal wall disruption: A rare complication of pediatric tracheotomy and bronchoscopy. Laryngoscope 1986;96:1279-82. |
|7.||Orringer MB. Endotracheal intubation and tracheostomy: Indications, techniques, and complications. Surg Clin North Am 1980;60:1447-64. |
|8.||Schütz P, Hamed HH. Submental intubation versus tracheostomy in maxillofacial trauma patients. J Oral Maxillofac Surg 2008;66:1404-9. |
|9.||MacInnis E, Baig M. A modified submental approach for oral endotracheal intubation. Int J Oral Maxillofac Surg 1999;28:344-6. |
|10.||Hernández Altemir F. The submental route for endotracheal intubation. A new technique. J Maxillofac Surg 1986;14:64-5. |
|11.||Adeyemo WL, Ogunlewe MO, Desalu I, Akanmu ON, Ladeinde AL. Submental/transmylohyoid intubation in maxillofacial surgery: Report of two cases. Niger J Clin Pract 2011;14:98-101. |
|12.||Zmyslowski WP, Maloney PL. Nasotracheal intubation in the presence of facial fractures. JAMA 1989;262:1327-8. |
|13.||Mohiuddin A, Shabir A. Case report - Submental intubation in extensive maxillofacial trauma. Anaesth Pain Intensive Care 2010;15:182-4. |
|14.||Gadre KS, Waknis PP. Transmylohyoid/submental intubation: Review, analysis, and refinements. J Craniofac Surg 2010;21:516-9. |
|15.||Meyer C, Valfrey J, Kjartansdottir T, Wilk A, Barrière P. Indication for and technical refinements of submental intubation in oral and maxillofacial surgery. J Craniomaxillofac Surg 2003;31:383-8. |
[Figure 1], [Figure 2], [Figure 3]