Submental Intubation as an Alternate Technique to Tracheotomy in the Treatment of Maxillofacial Traumatic Injuries
Complex maxillofacial injury precluding nasal intubation and requiring maxillomandibular fixation presents a significant problem with regards to airway access and management. Therefore these patients require alternative approaches to safe airway management including the gold standard of tracheotomy. However, tracheotomy comes with significant risks. In a recent review of tracheotomies performed by Carlson et al, a complication rate of 16% was reported from 192 cases. These complications included bleeding (intra and post operative), tracheoesophageal fistulas (1%) and other rare complications including respiratory distress (0.5%). However, no trachea-innominate fistulas were reported. Thus for patients not requiring long term ventilatory support, submental intubation is investigated as a safe non-permanent alternative airway access.
Study Method:
This study was a retrospective review of all patients admitted for maxillofacial trauma that precluded nasal or oral intubation for surgical repair at the Hospital of University of Pennsylvania from August 2009 to April 2012. Data collected include type of airway accessed for surgical repair of facial injuries, etiology of injury, and complication resulting from submental intubation.
Results:
A total of 19 patients with maxillofacial trauma that precluded nasal or oral intubation were identified. Six patients (32%) underwent submental intubation as a surrogate for tracheotomy in the treatment of maxillofacial trauma. The surgeries were performed by two surgeons (one completed four of the cases and the other two of the cases). The technique employed for submental intubation was similar to the technique described by Altemir in 1986. Etiology of the facial injuries included falls, blunt trauma to the maxillofacial skeleton, and motor vehicle accidents. Of the six included patients there were no complications during or after the procedure including accidental extubation, damage to the sublingual duct or floor of mouth structures, sublingual hematoma, damage to the lingual nerve, post-operative dysphagia, infection, massive bleeding, or wound failure.
Conclusion:
Submental intubation may provide a safe alternate technique for patients with complex maxillofacial injuries that cannot undergo oral or nasal intubation and allows them to avoid the m morbidity and mortality of tracheotomy if they do not require long term ventilator support.
References:
- Altemir FH. The submental route for endotracheal intubation. J Maxillofac Surg. 1986; 14:64-65.
- Carlson, E.R., Oreadi, D., Morbidity and mortality associated with tracheotomy procedure in a university medical centre. Int. J. Oral Maxillofac. Surg. 2012; 41: 974– 977.