Submental Intubation in Maxillofacial Surgery

Submental intubation was originally reported by Francisco Hernández Altemir in 1986. It presents undeniable advantages and near zero morbidity in comparison to tracheostomy in facial trauma patients. This technique is as an alternative airway maneuver for maxillofacial procedures. This method was recently implemented in the case of a patient with altered nasal anatomy who sustained a mandibular fracture necessitating maxillomandibular fixation. Indications for submental intubation are: Craniofacial traumatic injuries; Minimal neurologic deficit; Short-term intraoperative intermaxillary fixation required to establish reduction and rigid fixation of fractures; Large pharyngeal flaps; And combined bimaxillary orthognathic surgeries and rhinoplasty cases. Its contraindications are: Patients with multisystem trauma; Long-term airway maintenance support required; Severe keloid previous knowledge; and severe neurological deficits. It provides a secure airway and no interference with maxillomandibular fixation or access to naso-orbito-ethmoid fractures. It avoids potential complications associated with nasotracheal intubation and tracheostomy in patients with multiple facial fractures, and obviates the need to alternate between oral and nasal intubation intraoperatively. Submental intubation is a safe, effective technique for many maxillofacial procedures, requiring the cooperation of both anesthesiologists and maxillofacial surgeons, and it can be used in cases of pan facial fractures, when oral/nasotracheal intubation is contraindicated, and the tracheostomy it is not possible , due to post operatory complications. Although this technique demands some surgical skill, the learning curve is not very steep and it is simple and easy to learn. No specialized equipment is needed, which makes it even more acceptable. Since 1986, this technique has been modified; this procedure consists of exteriorizing an oral endotracheal tube through the floor of the mouth and submental triangle. The original surgical protocol dictates a 2 cm incision in the submental, paramedial region extending cephalad, the lingual mucosa is tented with a hemostat after which another 2 cm incision parallel to the mandible is made in the lingual gingivae. The breathing circuit is briefly disconnected as the tube is externalized through the submental region and reconnected to the circuit and secured to the patient. The aim of this study is to show the efficiency of submental intubation in the cases performed in the maxillofacial and oral surgery service. From August 2015 to March 2016, four patients with facial fractures underwent this submental intubation, in São Vicente Hospital, Passo Fundo, RS, Brazil. By using this technique, it was possible to reestablish the dental occlusion, and reduce all facial fractures in just one surgery, with no tube interference. All patients presented an acceptable post-operatory evolution, and there were no intercurrences. It can be concluded that submental intubation allows the surgeon and the anesthesiologist a comfortable, control LED airway maneuver and the possibility to reestablish dental occlusion. It provides an unobstructed intraoral surgical field, avoids intraoperative and postoperative complications of tracheostomy, and overcomes the disadvantages of naso-tracheal intubation. The surgeon and the anesthesiologist should have alternative techniques of intubation in order to restore aesthetics, function, and dental occlusion and perform the reduction and fixation of all facial fractures at the same surgical time with lower morbidity.

References:

1. Eisemann B, Eisemann M, Rizvi M, Urata MM, Lypka MA: Defining the role for submental intubation. Journal of Clinical Anesthesia. 2014 Jan 1;26(3):238-242. Available from: 10.1016/j.jclinane.2013.09.009

2. Jaisani MR, Pradhan L, Bhattarai B, Sagtani A: Intubation Techniques: Preferences of Maxillofacial Trauma Surgeons. J Maxillofac Oral Surg. 2015 Jun;14(2):501-5. doi: 10.1007/s12663-014-0679-8. Epub 2014 Aug 26.

3. O’Connell, JE, Kearns, GJ: Submental intubation: a retrospective review of 45 cases. Ir J Med Sci (2013) 182:309–313

4. Prakash VJ, Chakravarthy C, Attar AH: Submental/Transmylohyoid Route for Endotracheal Intubation in Maxillofacial Surgical Procedures: A Review. Journal of International Oral Health 2014; 6(3):125-128