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ORIGINAL ARTICLE
Year : 2015  |  Volume : 29  |  Issue : 1  |  Page : 23-25

Submental intubation: A solution for anesthetic dilemma in mid- and panfacial fractures


1 Department of Plastic Surgery, Assam Medical College, Dibrugarh, Assam, India
2 Department of Plastic Surgery, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
3 Department of Plastic Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India

Date of Web Publication17-Jun-2015

Correspondence Address:
Prof. Pradeep Jain
Department of Plastic Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi - 221 005, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-4958.158925

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  Abstract 

Introduction: Faciomaxillary injuries are very common following trauma, specifically following road traffic accidents. Many a time, those injured present with panfacial fractures. Such patients need urgent surgical attention for stabilization and fixation of the fractures. Materials and Method: The patient is intubated by oral route in the conventional manner with an armored tracheal tube as the first step. This tube is taken out externally via a mucosal incision in the floor of mouth and submental incision and connected with the ventilator. The cuff is inflated and the tube is secured with the suture with the skin. The skin and the mucosal incisions are closed. Discussion: Securing the endotracheal tube during the operation for patients with panfacial fracture without coming in the way of oral procedure always poses a problem for the anesthetist. Fracture of the base of the skull or the naso-orbital ethmoid complex excludes the option of nasal intubation, while oral intubation would prevent the surgeon from obtaining a proper occlusion. In these circumstances, submental intubation is a simple and safe procedure that can be carried out. However, if a patient needs prolonged intubation even after surgery due to upper respiratory obstruction, tracheostomy remains the procedure of choice. Conclusion: Submental intubation is helpful in allowing the surgeon to operate intraorally and ensure proper dental occlusion in patients with panfacial fractures.

Keywords: Panfacial fracture, Retromolar intubation, Submental intubation


How to cite this article:
Deka D, Jain V, Dutta P, Goswami P, Jain P. Submental intubation: A solution for anesthetic dilemma in mid- and panfacial fractures. J Med Soc 2015;29:23-5

How to cite this URL:
Deka D, Jain V, Dutta P, Goswami P, Jain P. Submental intubation: A solution for anesthetic dilemma in mid- and panfacial fractures. J Med Soc [serial online] 2015 [cited 2019 Dec 14];29:23-5. Available from: http://www.jmedsoc.org/text.asp?2015/29/1/23/158925


  Introduction Top


The rising interest in high-speed automobiles among young people and associated reckless driving have resulted in a high incidence of faciomaxillary injuries, with a preponderance of complex midfacial and Panfacial fractures. These patients need urgent surgical attention in the form of reduction, stabilization, and fixation of the fractures to prevent ocular complications and for proper occlusion, which is essential. However, securing the airway during the operation for these multiple facial fractures always poses a problem for the anesthetist. While a fracture of the base of the skull or the naso-orbitalethomoid complex excludes the option of nasal intubation, oral intubation prevents the surgeon from obtaining a proper occlusion, which is mandatory before fracture fixation can be achieved. In these circumstances, submental intubation is a simple and safe procedure that can be carried out. However, if the patient needs prolonged intubation even after surgery due to upper respiratory obstruction, intubation through tracheostomy remains the procedure of choice.

At our institution, we prefer to perform submental intubation in patients who need fixation of both the mandible and maxilla and in panfacial fractures. It is very safe, quick, and devoid of any complications. Though injury to submandibular or sublingual salivary glands and the occurrence of orocutaneous fistula are described in the literature, we have never faced such complications.


  Materials and Methods Top


Surgical technique

The first step in the procedure is to intubate the patient by oral route in the conventional manner with an armored tracheal tube [Figure 1]a. An ordinary PVC tube should not be used as it kinks very often. Our aim is to take out the tube externally via a submental incision. Taking all aseptic precautions, a 1.5-2 cm-long incision is made in the submental region parallel and just medial to the inferior border of the mandible. This long incision is sufficient to take out the endotracheal tube comfortably. After making the skin incision, a long, curved artery forceps is introduced through it. A tunnel is made keeping the direction toward the floor of the mouth. One must be careful not to injure asubmandibular or sublingual salivary gland, salivary duct, or lingual nerve. To avoid injury to these structures, it is necessary to keep the forceps close to the inner surface of mandible. An incision is made in the oral mucosa of the floor of the mouth tented over the tip of the forceps. The endotracheal tube is now disconnected and taken out along with the tube cuff through the tunnel by holding it together with the artery forceps. It is now reconnected with the ventilator, the cuff is reinflated, and itis secured with suture with the skin [Figure 1]b and [Figure 2].
Figure 1:Submental intubation.(a) Oral intubation in the first stage(b) Second stage; tube brought out submentally


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Figure 2: Another case with submental intubation


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Two technical points need clarification: First, the site and second, the side of the skin incision. The skin incision can be made in the midline or lateral to it on either side. We usually use a lateral incision (4-5 cm from the midline). However, this gives no advantage over a midline incision. The side of the incision hardly matters for the surgeon, but the anesthetist usually prefers to bring out the tube through the right side. It allows better visualization of the oral cavity by direct laryngoscopy, as the tongue is moved from the right to the left during laryngoscopy.

After completion of the operative procedure, the whole process is reversed to bring back the tube again into the oral cavity. The skin incision is closed in layers and the mucosal incision is closed with absorbable suture.


  Discussion Top


Oral endotracheal intubation in spite of a good mouth opening is not suitable in patients with mid- and panfacial fractures, as the surgeon cannot then assess the occlusion. Again, if there is any associated fracture of the naso-orbital ethmoid complex or the base of the skull, any attempt at nasal intubation may lead to intracranial intubation, meningitis, epistaxis, and sinonasal infection. [1] In these situations, the options available to the anesthetist are:

  1. Retromolar intubation,
  2. Submental intubation, and
  3. Tracheostomy.


Retromolar intubation is a safe, simple, and not very time consuming procedure. This is nothing but positioning of the endotracheal tube into the retromolar area. After oral intubation, the tube is placed behind the last molar by the finger so that it rests in the retromolar space. The tube is taken out by the corner of the mouth. As the tube is behind the molar area, occlusion can be checked and there is no compression on the tube. However, retromolar intubation cannot be done in all patients because it is difficult to retain the tube there in patients with limited retromolar space. Moreover, the tube may get dislodged from the retromolar site and keep disturbing the surgeon. It may also get caught in the wires during the process of intermaxillary fixation.

Tracheostomy is another method for securing the airway in these patients. Patients who present with upper respiratory tract obstruction may need intubation even after the completion of surgery. In such a case, the best answer is tracheostomy. But the majority of the patients do not fall in this category. Therefore an invasive procedure like tracheostomy, with lots of complications, such as infection, occlusion of the tube by dried secretions, tube dislodgement with loss of airway, surgical emphysema, and pressure necrosis of underlying tissues, is not justifiable as the procedure of choice in most patients.

Although it requires a helping hand from the surgeon (as also with tracheostomy intubation), submental intubation can be a better procedure in comparison to the other two possible options. First described by Hernandez Altmir in 1986, it is very safe and can be carried out in all patients where both oral and nasal intubations are contraindicated. [2] The only prerequisite is that the patient should have an adequate mouth opening. It keeps both the surgeon and the anesthetist very comfortable during the operation. Postoperative complication in the form of injury to the submandibular structures, though possible, is very rare. The scar from the skin incision also lies in a hidden area, falls along the relaxed skin tension lines in the neck, and is aesthetically sound. Performing this procedure also avoids the risks inherent with tracheostomy intubation, both immediate and late. Submental intubation is thus, in fact, positioning of the orally introduced endotracheal tube submentally to prevent it from getting in the way of testing for proper dental occlusion, a step that is crucial for exact reduction of mid- and panfacial fractures.


  Conclusion Top


Submental intubation is a simple, safe, and easy-to-execute procedure specially indicated in patients with midfacial and panfacial fractures, as the endotracheal tube does not then get in the way of achieving normal occlusion during the reduction and fixation of fractured segments.

 
  References Top

1.
Hall D. Nasotracheal intubation with facial fractures. JAMA1989; 261:1198.  Back to cited text no. 1
    
2.
Hernández Altemir F. The submental route for endotracheal intubation. A new technique. J Maxillofac Surg 1986;14:64-5.  Back to cited text no. 2
    


    Figures

  [Figure 1], [Figure 2]



 

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Introduction
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