|Year : 2011 | Volume
| Issue : 1 | Page : 37-41
Submental orotracheal intubation: Our experience and review
Ramakrishna S Shenoi, Samprati J Badjate, Nilima J Budhraja
Department of Oral and Maxillofacial Surgery, V.S.P.M's Dental College and Research, Nagpur, Maharashtra, India
|Date of Web Publication||26-Jul-2011|
Ramakrishna S Shenoi
Department of Oral and Maxillofacial Surgery, V.S.P.M's Dental College and Research, Nagpur, Maharashtra
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. Aims : To evaluate the outcome of airway management in patients with complex maxillofacial fracture by submental intubation, time required for intubation, accidental extubation, postoperative complications, and to discuss indications, contraindications, advantages and disadvantages of submental intubation. Settings and Design : A retrospective study is designed. Materials and Methods : The medical records of seven patients who underwent submental intubation from December 2008 to June 2010 were reviewed and no statistical analysis was used. Results : At the end of the procedure all seven patients were extubated without any complications. Postoperatively only one patient presented with superficial infection of the submental wound. Conclusions : 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: Panfacial trauma, submental orotracheal intubation, tracheostomy, transmylohyoid intubation
|How to cite this article:|
Shenoi RS, Badjate SJ, Budhraja NJ. Submental orotracheal intubation: Our experience and review. Ann Maxillofac Surg 2011;1:37-41
| Introduction|| |
The submental approach for intubation allows an unhindered reduction and fixation of the complex maxillofacial fractures in which simultaneous access to nasal pyramid fractures is required and thereby avoiding the need for tracheostomy.
Submental intubation was first described by Altemir.  The term transmylohyoid intubation was given by Gadre and Kushte  since the path of exit of the endotracheal tube is across the mylohyoid muscle and not restricted to the submental triangle.
We present a study of seven cases with review of literature, emphasizing on technical details, indications, contraindications, advantages, disadvantages, and complications of this technique.
| Materials and Methods|| |
Patients having maxillofacial trauma in whom submental intubation was used were reviewed retrospectively from December 2008 to June 2010. Data recorded included personal details, type of maxillofacial fracture, time required for intubation, and intraoperative and postoperative complications related to the use of submental intubation. A total of seven patients had undergone submental intubation for management of complex craniomaxillofacial or panfacial fractures.
All preparations for difficult airway were carried out. The patient was premedicated with atropine, ranitidine and ondansetron, preoxygenated and anesthesia induced with pethidine and propofol. Mask ventilation was possible after insertion of an oropharyngeal airway. 100 mg of suxamethonium chloride was administered. Prior to intubation it is important to detach and reattach the sealed universal connector gently from the proximal end of the flexometallic endotracheal tube (ETT) (Portex, Smiths Medical ASD, Inc., USA) so that it can be easily disconnected during the procedure. Flexometallic ETT is preferred since it is reinforced with a metallic spring material which has a shape memory and thus the tube is flexible, kink-resistant and retains patency despite the acute angle of the airway, particularly at the submental route. Initially standard orotracheal intubation was carried out and ETT is connected to the breathing circuit. The orotracheal intubation is then transformed into the submental intubation using the following surgical technique. A standard extubation procedure was carried out after completion of the anticipated procedure.
A temporary draping of the mouth and chin was carried out after standard skin preparation with 10% povidone-iodine solution. Subsequently, a 1.5-2 cm skin incision was made in the paramedian submental region, directly adjacent to the medial aspect of the lower border of the mandible [Figure 1]. The muscular layers, i.e. platysma and mylohyoid muscles were traversed using a pair of curved artery forceps that were always in contact with the lingual cortex of the mandible. The mucosal layer in the floor of the mouth was incised over the distal end of the forceps and the forceps were then opened, creating a wide tunnel so that the tube can be drawn easily [Figure 2].
We prefer to pass the tube in two steps. The tube cuff was first introduced into the mouth. After its deflation, a closed curved artery forceps was inserted intraorally through the surgically-created tunnel, then the tube cuff was grasped with curved artery forceps and pulled inferiorly to pass through the tunnel and emerge through the incision in the submental skin. The same maneuver was then carried out with the proximal end of the ETT tube itself, after disconnection from the circuit and detachment of the connecter. It should be noted that the patient is ventilated with 100% oxygen for around 3 min to prevent oxygen desaturation during the period of ventilator interruption while passing the ETT across the floor of mouth. After the ETT tube has emerged extraorally through the tunnel, the connector was reattached and the circuit was re-established. Auscultation was used to confirm the final position of ETT. At this point, the position of the ETT tube was reassessed and adjustments of the ETT were made so that there is equal bilateral air entry. A pharyngeal pack was then inserted to seal the pharynx from blood and debris during surgery.
Stay sutures with 3-0 silk were placed round the ETT to secure it, thus minimizing the perioperative movement and prevent accidental extubation [Figure 3]. The tube crossed the oral mucous membrane of the floor of the mouth, submucosa, mylohyoid muscle, deep cervical fascia, platysma, subcutaneous tissue, and skin of the paramedian submental region. After completion of submental intubation the anticipated procedure was carried out. At the end of the procedure, the stay sutures around the ETT were removed and the deflated pilot tube cuff and the ETT were pulled in reverse order from the tunnel to the oral cavity and thus submental intubation transformed into orotracheal intubation. The skin wound was closed with simple interrupted sutures using 3-0 prolene while intraoral wound was left to heal secondarily.
| Results|| |
Submental orotracheal intubation was completed successfully in seven male patients with ages ranged from 18 to 32 years. No accidental extubation or tube injuries occurred. The mean time required for the procedure was 10 min. Disconnection time from the ventilator was approximately 2 min and there was no significant oxygen desaturation in any patient during the procedure. No major complications such as hemorrhage, injury to the sublingual glands, Wharton's duct, lingual nerve, or orocutaneous fistula were observed. No motor or sensory nerve disturbance was recorded. Postoperative scarring of the submental wound was detectable only upon close inspection with the neck hyperextended [Figure 4]. None of the cases showed keloid or hypertrophic scars. However, we experienced one case of superficial infection of the submental wound, which got resolved after systemic antibiotics and debridement.
| Discussion|| |
Difficulty in securing an airway is often associated with the management of complex maxillofacial trauma. When neither nasotracheal nor orotracheal intubation is suitable, tracheostomy is a traditional method favored by some surgeons and anesthesiologists. However, this procedure is associated with complications such as hemorrhage, subcutaneous emphysema pneumomediastenum, blockage of tracheostomy cannula, tracheitis, cellulitis, pulmonary atelectasis, tracheoesophageal fistula, tracheocutaneous fistula, pneumothorax, recurrent laryngeal nerve damage, stomal and respiratory tract infection, tracheal stenosis, tracheal erosions, dysphagia, problems with decanulation, excessive scarring and requires careful surgical and perioperative management. ,,,
Different alternatives to tracheostomy have been proposed in the literature. In maxillofacial trauma, which requires maxillomandibular fixation and simultaneous nasal fracture reduction, switching an ETT from the nasal route to the oral route without extubation was proposed by Werther et al.  However, sterility of the surgical field is interfered by this switch method. The reason for avoidance of nasotracheal intubation (NTI) in panfacial fracture, skull base fracture, and nasoorbitoethmoid complex fracture is the danger of accidental passage of the tracheal tube into the cranial cavity during nasal intubation, this can lead to major complications such as meningitis, sepsis, and cerebrospinal fluid leakage. , NTI is frequently avoided in nasal bone fractures, which cannot be properly managed in the presence of a nasal tube and is also avoided in patients with a deviated nasal septum, polyposis, or other intranasal pathologic conditions.
Martinez-Lage et al.  performed 'Retromolar intubation' for securing airway in the management of patients with complex maxillofacial trauma and in patients requiring a cranial base approach. In this procedure, a semilunar osteotomy is done in the retromolar space. Thus, in the prepared retromolar area the orotracheal tube is placed below the occlusal plane. However, there are disadvantages of this technique as well. Bone anatomy is altered to prepare space for the tube, damage to lingual nerve, the procedure requires a mean of 25 min to perform and there is always a risk of dislodgement of the orotracheal tube.
Submental intubation is now a known alternative to tracheostomy to secure airway in the management of severe maxillofacial injuries. It is a versatile technique which allows intubation of patients in the presence of polytrauma and allows maxillamandibular fixation along with simultaneous access to nasal pyramid fractures. The submental intubation technique apart from securing airway provides an unobstructed intraoral surgical field, avoids intraoperative and postoperative complications of tracheostomy, and overcomes disadvantages of NTI. Schutz and Hamed  in their comparative study between submental intubation and tracheostomy concluded that the submental intubation is associated with low morbidity and can replace tracheostomy in selected cases of maxillofacial trauma.
Other indications of submental intubation are simultaneous orthognathic surgery with rhinoplasty , and transfacial cranial base surgery.  In orthognathic surgery, submental intubation allows a simultaneous rhinoplasty procedure without any interference and allows better assessment of soft tissue changes in nose and lip. According to Biglioli et al.,  submental intubation can be performed during transmaxillary approaches for the exposure of the clivus in which if orotracheal intubation is performed, the orotracheal tube can obstruct the downward retraction of the maxilla after a Le Fort I osteotomy.
The submental intubation technique is contraindicated in patients who require a prolonged period of assisted ventilation, that is, polytrauma patients presenting with severe neurologic damage or major thoracic trauma and patients expected to need repeated surgical interventions. 
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. Stoll et al.  advocated the submandibular approach instead of the laterosubmental approach. 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 ducts, interfere with attachment of the genioglossus and geniohyoid muscles. Extraperiosteal dissection in close contact with lingual periosteum of the mandible instead of subperiosteal dissection has been the main modification suggested by Taglialatela et al. 
Anesthetic modifications have been given by several authors. Green and Moore  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. According to Altemir and Montero  laryngeal mask can be used with the technique in patients with laryngeal trauma, unstable cervical fracture, and in voice professionals. Drolet et al.  used a lubricated tube exchanger to replace the submental tracheal tube with a fresh re-enforced armoured one. Tube obstruction or damage is difficult to manage with submental route. To overcome these difficulties ETT exchanger is beneficial to replace the damaged ETT. Amin et al.  used a 100% silicone wire-reinforced tube with a removable connector, originally designed for the use with the intubating laryngeal mask airway. Lim et al.  suggested covering the proximal end of the ETT with a blue cup of thoracic catheter to facilitate externalization of the orotracheal tube and to prevent entering of blood and soft tissue during pulling of the tube through the submental canal. Retrograde intubation is recommended by Arya et al.  in patients with restricted mouth opening.
In our patients, we opted to use single reinforced ETT, a paramedian submental approach. In all of our patients submental intubation permitted simultaneous reduction and fixation of all fractures and intraoperative control of dental occlusion without interference from the tube in the surgical field.
There are disadvantages of the submental intubation technique as well. It is an extraoral procedure and reported complications include detachment of pilot balloon or its damage during exteriorization, , damage to the cuff of the tracheal tube,  abscess formation in the floor of mouth, infection of the submental wound, , salivary fistula,  development of mucocele,  and facial scarring. Complications associated with submental intubation are not as severe as seen in tracheostomy and can be avoided by following a proper surgical technique. According to Gadre and Kushte [ 28] 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. Also remaining anterior to the masseter muscle guarantees protection to the facial artery.
Rare complications are associated with submental intubation out of which we have encountered only one complication of superficial submental wound infection, which was managed by systemic antibiotic coverage and debridement.
| Conclusion|| |
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 NTI and orotracheal intubation by allowing access to the interdental occlusion and nasal pyramid, respectively. Submental intubation has proven effective in terms of both the result and surgical time required. 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.
| References|| |
|1.||Altemir FH. The submental route for endotracheal intubation. J Maxillofac Surg 1986;14:64-5 . |
|2.||Gadre KS, Kushte D. Transmylohyoid oroendotracheal intubation: A novel method. J Craniomaxillofac Surg 1992;3:39-40. |
|3.||Chew JY, Cantrell RW. Tracheostomy, complications and their management. Arch Otolaryngol 1972;96:538-45. |
|4.||Walker DG. Complications of tracheostomy: Their prevention and treatment. J Oral Surg 1973;31:480-2. |
|5.||Stauffer JL, Olson DE, Petty TL. Complications and consequences of endotracheal intubation and tracheotomy. Am J Med 1981;70:65-76. |
|6.||Wood DE. Tracheostomy. Chest Surg Clin N Am 1996;6:749. |
|7.||Werther JR, Richardson G, McIlwain MR. Nasal tube switch: Converting from a nasal to an oral endotracheal tube without extubation. J Oral Maxillofac Surg 1994;52:994-6. |
|8.||Muzzi DM, Losasso TJ, Cucchiara RF. Complications from a nasopharyngeal airway in a patient with a basilar skull fractures. Anesthesiology 1991;74:366-72. |
|9.||Marlow TJ, Goltra DD, Schabel SI. Intracranial placement of a nasotracheal tube after facial fracture: A rare complication. J Emerg Med 1997;5:187-91. |
|10.||Martinez-Lage JL, Eslara JM, Cebrecos AI, Marcos O. Retromolar intubation. J Oral Maxillofac Surg 1998;56:302-6. |
|11.||Schutz P, Hamed HH. Submental intubation versus tracheostomy in maxillofacial trauma patients. J Oral Maxillofac Surg 2008;66:1404-9. |
|12.||Nyarady Z, Sari F, Olasz L, Nyarady J. Submental endotracheal intubation in concurrent orthognathic surgery: A technical note. J Craniomaxillofac Surg 2006;34:362-5. |
|13.||Chandu A, Witherow H, Stewart A. Submental intubation in orthognathic surgery: Initial experience . Br J Oral Maxillofac Surg 2008;46:561-3. |
|14.||Biglioli F, Mortini P, Goisis M. Submental orotracheal intubation: An alternative to tracheotomy in transfacial cranial base surgery . Skull Base Surg 2003;13:189-95. |
|15.||Meyer C, Valfrey J, Kjartansdottir T. Indication for and technical refinements of submental intubation in oral and maxillofacial surgery. J Craniomaxillofac Surg 2003;31:383-8. |
|16.||Stoll P, Galli C, Wachter R, Bahr W. Submandibular endotracheal intubation in panfacial fractures. J Clin Anesth 1994;6:83-6. |
|17.||MacInnis E, Baig M. A modified submental approach for oral endotracheal intubation. Int J Oral Maxillofac Surg 1999;28:344-6. |
|18.||Taglialatela S, Maio G, Aliberti F. Submento-submandibular intubation: Is the subperiosteal passage essential? Experience in 107 consecutive cases. Br J Maxillofac Surg 2006;44:12-4. |
|19.||Green JD, Moore UJ. A modification of sub-mental intubation. Br J Anaesth 1996;77:789-91. |
|20.||Altemir FH, Montero SH. The submental route revisited using the laryngeal mask airway: A technical note. J Craniomaxillofac Surg 2000;28:343-4. |
|21.||Drolet P, Girard M, Poirier J, Grenier Y. Facilitating submental endotracheal intubation with an endotracheal tube exchanger. Anesth Analg 2000;90:222-3. |
|22.||Amin M, Dill-Russell P, Manisali M, Lee R, Sinton I. Facial fractures and submental tracheal intubation. Anaesthesia 2002;57:1195-9. |
|23.||Lim HK, Kim IK, Han JU. Modified submental orotracheal intubation using the blue cap on the end of the thoracic catheter. Yonsei Med J 2003;44:919-22. |
|24.||Arya VK, Kumar A, Makkar SS. Retrograde submental intubation by pharyngeal loop technique in a patient with faciomaxillary trauma and restricted mouth opening. Anesth Analg 2005;100:534-7. |
|25.||Caron G, Paquin R, Lessard MR, Trepanier CA, Landry PE. Submental endotracheal intubation: An alternative to tracheotomy in patients with midfacial and panfacial fractures. J Trauma 2000;48:235-40. |
|26.||Gordon NC, Tolstunov L. Submental approach to oroendotracheal intubation in patient with midfacial fractures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;79:269-72. |
|27.||Stranc MF, Skoracki R. A complication of submandibular intubation in a panfacial fracture patient. J Oral Maxillofac Surg 2001;29:174-6. |
|28.||Gadre KS, Waknis PP. Transmylohyoid/Submental Intubation: Review, Analysis, and Refinements. J Craniomaxillofac Surg 2010;21:516-9. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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