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Indian J. Anaesth. 2002; 46 (5) : 400-402 SUBMENTAL ENDOTRACHEAL INTUBATION: A USEFUL ALTERNATIVE TO TRACHEOSTOMY Dr. Naveen Malhotra 1 Dr. Neerja Bhardwaj 2 Dr. P. Chari 3 SUMMARY Submental route of endotracheal intubation is a simple, safe and useful technique in maxillofacial trauma, where oral and nasal endotracheal intubation cannot be performed. It avoids the need for tracheostomy and its consequent morbidity. We present a case of multiple facial fractures where we avoided tracheostomy by the use of submental endotracheal intubation technique. Keywords : Maxillofacial trauma, Submental endotracheal intubation. Surgical repair of maxillofacial trauma requires modification of the standard anaesthesia technique. Nasal endotracheal intubation is often contraindicated in the presence of fracture of base of the skull. 1 Comminuted midfacial fractures cause physical obstruction to the passage of nasotracheal tube. 2 Further, the presence of nasotracheal tube can interfere with surgical reconstruction of fractures of the naso-orbital ethmoid (NOE) complex. 3 Surgical reconstruction often involves maxillo-mandibular fixation in the intraoperative period to restore patient’s dental occlusion. This precludes the use of oral endotracheal intubation in such cases. In these conditions tracheostomy may be indicated but it carries a significant morbidity. 4-6 Submental endotracheal intubation has been described as an useful alternative to tracheostomy with minimal complications in these conditions. 7-10 Case report A 16 year old, 50 kg youth met with a road traffic accident and was admitted to accident and emergency department of the institute. On admission patient was conscious, with a Glasgow coma score of 15 (E 4 V 5 M 6 ). On examination, there was facial swelling, epistaxis, bilateral periorbital oedema, bilateral subconjunctival haemorrhage and loss of left upper incisors (figure 1). Cerebrospinal fluid rhinorrhoea was also present. There was midface mobility with palatal split and the occlusion 1. M.D., DNB, Senior Resident 2. M.D., Additional Professor 3. M.D., M.A.M.S., F.A.M.S., Professor and Head Department of Anaesthesia and Intensive Care Postgraduate Institute of Medical Education and Research Chandigarh -160012, India. Correspond to : Dr. Naveen Malhotra 128/19, Naveen Niketan, Civil Hospital Road, Rohtak - 124001 (Haryana) Tel: 01262-47368, 58387 E-mail : [email protected] was impaired. Radiological examination confirmed the presence of Lefort III fracture on the right side, LeFort II fracture on the left side, fracture of mandible in midline, fracture of dentoalveolous in the upper jaw and fracture of nasal bone. The patient was scheduled for surgical correction of multiple facial fractures. Nasal endotracheal intubation was contraindicated in the presence of cerebrospinal fluid rhinorrhoea, epistaxis and fracture of nasal bone. Oral endotracheal intubation was not possible because the surgical procedure involved intraoperative intermaxillary fixation to check occlusion. In order to avoid tracheostomy, submental endotracheal intubation was planned. Patient was kept fasting for 8 hours preoperatively. He was premedicated with tablet ranitidine 150 mg HS and 2 hours before surgery along with tablet metoclopramide 10 mg taken with a sip of water. Patient was also administered injection hydrocortisone 100 mg intravenously HS and 1 hour before surgery. In the operation theatre patient was preoxygenated with 100% oxygen for three minutes, after which anaesthesia was induced with injection thiopentone 5 mgkg -1 intravenously. After induction, mask ventilation was checked and found to be adequate. Injection suxamethonium 1.5 mgkg -1 intravenously was administered. On direct laryngoscopy there was no airway oedema. Oral endotracheal intubation was performed with 32 FG cuffed flexometallic endotracheal tube (RUSCH) (figure 2). Anaesthesia was maintained with 33% oxygen in nitrous oxide and halothane. Intraoperatrively analgesia was maintained with injection morphine 0.1 mgkg -1 intravenously and muscle relaxation achieved by injection pancuronium 0.8 mgkg -1 intravenously and incremental doses of 0.8 mg intravenously. A 2 cm incision was made in right submental region parallel and medial to inferior border of mandible by the surgeon. It was extended intraorally through the mylohyoid muscle by blunt dissection. The endotracheal tube was briefly disconnected from the 400

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INDIAN JOURNAL OF ANAESTHESIA, OCTOBER 2002400Indian J. Anaesth. 2002; 46 (5) : 400-402

SUBMENTAL ENDOTRACHEAL INTUBATION:A USEFUL ALTERNATIVE TO TRACHEOSTOMY

Dr. Naveen Malhotra1 Dr. Neerja Bhardwaj2 Dr. P. Chari3

SUMMARYSubmental route of endotracheal intubation is a simple, safe and useful technique in maxillofacial trauma, where oral and nasalendotracheal intubation cannot be performed. It avoids the need for tracheostomy and its consequent morbidity. We present a caseof multiple facial fractures where we avoided tracheostomy by the use of submental endotracheal intubation technique.Keywords : Maxillofacial trauma, Submental endotracheal intubation.

Surgical repair of maxillofacial trauma requiresmodification of the standard anaesthesia technique. Nasalendotracheal intubation is often contraindicated in thepresence of fracture of base of the skull.1 Comminutedmidfacial fractures cause physical obstruction to thepassage of nasotracheal tube.2 Further, the presence ofnasotracheal tube can interfere with surgical reconstructionof fractures of the naso-orbital ethmoid (NOE) complex.3Surgical reconstruction often involves maxillo-mandibularfixation in the intraoperative period to restore patient’sdental occlusion. This precludes the use of oralendotracheal intubation in such cases. In these conditionstracheostomy may be indicated but it carries a significantmorbidity.4-6 Submental endotracheal intubation has beendescribed as an useful alternative to tracheostomy withminimal complications in these conditions.7-10

Case reportA 16 year old, 50 kg youth met with a road traffic

accident and was admitted to accident and emergencydepartment of the institute. On admission patient wasconscious, with a Glasgow coma score of 15 (E4V5M6).On examination, there was facial swelling, epistaxis,bilateral periorbital oedema, bilateral subconjunctivalhaemorrhage and loss of left upper incisors (figure 1).Cerebrospinal fluid rhinorrhoea was also present. Therewas midface mobility with palatal split and the occlusion

1. M.D., DNB, Senior Resident2. M.D., Additional Professor3. M.D., M.A.M.S., F.A.M.S., Professor and Head

Department of Anaesthesia and Intensive CarePostgraduate Institute of Medical Education and ResearchChandigarh -160012, India.Correspond to :Dr. Naveen Malhotra128/19, Naveen Niketan, Civil Hospital Road,Rohtak - 124001 (Haryana)Tel: 01262-47368, 58387E-mail : [email protected]

was impaired. Radiological examination confirmed thepresence of Lefort III fracture on the right side, LeFortII fracture on the left side, fracture of mandible in midline,fracture of dentoalveolous in the upper jaw and fractureof nasal bone.

The patient was scheduled for surgical correctionof multiple facial fractures. Nasal endotracheal intubationwas contraindicated in the presence of cerebrospinal fluidrhinorrhoea, epistaxis and fracture of nasal bone. Oralendotracheal intubation was not possible because thesurgical procedure involved intraoperative intermaxillaryfixation to check occlusion. In order to avoid tracheostomy,submental endotracheal intubation was planned.

Patient was kept fasting for 8 hours preoperatively.He was premedicated with tablet ranitidine 150 mg HSand 2 hours before surgery along with tabletmetoclopramide 10 mg taken with a sip of water. Patientwas also administered injection hydrocortisone 100 mgintravenously HS and 1 hour before surgery. In theoperation theatre patient was preoxygenated with 100%oxygen for three minutes, after which anaesthesia wasinduced with injection thiopentone 5 mgkg-1 intravenously.After induction, mask ventilation was checked and foundto be adequate. Injection suxamethonium 1.5 mgkg-1

intravenously was administered. On direct laryngoscopythere was no airway oedema. Oral endotracheal intubationwas performed with 32 FG cuffed flexometallicendotracheal tube (RUSCH) (figure 2). Anaesthesiawas maintained with 33% oxygen in nitrous oxideand halothane. Intraoperatrively analgesia was maintainedwith injection morphine 0.1 mgkg-1 intravenously andmuscle relaxation achieved by injection pancuronium0.8 mgkg-1 intravenously and incremental doses of0.8 mg intravenously. A 2 cm incision was made in rightsubmental region parallel and medial to inferior border ofmandible by the surgeon. It was extended intraorallythrough the mylohyoid muscle by blunt dissection. Theendotracheal tube was briefly disconnected from the

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MALHOTRA, BHARDWAJ, CHARI : SUBMENTAL ENDOTRACHEAL INTUBATION 401

breathing circuit and the tube connector was removedfrom the tube. The pilot balloon followed by endotrachealtube were gently pulled out through the incision. Thetube connector was reattached and the endotracheal tubereconnected to anaesthesia breathing circuit (figure 3).Bilateral air entry was rechecked and found to be equaland the tube was fixed with 1’0 silk suture. Intraoperatively,the endotracheal tube was away from the surgical fieldand the surgeons could easily do the intermaxillary fixationto check occlusion. The total duration of surgery wasfour hours. At the end of surgery, submental intubationwas converted to oral intubation. First the pilot balloonand then the endotracheal tube were pulled intraorally.The submental incision was closed not so tightly with twoskin sutures so as to allow certain degree of drainage.Direct laryngoscopy was performed again and showed noairway oedema. So, neuromuscular blockade was reversedwith injection atropine 0.02 mgkg-1 and injection neostigmine0.05 mgkg-1 intravenously. Patient was allowed to regainconsciousness and trachea was extubated after the returnof protective reflexes.

Intraoperative and postoperative period wasuneventful. There was no episode of arterial desaturationwhile converting oral intubation to submental intubationand vice-versa. The endotracheal tube connector could beeasily removed and reattached firmly. Care was taken notto damage the pilot balloon. Endotracheal suction couldbe easily done through the submental route.Perioperatively, the patient received routine antibioticcoverage for trauma surgery procedure and oral hygienewas maintained. Regular mouthwash with 0.2%chlorhexidine gluconate solution was done. Nocomplication was noted and the submental scar after 2months was almost invisible.

DiscussionAltemir, in 1986, first described the submental route

for endotracheal intubation.7 This technique provided asecure airway, an unobstructed intraoral surgical fieldand allowed maxillomandibular fixation while avoidingthe drawbacks and complications of nasotracheal intubationand tracheostomy.8 Nasotracheal intubation is not possiblein the presence of fractures of nasal skeleton, skull basefractures and cerebrospinal fluid rhinorrhoea. Any attempttowards nasotracheal intubation can lead to passage oftube into the cranium, meningitis, sepsis, sinusitis andepistaxis.1,11,12 Our patient had cerebrospinal fluidrhinorrhoea, epistaxis and fracture of nasal bone; all ofwhich precluded nasotracheal intubation.

Tracheostomy, an alternate technique preferred bysome surgeons and anaesthesiologists, is associated withcomplications like haemorrhage, subcutaneous emphysema,

Fig.1: Photograph of patient showing facial swelling, subconjunctivalhaemorrhage and bilateral periorbital oedema.

Fig.2: Orotracheal intubation with flexometallic endotracheal tube.

Fig.3: Submental intubation with flexometallic endotracheal tube sutured inposition.

INDIAN JOURNAL OF ANAESTHESIA, OCTOBER 2002402

pneuomediastinum, pneumothorax, recurrent laryngealnerve damage, stomal and respiratory tract infection,tracheal stenosis, tracheal erosions, dysphagia, problemswith decanulation and excessive scarring.4-6

Submental endotracheal intubation is not free ofadverse events and complications. Adverse events canoccur while the endotracheal tube is passed through theincision from interior to exterior. It may be difficult topass the tube through the incision or reattaching theconnector to endotracheal tube. These adverse events canbe overcome by Green and Moore’s modification to theoriginal technique. They used two endotracheal tubes intheir technique. They first secured the airway withconventionally placed oral tracheal tube. Reinforcedendotracheal tube was then drawn in from exterior tointerior through the submental incision. The original oraltube was withdrawn and reinforced tube substituted. Atthe end of the procedure, the process may be reversed.This technique is also useful when manufacturer’s designspecifically prevents the removal of tube connector.13

However, grasping and drawing in the tracheal end of theendotracheal tube can damage the cuff.

Maclnnis and Baig reported that their experiencewith standard technique as described by Altemir was lessthan satisfactory because of bleeding, difficult tube passageand sublingual gland involvement. Instead of slight lateralexit wound submentally, they modified the technique tostrict midline approach in 15 patients with satisfactoryresults.14 However, we followed the original techniqueand had no difficulty in passing the tube through theincision, the endotracheal tube connector could be easilydetached and reattached and there was no bleeding.

Accidental extubation, tube obstruction and damagedtube (leaking cuff) are more difficult to manage insubmental route. Endotracheal tube exchanger has beenused successfully to replace the damaged tracheal tube bythe submental approach.15 Other potential complicationsare superficial infection of the submental wound, traumato submandibular and sublingual glands or ducts, damageto lingual nerve, orocutaneous fistula and hypertrophicscar.7 However, no complication occurred in our patient.Perioperative antibiotic cover, good oral hygiene and notso tight closure of submental incision resulted in preventionof infectious complications.

Submental tracheal tube has been kept in situ forupto two to three days postoperatively. In such cases, itis mandatory that an immediate access to oral airway isensured at all times and maxillomandibular fixation should

not be used until after extubation and confirmation ofsecure airway.8,9 In our patient we did not keep theendotracheal tube in situ as there was no airway oedema.

Therefore, in selected group of patients with severemaxillofacial trauma, submental endotracheal intubationis a useful and relatively harmless alternative totracheostomy for securing airway.

References1. Muzzi DA, Losasso TJ, Cucchiara RF. Complication from a

nasopharyngeal airway in a patient with a basilar skull fracture.Anesthesiology 1991; 74: 366-8.

2. Zmyslowski WP, Maloney PL. Naso-tracheal intubation in thepresence of facial fractures. JAMA 1989; 262: 1327-8.

3. Haug RH, Indresano AT. Management of maxillary fractures.In: Peterson LJ, ed. Principles of oral and maxillofacialsurgery. Philadelphia: JB Lippincott, 1992: 469-88.

4. Chew JY, Cantrell RW. Tracheostomy, complications and theirmanagement. Arch Otolaryngol 1972; 96: 538-45.

5. Walker DG. Complications of tracheostomy: their preventionand treatment. J Oral Surg 1973; 31: 480-2.

6. Stauffer JL, Olson DE, Petty TL. Complications andconsequences of endotracheal intubation and tracheotomy. AmJ Med 1981; 70: 65-76.

7. Altemir FH. The submental route for endotracheal intubation:a new technique. J Maxillofac Surg 1986; 14: 64-5.

8. Caron G, Paquin R, Lessard MR, Trepanier CA and LandryPE. Submental endotracheal intubation: an alternative totracheotomy in patients with midfacial and panfacial fractures.J Trauma 2000; 48: 235-40.

9. Gordon NC, Tolstunov L. Submental approach tooroendotracheal intubation in patient with midfacial fractures.Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;79: 269-72.

10. Chandu A, Smith ACH, Gebert R. Submental intubation: analternative to short-term tracheostomy. Anaesth Intensive Care2000; 28: 193-5.

11. Seebacher J, Nozik D, Mathieu A. Inadvertent intracranialintroduction of a nasogastric tube, a complication of severemaxillofacial trauma. Anesthesiology 1975; 42: 100-2.

12. Stone DJ, Bogdonoff DL. Airway considerations in themanagement of patients requiring long-term endotrachealintubation. Anesth Analg 1972; 74: 276-87.

13. Green JD, Moore UJ. A modification of sub-mental intubation.Br J Anaesth 1996; 77: 789-91.

14. Maclnnis E, Baig M. A modified submental approach fororal endotracheal intubation. Int J Oral Maxillofac Surg 1999;28: 344-6.

15. Drolet P, Girard M, Poirier J, Grenier Y. Facilitating submentalendotracheal intubation with an endotracheal tube exchanger.Anesth Analg 2000; 90: 222-3.