Submental intubation in panfacial injuries:our experience

Securing an airway in patients with panfacial injuriesremain a challenge to an anaesthesiologist. No consensusexists till date as to which is the best way of securing anairway when orotracheal and nasotracheal intubationare contraindicated (1). Tracheostomy remains an excel-lent technique to secure an airway in panfacial fracturesbut it is not free of its inherent complications. Submentalintubation has been described as an alternative tech-nique, as it offers a secure airway to the anaesthesiolo-gist, an optimum operating eld and an opportunity forsurgeon to check dental occlusion per operatively withlimited morbidity for the patients. We here describe ourexperience with this technique.

Materials and methods

From November 2006 to November 2008 ten patients ofpanfacial injuries were intubated using submental intu-bation. There were six male and four female patientswith mean age of 30 years (2040 years). Most of facialinjuries were a combination of fractures affecting dentalocclusion (Maxillary fractures of Le fort Type 1,Mandibular fractures or alveolar fractures) and associ-ated with another fracture dislocating either the anteriorskull base (Le fort Type II or III fractures) or nasalpyramid (Naso Orbito Ethmoidal fractures).

All patients underwent pre anaesthetic checkup andwere of ASA grade 1 & 2. Informed consent was takenand all patients were kept fasting for 8 h. We followedstandard anaesthesia technique in all patients. In oper-ation theatre IV line was secured with 18G IV cannulaand routine monitoring was done. Patients were pre-medicated with Inj Glycopyrollate 0.2 mg, Inj midazo-

lam 0.05 mg kg)1, Inj Fentanyl 2 lg kg)1, Inj Ranitidine50 mg and Inj Metoclopramide 10 mg IV. Patients werepre-oxygenated for 3 min and were induced with InjPropofol 2 mg kg)1 IV and after proper mask ventila-tion Inj succinylcholine 2 mg kg)1 IV was administered.Initially oral endotracheal intubation was performedwith a 32G exometallic endotracheal tube (Willy RuschAG, Kernen, Germany). After proper packing of throat,ETT connector was removed from the tube with the helpof mosquito forceps so that it can be easily removed andreattached in the next step. After sterile painting anddraping of chin and mouth, 2 ml of lignocaine withadrenaline (2%) was injected at the incision site (Fig. 1).A 1.5 cm transverse skin incision was made in themedian region of submental area, directly adjacent tolower border of mandible (Fig. 2). The site used forincision was selected by presence of concurrent mandiblefracture, main aim being to stay as far as possible fromthe fracture site in order to reduce interference from thetube. Mouth opening was maintained using mouth gag.Floor of the mouth was exposed by retracting thetongue. A closed artery forceps was introduced throughsubmental incision and blunt dissection was performedbetween anterior bellies of digastrics, mylohyoid, geni-ohyoid and genioglossus muscles (Fig. 3). Intraorally alongitudinal incision was made in midline betweensubmandibular ducts close to the base of the tongue.A tunnel is made wide enough to accommodate ETT.The ETT was then disconnected from breathing circuitand connector removed. Pilot balloon followed by ETTwas gently pulled out through the incision (Fig. 4). Thetube connector was reattached and ETT was reconnectedto circuit (Fig. 5). Bilateral air entry was checked and

Dental Traumatology 2010; 26: 9093; doi: 10.1111/j.1600-9657.2009.00850.x

90 2010 John Wiley & Sons A/S

Munish Garg1, Bhawna Rastogi1,Manish Jain1, HimanshuChauhan1, Vishal Bansal2

1Anaesthesiology & Critical Care Department in

NSCB Subharti Medical College, Meerut (UP),

India; 2Oral & Maxillofacial Department in GGS

Subharti Dental College, Meerut (UP), India

Correspondence to: Munish Garg,Flat No. 11, X Block, Subharti MedicalCollege, Delhi Haridwar Bypass Road,Meerut (U.P.), IndiaTel.: +91 9897394212Fax: +91 0121 2767018e-mail: drmunish74@gmail.com

Accepted 2 October, 2009

Abstract Panfacial fractures present a unique set of problems to theanaesthesiologist and surgeon. Airway management in panfacial fractures isstill a challenge to the anaesthesiologist as all modalities available such asorotracheal intubation, nasotracheal intubation, tracheostomy, etc., have theirown advantages and disadvantages. When all the conventional modalities tosecure airway seem unsuitable then submental route offers an excellentalternative to manage airway in such patients. Here we describe our experiencewith submental intubation technique in 10 patients with panfacial injuries over aperiod of two years.

tube was xed with 3-0 silk sutures. Mean duration forsurgery was 3 h (24 h). At the end of surgery submentalintubation was converted to oral intubation. First pilot

balloon and then ETT were pulled intraorally. Submen-tal incision was closed with two loose skin sutures toallow certain degree of drainage. 4-0 vycril was usedto suture intraoral layer. After removal of pack reversalof neuromuscular blockade was done with neostigmineand Glycopyrollate. Out of 10 patients, eight wereextubated after return of reexes and two of patientswere shifted to ICU for elective ventilatory support.

Results

In all patients submental intubation permitted simulta-neous reduction and xation of all fractures and intra-operative control of dental occlusion without anyinterference during the operation.

In all patients intraoperative and postoperative periodwas uneventful. There were no episodes of arterialdesaturation while converting oral intubation to sub-mental intubation and vice versa. Care was taken not todamage pilot balloon and ETT connector could be easilyremoved and reattached rmly. During the procedure nodifculty was encountered in passing the tube through

Fig. 1. Local inltration at incision site.

Fig. 2. Incision for submental intubation.

Fig. 3. Blunt dissection of oor of mouth.

Fig. 4. Pulling of exometallic tube along with pilot balloonthrough incision.

Fig. 5. Secured exometallic tube through submentalapproach.

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2010 John Wiley & Sons A/S

the oor of mouth. Total procedure time from incisionmaking to passing ETT submentally till reconnection ofcircuit was less than 8 min. Disconnection time fromcircuit was approximately 1 min.

There were some minor complications encountered intwo patients. In one of the patients there was accidentaldisconnection of tube from the circuit per-operativelywhich was recognized immediately and taken care of. Inanother patient, there was a slight wound infection atincision site postoperatively which was cured withregular dressing and antibiotics.

In all patients, after two months submental incisionscar was almost invisible.

Discussion

Airwaymanagement of patientswho suffer frompanfacialfractures is a complicated task. Due to the teeth embeddedin facial bones, the treatment of facial fractures requiresnot only the alignment of fractures fragments but alsoproper occlusion of teeth.

Nasotracheal intubation is usually contraindicated inmaxillofacial fractures since there are many complica-tions like inadvertent introduction of tube into thecranium, haemorrhage, obstruction of tube by distortedairway architecture, distal dislodgement of bony frag-ments by tube, meningitis, sepsis, sinusitis, etc. (212).

Orotracheal tube compromises with the reduction andmaintenance of pan facial fractures (13). Further, it isdifcult to check dental occlusion intra-operatively whenorotracheal tube is in place.

Tracheostomy, an alternate favourite method, has itsown complications like haemorrhage, recurrent laryngealnerve damage, subcutaneous emphysema, tracheal steno-sis, trachea-oesophageal stula and scarring (6, 1418).

Martinez Lage et al described an alternative techniquecalled retromolar intubation for panfacial fractures inwhich a semilunar osteotomy is made in retromolarspace (19). Orotracheal tube is then placed in theretromolar area lying below occlusion plane, giving anunobstructed intraoral surgical eld with secure airwaymanagement moreover intermaxillary xation can bedone without any obstruction from tube. However themain disadvantages of this technique are that it takes amean duration of 25 min to perform this procedure,bone anatomy is destroyed to make space for tube andevaluation of restoration of individual occlusion ispartially impaired by presence of tube in oral vestibule(20, 21).

Altemir, a maxillofacial surgeon rst described thetechnique of submental intubation in 1986 (22). Since therst application of this technique, many trials haveshown the submental route to be a simple, quick and safeapproach to the airway management. This techniqueprovided a secure airway, an unobstructed intraoralsurgical eld and allowed maxillomandible xation whileavoiding the complications of nasotracheal and orotrac-heal intubation and tracheostomy.

Since its rst description submental intubation hasundergone various modications and found new indica-tions (13, 2329). It could be safely used in patients withmidfacial or panfacial fractures with possible base of

skull fractures as well as in patients undergoing electiveLe Fort osteotimies or simultaneous elective mandibularorthognathic surgery and rhinoplasty procedure (2, 6,21).

Infections at the site of incision, bleeding diasthesis,disrupted laryngotracheal anatomy, restricted retromo-lar space to allow suctioning, requirement of prolongedcontrol of airway and permanent airway requirementare the few contraindications of this technique (2, 29).

Some authors have recommended lateral incisiontechnique through the body of mandible (30, 31).However we opted for midline approach as describedby MacInnis (24) for two reasons: rst, only fewanatomic structures are present and there is minimumrisk of neurovascular damage. Secondly, the midlineincision heals almost imperceptibly and therefore iscosmetically superior.

Conclusion

Submental intubation is a useful alternative technique ofairway management in patients with panfacial fractures.It provides a safe and reliable route for endotrachealintubation and also allows checking of dental occlusionperopertively without causing signicant morbidity tothe patient. This procedure is simple, safe and quick toexecute. Finally, it has low incidence of operative andpostoperative complication, eliminates drawbacks oftracheostomy and allows both surgeon and anaesthetistto give better quality of patient care.

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