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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:
[email protected]
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.
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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.
Submental intubation 91
2010 John Wiley & Sons A/S
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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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