Submental intubation an alternative to tracheostomy in maxillofacial trauma: our experience of 10 cases
Dr Sanjay Asnani, Senior Lecturer, Dept of oral and maxillofacial Surgery
YCMM Dental College , Ahmednagar 414003, India
Dr Uma Mahindra, Professor & HOD, Dept of Oral and Maxillofacial Surgery
Rural Dental College, Loni
Loni BK 413736.
Dr Harish Saluja, MDS, Dept of Oral and Maxillofacial Surgery
Rural Dental College, Loni
ABSTRACT: Airway management in complex craniomaxillofacial traumas is often difficult. The choice of intubation technique requires good assessment from a multidisciplinary team that includes maxillofacial surgeons and neurosurgeons as well as good communication between the surgeons and anesthetist. In many conditions such as craniomaxillofacial trauma, neither nasal nor orotracheal intubation is possible. In fact, nasotracheal intubation precludes the treatment of nasal fractures. It can result in meningitis or the tube can be passed intracranially in patients with fronto basilar fractures. An alternative for tracheostomy was first described by Hernandez Altemir in 1986. The submental route for endotracheal intubation consists of pulling the free end of an endotracheal tube (universal connector removed) through a submental incision, after a usual orotracheal intubation has been performed. The use of submental intubation with Altemir's technique and its modifications has been used in a large number of patients with maxillofacial injuries.
KEY WORDS: submental intubation, craniomaxillofacial trauma, tracheostomy.
INTRODUCTION: Airway management in complex craniomaxillofacial traumas is often difficult. The choice of intubation technique requires good assessment from a multidisciplinary team that includes maxillofacial surgeons and neurosurgeons as well as good communication between the surgeons and anaesthetist.1 In many conditions such as craniomaxillofacial trauma, neither nasal nor orotracheal intubation is possible. In fact, nasotracheal intubation precludes the treatment of nasal fractures. It can result in meningitis or the tube can be passed intracranially in patients with fronto basilar fractures.2 Conversely, an orotracheal tube interferes with maxillomandibular fixation, compromising the reduction and stabilization of maxillary and mandibular fractures.7 Often neither nasal nor orotracheal intubation is suitable for transfacial approaches to the cranial base.8 In fact, during transmaxillary approaches the orotracheal tube can obstruct the downward retraction of the maxilla after a Le Fort I osteotomy, limiting the exposure of the cranial base.6, 8 The tube can also be clamped between the teeth, reducing the airway lumen.6, 8 At the end of surgery, restoring an individual occlusion may not be tested and, if needed, intermaxillary fixation cannot be performed. In these situations, which require teamwork from several disciplines, tracheostomy is considered the technique of choice for airway control by many anesthetists and surgeons.1, 9
An alternative for tracheostomy was first described by Hernandez Altemir in 1986.10 The submental route for endotracheal intubation10 consists of pulling the free end of an endotracheal tube (universal connector removed) through a submental incision, after a usual orotracheal intubation has been performed.7The use of submental intubation with Altemir's technique and its modifications has been used in a large number of patients with maxillofacial injuries.1, 11Many studies have compared the disadvantages and risks of tracheostomy and submental intubation for the treatment of facial fractures.1, 7However, the use of Altemir's technique in cranial base surgery has not been adequately assessed. This retrospective study therefore evaluated the experience of our multidisciplinary team using submental intubation not only during the treatment of craniomaxillofacial trauma.
MATERIAL AND METHOD:
Ten patients with maxillofacial trauma were treated in our department of oral and maxillofacial surgery. All the patients were intubated via submental route of intubation .In all the patients nasal and orotracheal intubation was not possible as it would have complicated the situation so we preferred submental route of intubation.
Fig 1 Marking for incision in submental region
Fig 2 The end of the tube grasped with the hemostat and withdrawn through the submental tunnel
Fig 3 Tube withdrawn through submental route and reconnected
After normal oral intubation, an incision measuring approximately 2 cm. was made in the submental and paramedian region, parallel with the mandibular lower border and at about a finger's breadth from the latter (fig.1). The lower medial mandibular edge was identified using a curved haemostat. The cervical fascia and the skin of the neck were incised, passing the forceps subperiostially from distal to proximal, about 2 cm.
The mylohyoid muscle was crossed in the area of its mandibular insertion, to reach the sublingual space. Where the mucosa is still tightly adherent, an incision was made, parallel with the gingival margin and which measures approximately 2 cm. in length. With the haemostat the lower edge of this last incision was detached.
A passage for the tube was created from the mouth, through the mylohyoid muscle to the submental incision . The orotracheal tube was secured in the mouth to avoid accidental extubation. It was then disconnected from the breathing circuit. The end was grasped with the hemostat and withdrawn through the submental tunnel and reconnected(fig .2). When capnography and lungs auscultation confirmed the correct tracheal position of the tube, the tube was fixed at the submental level with 2–0 silk suture, in a similar fashion as a drainage tube(fig.3).
At the end of the procedure, anesthesia was discontinued and the patient was extubated in the operating room. The submental access was sutured after extubation using suture
Submental orotracheal intubation was completed successfully in all 10 patients. No accidental extubations or tube injuries occurred. The mean time required to place the tube was 7 minutes. No major complications (hemorrhage; injury to the sublingual glands, Wharton's duct or lingual nerve or orotracheal fistula) were observed during the mean follow–up period of 12 months. Only two minor complication occurred in two patients. There was superficial infection in two cases, which resolved in four days after washing with saline solution and drainage. The submental incisions healed in all of the patients with minimal scarring.
When neither nasotracheal nor orotracheal intubation is suitable, temporary tracheostomy is frequently the option of choice.7 This technique, however, is associated with significant morbidity. Complications include hemorrhage, recurrent laryngeal nerve damage, subcutaneous emphysema, tracheal stenosis, and a cosmetically undesirable scar.1
Different procedures have been proposed as an alternative to tracheostomy. In panmaxillofacial trauma, which requires maxillomandibular fixation and nasal fracture reduction, switching an endotracheal tube from the nasal route to the oral route without extubation can be a good option.1, This maneuver can be completed in less than 10 minutes. The conversion can also be completed more rapidly with the use of tube exchangers.11, Nevertheless, in patients with frontobasilar fractures associated with maxillofacial trauma, the nasotracheal intubation can lead to major complications such as meningitis, sepsis, and cerebrospinal fluid leakage. Furthermore, the nasal tube can be introduced intracranially, causing significant brain damage.1,2
The submental route for endotracheal intubation represents a fast and low–morbidity alternative to tracheostomy.7 The Altemir intubation procedure requires no more than 5 minutes to perform.7, 11 The technique is very easy, and the risk of damage to structures such as the sublingual and submaxillary glands, Wharton's duct, and the lingual nerve is very low. In fact, these major complications have never been reported
There are certain disadvantages of this technique which can be avoided if proper precautions are taken. Infection in the floor of the mouth (careful active or passive oral hygiene is mandatory, prior to the operation), risk of submental fistulae and anomalous scars occurring, if the submental intubation is excessively prolonged, damage to important structures of the floor of the mouth.
The disadvantage of having to make a submental incision has to be weighed against the trauma which accompanies a tracheostomy.
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First Published January 2012