Management of the airway is always a primary concern during any maxillofacial surgery. Operating in the field free from the intubation tube is comfortable for a surgeon; while for an anaesthesiologist, the safety of the tube and efficiency of ventilation are important. Modern techniques for surgical treatment of midfacial and panfacial fractures in maxillofacial trauma pose special problems for airway management.
Implementing a safe and acceptable alternative to tracheostomy for short-term airway management is a desirable objective for optimal management of complex craniofacial injuries. Nasotracheal intubation may best be avoided in these groups of patients because of reported dangers of nasotracheal intubation in the presence of midfacial and basilar skull fractures, such as cranial intubation, epistaxis, trauma to the pharynx, pressure necrosis of external nares, otitis media, sinusitis, sepsis and inability to pass a tube through nasal passages.[6
] Often surgical correction of these nasal fractures requires tube-free surgical areas, which can be achieved by opting for avoidance of nasal intubations.
The alternative of orotracheal intubation significantly facilitates manoeuvres for reduction and stabilization of the jaws, which often requires immobilization with arch bars and wires. Hence oral intubation was avoided.
Anaesthesia via tracheostomy was the alternative route for short-term airway management. However, tracheostomy may cause many general, local, early and late complications. Early general complications include cardiac arrest caused by stimulation of vagus nerve, post-hypercapnic shock due to sudden lowering of the carbon dioxide level and aeroembolism. Early local complications comprise haemorrhage, subcutaneous or mediastinal emphysema and recurrent laryngeal nerve damage with all its consequences.[7
] Late complications include laryngeal or tracheal stricture, haemorrhage from large blood vessels caused by decubitus of vessel walls, tracheo-oesophageal fistula, extensive granulation and inflammatory complications.[11
] Due to these potential complications, tracheostomy for airway management was avoided in our study subjects.
There have been several attempts to achieve short-term airway management, including retromolar intubation and nasal tube switch technique. According to literature, retromolar intubation has been reported to have disadvantages like being more traumatic, obtrusive, costly and requiring more operating time.[12
] Another alternative nasal tube switch technique was not performed due to problems associated with the intraoperative re-intubation, like risk of aspiration due to posterior nasal bleeding, potential airway compromise with need for emergency tracheostomy/cricothyroidotomy, unfavourable manipulation of an unstable cervical spine, excessive stress on fixations with possible loosening of plates and screws.[13
Since the first description, submental intubation has undergone various modifications and found new indications.[14
] It could be safely used in patients with midfacial or panfacial fractures with possible base of skull fractures, as well as in patients undergoing elective Le Fort osteotomies or simultaneous elective mandibular orthognathic surgery and rhinoplasty procedure.[15
] In our present series, submental intubations were possible in all the patients without any major complications, allowing unimpeded manipulation of the fractured fragments, satisfactory achievement of occlusion, establishment of maxillomandibular fixation and complete assessment of facial symmetry, as well as easy access to endotracheal tube for the anaesthesiologist. Moreover, extubation was found to be simple and the cosmetic results were acceptable, with no long-term morbidity.
In our series, no episodes of compromised airway or arterial desaturation occurred during the procedure. Other possible potential complications such as orocutaneous fistula, trauma to the submandibular and sublingual glands or canals, damage to the lingual nerve, and hypertrophic scar were also not observed.
Some precautions must be considered to make submental endotracheal intubation a successful technique with minimal morbidity. At every step, good communication between the surgeon and the anaesthesiologist is mandatory. Initial management of the airway of patients with facial trauma can be challenging. Submental intubation is always a second step after the airway has been secured. During the submental intubation procedure, the endotracheal tube must be firmly secured intraorally to prevent accidental extubation. To avoid injuries to the salivary glands and ducts, blunt dissection with the haemostat clamp must run in close approximation to the medial border of the mandible.
Another crucial decision during the management of patients with maxillofacial trauma is when to remove the endotracheal tube. Tracheal extubation of these patients must be done only after adequate evaluation. It is based on the patient's ability to maintain airway reflexes, the potential for residual respiratory depression, and airway oedema.[4
] With the availability of modern craniomaxillofacial fixation techniques, maxillomandibular fixation is usually not required in the postoperative period.[17
] Even if maxillomandibular fixation is required, in rare cases it need not be placed during the immediate postoperative period. Postoperative maxillomandibular fixation could be achieved by simple elastics after extubation. In modern maxillofacial trauma care, elastics are routinely used for achieving maxillomandibular fixation, instead of traditional wires. These elastics could be cut and removed easily by the patient himself or by any paramedical staff without the need for any specialized instruments. Hence if mechanical ventilation or intubation is required postoperatively, the submental intubation could be switched over back to standard orotracheal intubation.[18
] However, if mechanical ventilation is expected to be required for prolonged period because of severe head or torso injury, tracheostomy remains the preferred technique for airway management.[18
Some authors have recommended the technique of lateral incision through the body of mandible.[19
] However, for two reasons we opted for midline approach as described by MacInnis: firstly, only few anatomic structures are present and there is minimum risk of neurovascular damage. Secondly, the midline incision heals almost imperceptibly and therefore is cosmetically superior.[21
The present study reports good results with the use of submental endotracheal intubation for surgical treatment of 10 patients with panfacial fractures. In all cases, the planned surgery was completed without interference from the artificial airway and, most importantly, without compromising the airway.