Submental intubation is an interesting alternative to tracheostomy, especially when short-term postoperative control of airway is desirable with the presence of undisturbed access to oral as well as nasal airways and a good dental occlusion. Submental intubation with midline incision has been used in 10 cases from October 2008 to March 2010 in the Department of Oral and Maxillofacial Surgery, Manipal College of Dental Sciences, Mangalore. All patients had fractures of the jaws disturbing the dental occlusion associated with fracture of the base of the skull, or/and a displaced nasal bone fracture. After standard orotracheal intubation, a passage was created by blunt dissection with a haemostat clamp through the floor of the mouth in the submental area. The proximal end of the orotracheal tube was pulled through the submental incision. Surgery was completed without interference from the endotracheal tube. At the end of surgery, the tube was pulled back to the usual oral route. There were no perioperative complications related to the submental intubation procedure. Average duration of the procedure was less than 6 minutes. Submental intubation is a simple technique associated with low rates of morbidity. It is an attractive alternative to tracheotomy in the surgical management of selected cases of panfacial trauma.
Airway management; panfacial fractures; submental intubation
Airway management in patients with faciomaxillary injuries is challenging due to disruption of components of upper airway. The anesthesiologist has to share the airway with the surgeons. Oral and nasal routes for intubation are often not feasible. Most patients have associated nasal fractures, which precludes use of nasal route of intubation. Intermittent intraoperative dental occlusion is needed to check alignment of the fracture fragments, which contraindicates the use of orotracheal intubation. Tracheostomy in such situations is conventional and time-tested; however, it has life-threatening complications, it needs special postoperative care, lengthens hospital stay, and adds to expenses. Retromolar intubation may be an option, But the retromolar space may not be adequate in all adult patients. Submental intubation provides intraoperative airway control, avoids use of oral and nasal route, with minimal complications. Submental intubation allows intraoperative dental occlusion and is an acceptable option, especially when long-term postoperative ventilation is not planned. This technique has minimal complications and has better patients’ and surgeons’ acceptability. There have been several modifications of this technique with an expectation of an improved outcome. The limitations are longer time for preparation, inability to maintain long-term postoperative ventilation and unfamiliarity of the technique itself. The technique is an acceptable alternative to tracheostomy for the good per-operative airway access.
Adult; intubation; intratracheal methods; maxillofacial injuries/surgery; oral/methods; surgery
This retrospective study evaluated the safety and efficacy of submental intubation not only for trauma treatment but also for oncological cranial base surgery. The medical records of 24 patients who underwent submental intubation from 1996 to 2002 were reviewed. There were 6 procedures for craniofacial trauma, 12 transmaxillary approaches to the clivus for clivus chordomas, and 6 transmaxillary approaches to the cranial base for chondrosarcomas. Time required for intubation, accidental extubation, postoperative complications, and the healing of intraoral and submental scars were evaluated. The submental orotracheal intubation was completed successfully in all patients. No accidental extubations or tube injuries occurred. The mean time required for intubation was 5 minutes. The only complication was one case of superficial infection of the submental wound. The intraoral and submental accesses healed with minimal scarring in all patients. Submental orotracheal intubation is a useful and safe technique for airway management of craniomaxillofacial traumas and during transfacial approaches to the cranial base. It avoids the complications associated with tracheostomy. It also permits considerable downward retraction of the maxilla after a Le Fort I osteotomy and is associated with good clival exposure. Furthermore, it does not interfere with maxillomandibular fixation at the end of the surgery.
Intubation; submental intubation; chordoma
Management of airway is a significant issue especially in cases of complex maxillofacial trauma like panfacial fractures or concomitant nasoethmoidal injuries, where the nasotracheal intubation is contraindicated or possess a significant problem. In these cases the only other alternative is tracheostomy. Submental intubation is an alternative to tracheostomy and it can be easily performed with little or lesser post-operative complications. This method involves lesser expenses as it does away with longer post-operative stay in the hospital as required by tracheostomy patients.
The patient is orally intubated with a reinforced armoured tube with a detachable plastic gas connector. An incision is made in the submental area of the patient and a tunnel is prepared from this region to the floor of the mouth through which the proximal end of the tube is diverted. Thus the occlusion of the patient can be checked intraoperatively. After completion of the surgery the proximal end in reintroduced onto the oral cavity and the patient is extubated orally.
Originally proposed by Altemir in 1986, this method cannot be used in all cases as it is not without limitations. In spite of these, submental intubation can be a useful alternative to tracheostomy, especially in regions where cost cutting is a major factor in health infrastructure.
Maxillofacial surgeons addressing major facial trauma surgery may have this procedure in mind before opting for tracheostomy. It avoids a lot of complications associated with tracheostomy.
Submental intubation; Maxillofacial surgery; Tracheostomy; Nasoethmoidal injury
In maxillofacial injuries, a choice has often to be made between different ways of intubation when surgical access to fractured nasal bone and simultaneous establishment of occlusion are required. We report our experience with submental intubation in the airway management of complex maxillofacial trauma patients.
To evaluate the outcome of airway management in patients with complex maxillofacial fracture by submental intubation, time required for intubation, accidental extubation, postoperative complications, and to discuss indications, contraindications, advantages and disadvantages of submental intubation.
Settings and Design:
A retrospective study is designed.
Materials and Methods:
The medical records of seven patients who underwent submental intubation from December 2008 to June 2010 were reviewed and no statistical analysis was used.
At the end of the procedure all seven patients were extubated without any complications. Postoperatively only one patient presented with superficial infection of the submental wound.
Submental endotracheal intubation is a simple technique with very low morbidity and can be used as an alternative to tracheostomy in selected cases of maxillofacial trauma.
Panfacial trauma; submental orotracheal intubation; tracheostomy; transmylohyoid intubation
Maxillofacial trauma presents a complex problem due to the disruption of normal anatomy. In such cases, we anticipate a difficult oral intubation that may hinder intraoperative IMF. Nasal and skull base fractures do not advocate use of nasotracheal intubation. Hence, other anesthetic techniques should be considered in management of maxillofacial trauma patients with occlusal derangement and nasal deformity. This study evaluates the indications and outcomes of anesthetic management by retromolar, nasal, submental intubation and tracheostomy.
Of the 49 maxillofacial trauma cases reviewed, that required intraoperative IMF, 32 underwent nasal intubation, 9 patients had tracheostomy, 5 patients utilized submental approach and 3 underwent retromolar intubation.
Among patients who underwent nasal intubation, eight cases needed fiberoptic assistance. In retromolar approach, though no complication was encountered, constant monitoring was mandatory to avoid risk of tube displacement. Consequently, submental intubation required a surgical procedure which could result in a cosmetically acceptable scar. Though invasive, tracheostomy has its benefits for long term ventilation.
Intubation of any form performed in a maxillofacial trauma patient is complex and requires both sound judgement and considerable experience.
Maxillofacial trauma; Nasal intubation; Submental intubation; Retromolar technique; Tracheostomy; Intermaxillary fixation
Submental intubation (SI) has been proposed as an alternative to nasoendotracheal intubation when oral endotracheal intubation is contraindicated. In patients who require intubation for maxillofacial reconstruction, this is an alternative to a traditional tracheostomy. The present case report presents an 18-year-old woman who suffered a comminuted mandibular fracture. Two days after her accident, she was taken to the operating room for open reduction with internal fixation of her mandible; however, the anesthesia staff was unable to nasally intubate the patient. A SI was performed. The procedure was completed without complications and the surgery accomplished with the SI. The patient was able to avoid a tracheostomy for an isolated operation. SI avoids the dangers of nasoendotracheal intubation in patients with midfacial fractures and avoids complications related to tracheostomy. Thus, SI may serve as an alternative to tracheostomy in patients without other medical conditions and indications for long-term intubation.
Facial fractures; Maxillomandibular fixation; Maxillofacial reconstruction; Submental intubation
Submental endotracheal intubation is a simple and secure alternative to either nasoendotracheal intubation or a tracheostomy in the airway management of maxillofacial trauma. However, a submental endotracheal intubation is quite difficult to manage if adverse events such as a tube obstruction, accidental extubation, or a leaking cuff with the endotracheal tube in the submental route occur, which could endanger the patient. This paper describes the use of a LMA-Fastrach™ETT in the submental endotracheal intubation of patients suffering from maxillofacial trauma. One of the patients was a 16-year-old male, and the other was a 19-year-old male. They were scheduled for an open reduction and internal fixation of the maxillofacial fracture including naso-orbital-ethmoidal (NOE) complex, and a zygomaticomaxillary complex fracture. A submental intubation with a LMA-Fastrach™ETT was performed in both cases, and the operation proceeded without any difficulties. These cases show that the use of the LMA-Fastrach™ETT can improve the safety and efficacy of submental endotracheal intubation. This is because the LMA-Fastrach™ETT has a freely detachable connector, and is flexible enough to keep the patency despite the acute angle of airway.
LMA-Fastrach™ETT; maxillofacial trauma; submental intubation
Hernandez first described the submental route for endotracheal intubation in 1986 as an alternative airway maneuver for maxillofacial procedures. Since that time, several case studies have been performed demonstrating the efficacy of the submental approach. This method was recently implemented in the case of a patient with altered nasal anatomy who sustained a mandibular fracture necessitating maxillomandibular fixation. Unlike most of the cases described in the literature, this patient's operative course was confounded by the need to extubate through the submental tunnel. The patient tolerated the procedure well and was able to avoid other forms of surgical airway.
Airway management for patients who suffered midfacial fractures is complicated. In maxillofacial injuries, a choice has often to be made between different ways of intubation when surgical access to both the nasal and oral cavities is necessary. Submental intubation technique is an alternative to nasoendotracheal intubation and tracheostomy in the management of patients with severe midfacial fractures. This procedure is simple to do and has a low morbidity.
Submental intubation-paramedian technique has been used in 15 cases from May 2005–April 2007 in Hosmat Hospital, Bangalore. All patients had fractures disturbing the dental occlusion plus either an associated fracture of the skull base or a displaced nasal fracture.
Average duration of procedure was 7 minutes. Average duration of tube in vitro after surgery was 20 hours. There were 2 postoperative complications of tube obstruction which were successfully managed.
Submental intubation demands certain technical skills but it is simple, rapid and may avoid tracheostomy in selected patients.
Midfacial fractures; Submental intubation; Maxillofacial injuries
Oromaxillofacial surgical procedures present a unique set of problems both for the surgeon and for the anesthesist. Achieving dental occlusion is one of the fundamental aims of most oromaxillofacial procedures. Oral intubation precludes this surgical prerequisite of checking dental occlusion. Having the tube in the field of surgery is often disturbing for the surgeon too, especially in the patient for whom skull base surgery is planned. Nasotracheal intubation is usually contraindicated in the presence of nasal bone fractures seen either in isolation or as a component of Le Fort fractures. We utilized submental endotracheal intubation in such situations and the experience has been very satisfying.
Materials and Methods:
The technique has been used in 20 patients with maxillofacial injuries and those requiring Le Fort I approach with or without maxillary swing for skull base tumors. Initial oral intubation is done with a flexo-metallic tube. A small 1.5 cm incision is given in the submental region and a blunt tunnel is created in the floor of the mouth staying close to the lingual surface of mandible and a small opening is made in the mucosa. The tracheal end of tube is stabilized with Magil′s forceps, and the proximal end is brought out through submental incision by using a blunt hemostat taking care not to injure the pilot balloon. At the end of procedure extubation is done through submental location only.
The technique of submental intubation was used in a series of twenty patients from January 2005 to date. There were fifteen male patients and five female patients with a mean age of twenty seven years (range 10 to 52). Seven patients had Le Fort I osteotomy as part of the approach for skull base surgery. Twelve patients had midfacial fractures at the Le Fort II level, of which 8 patients in addition had naso-ethomoidal fractures and 10 patients an associated fracture mandible. Twelve patients were extubated in the theatre. Eight patients had delayed extubation in the post-operative ward between 1 and 3 days postoperatively.
In conclusion, the submental intubation technique has proved to be a simple solution for many a difficult problem one would encounter during oromaxillofacial surgical procedures. It provides a safe and reliable route for the endotracheal tube during intubation while staying clear of the surgical field and permitting the checking of the dental occlusion, all without causing any significant morbidity for the patient. Its usefulness both in the emergency setting and for elective procedures has been proved. The simplicity of the technique with no specialized equipment or technical expertise required makes it especially advantageous. This technique therefore, when used in appropriate cases, allows both the surgeon and the anesthetist deliver a better quality of patient care.
Avoiding tracheostomy; oromaxillofacial surgery; intubation
Complex maxillofacial trauma requires a modification of intubation as it precludes both oral and nasal intubation. Tracheostomy is not preferred due to its associated complications. Submental intubation comes as a rescue in such situations as it provides an uninterrupted access to the operative field with due control over airway and minimal side effects.
Difficult intubation; submental intubation; Maxillofacial injury
To describe a modified technique for submental intubation in severely traumatized maxillofacial patients and to evaluate complications arising from the procedure.
Materials and Methods:
Submental intubation was performed in twelve patients with maxillofacial trauma ,from 2007-2012, which were operated under general anesthesia for treatment of facial fractures.
The patients ranged in age from 14 to 39 years. No complications due to submental intubation, such as infection, hypertrophic scarring, lingual nerve injury, hematoma, bleeding, ranula formation, or orocutaneous fistula, were observed following submental intubation.
Submental intubation is a very useful technique in the management of maxillofacial trauma patients, with a low complication rate.
Intubation; Jaw fracture; Submental
Changes in middle cerebral arterial flow velocity (MCAV) during rapid intravenous induction and awake intubation using transcranial Doppler sonography were investigated. The study involved 20 patients without disorders of the central nervous or cardiovascular systems who were scheduled for maxillofacial surgery. In the intravenous induction group, anesthesia was induced with sodium thiopental, and orotracheal or nasotracheal intubation was facilitated with succinylcholine chloride or alcuronium chloride. In the awake intubation group, orotracheal or nasotracheal intubation was performed under intravenous sedation with diazepam and topical anesthesia with 4% lidocaine. Arterial blood pressures, heart rate, and MCAV were monitored at specific intervals. During intravenous induction, blood pressures decreased after the administration of thiopental and muscle relaxants and increased during endotracheal intubation. MCAV was remarkably slowed after the administration of thiopental and during mask ventilation. During awake intubation, blood pressures were increased by endotracheal intubation. MCAV was decreased from the administration of diazepam to the transtracheal injection of lidocaine, but returned to the control value from endotracheal spray to endotracheal intubation. These results suggest that smooth awake intubation may be the safest method of induction for patients with cerebrovascular disorders.
Airway management in patients with maxillofacial trauma is complicated by injuries to routes of intubation, and the surgeon is frequently asked to secure the airway. Airway obstruction from hemorrhage, tissue prolapse, or edema may require emergent intervention for which multiple intubation techniques exist. Competing needs for both airway and surgical access create intraoperative conflicts during repair of maxillofacial fractures. Postoperatively, edema and maxillomandibular fixation place the patient at risk for further airway compromise.
Airway obstruction; facial injuries; intubation; jaw fractures; laryngeal masks; mandibular fractures; maxillary fractures; maxillofacial injuries; tracheostomy
The study conducted is the retrospective study and the main objective is to evaluate the benefits and safety of early versus late tracheostomy in traumatic spinal cord injury (SCI) patients requiring mechanical ventilation. Tracheostomy offers many advantages in critical patients who require prolonged mechanical ventilation. Despite the large amount of patients treated, there is still an open debate about advantages of early versus late tracheostomy. Early tracheostomy following the short orotracheal intubation is probably beneficial in appropriately selected patients. It is a retrospective clinical study and we evaluated clinical records of 152 consecutive trauma patients who required mechanical ventilation and who received tracheostomy. The results show that the early placement (before day 7 of mechanical ventilation) offers clear advantages for shortening of mechanical ventilation, reducing ICU stay and lowering rates of severe orotracheal intubation complication, such as tracheal granulomas and concentric tracheal stenosis. On the other hand, we could not demonstrate that early tracheostomy avoids neither risk of ventilator-associated pneumonia nor the mortality rate. In SCI patients, the early tracheostomy was associated with shorter duration of mechanical ventilation, shorter length of ICU stay and decreased laryngotracheal complications. We conclude by suggesting early tracheostomy in traumatic SCI patients who are likely to require prolonged mechanical ventilation.
Tracheostomy; Spinal cord injury; Mechanical ventilation
Objectives. Airway control is the most critical treatment. The most common and basic method of endotracheal intubation is orotracheal intubation. To perform accurate and rapid tracheal intubation, appropriate education and training are required. We developed the virtual simulation program utilizing the 3-dimensional display and haptic device to exercise orotracheal intubation, and the educational effect of this program was compared with that of the mannequin method. Method. The control group used airway mannequin and virtual intubation group was trained with new program. We videotaped both groups during objective structured clinical examination (OSCE) with airway mannequin. The video was reviewed and scored, and the rate of success and time were calculated. Result. The success rate was 78.6% in virtual intubation group and 93.3% in control group (P = 0.273). There was no difference in overall score of OSCE (21.14 ± 4.28 in virtual intubation group and 23.33 ± 4.45 in control group, P = 0.188), the time spent in successful intubation (P = 0.432), and the number of trials (P > 0.101). Conclusion. The virtual simulation with haptics had a similar effect compared with mannequin, but it could be more cost effective and convenient than mannequin training in time and space.
Treatment techniques for airway obstruction in croup and epiglottitis are reviewed in the medical literature. Series totaling 295 nasotracheal intubations, and 591 tracheostomies were reviewed. There were two deaths attributable to airway complications in 126 patients in whom nasotracheal intubation was carried out. In three patients subglottic granulation tissue and subglottic stenoses developed from short-term nasotracheal intubation. There were no subglottic stenoses or tracheal stenoses reported in the 591 tracheostomies. From this review, it would seem feasible to use nasotracheal intubation for short-term airway treatment in croup and epiglottitis. The increasing occurrence of laryngeal and tracheal complications with long-term intubation suggests that tracheostomy be considered in such cases.
We present the case of a dermoid cyst with an oral and a submental component in a 21-year-old Japanese woman who presented with complaints of a mass in the oral cavity and difficulty in chewing and swallowing solid foods for about 2 years. MRI shows a 55 × 65 mm well-circumscribed cystic mass extending from the sublingual area to the mylohyoid muscle. Under general anesthesia and with nasotracheal intubation, the patient underwent surgical removal of the mass. Although the cyst was large and extending mylohyoid muscle, intraoral midline incision was performed through the mucosa overlying the swelling and the cyst was separated from the surrounding tissues with appropriate traction and countertraction and successfully removed without extraoral incision. Oral approach in surgical enucleation is useful procedure to avoid cosmetic problems in large and extending mylohyoid muscle cyst.
A significant proportion of trauma patients require tracheostomy during intensive care unit stay. The timing of this procedure remains a subject of debate. The decision for tracheostomy should take into consideration the risks and benefits of prolonged endotracheal intubation versus tracheostomy. Timing of tracheostomy is also influenced by the indications for the procedure, which include relief of upper airway obstruction, airway access in patients with cervical spine injury, management of retained airway secretions, maintenance of patent airway and airway access for prolonged mechanical ventilation. This review summarizes the potential advantages of tracheostomy versus endotracheal intubation, the different indications for tracheostomy in trauma patients and studies examining early versus late tracheostomy. It also reviews the predictors of prolonged mechanical ventilation, which may guide the decision regarding the timing of tracheostomy.
False passage and loss of airway during tracheostomy are not uncommon, especially in patients with short and thick necks. Distorted neck anatomy following either repeated insertion attempts or due to underlying malignancy may make it very difficult to locate the trachea even while attempting open/surgical tracheostomy, despite good exposure of the neck in such situations. The lightwand is not an ideal device for tracheal intubation in such patients. However, it can be useful in these patients while performing open tracheostomy. Passing the lightwand through the orotracheal tube can aid in rapid identification of the trachea in such situations and may help reduce the occurrence of complications subsequent to repeated false passage. We report a series of four such cases where use of lightwand aided in rapidly locating the trachea during tracheostomy complicated by distorted anatomy.
Decannulation; distorted anatomy; false passage; lightwand; open tracheostomy
Endotracheal intubation is widely used for airway management in a prehospital setting, despite a lack of controlled trials demonstrating a positive effect on survival or neurological outcome in adult patients. The benefits, in term of outcomes of invasive airway management before reaching hospital, remain controversial. However, inadequate airway management in this patient population is the primary cause of preventable mortality. An increase in intubation failures and in the rate of complications in trauma patients should induce us to improve airway management skills at the scene of trauma. If the addition of emergency physicians to a prehospital setting is to have any influence on outcome, further studies are merited. However, it has been established that sedation with rapid sequence intubation is superior in terms of success, complications and rates of intubation difficulty. Orotracheal intubation with planned neuromuscular blockade and in-line cervical alignment remains the safest and most effective method for airway control in patients who are severely injured.
airway management; intubation; prognosis; trauma patients
To assess the effect of timing and techniques of tracheostomy on morbidity, mortality, and the burden of resources in patients with acute traumatic spinal cord injuries (SCIs) undergoing mechanical ventilation.
Review of a prospectively collected database.
Intensive and intermediate care units of a monographic hospital for the treatment of SCI.
Consecutive patients admitted to the intensive care unit (ICU) during their first inpatient rehabilitation for cervical and thoracic traumatic SCI. A total of 323 patients were included: 297 required mechanical ventilation and 215 underwent tracheostomy.
Demographic data, data relevant to the patients’ neurological injuries (level and grade of spinal cord damage), tracheostomy technique and timing, duration of mechanical ventilation, length of stay at ICU, incidence of pneumonia, incidence of perioperative and early postoperative complications, and mortality.
Early tracheostomy (<7 days after orotracheal intubation) tracheostomy was performed in 101 patients (47%) and late (≥7 days) in 114 (53%). Surgical tracheostomy was employed in 119 cases (55%) and percutaneous tracheostomy in 96 (45%). There were 61 complications in 53 patients related to all tracheostomy procedures. Two were qualified as serious (tracheoesophageal fistula and mediastinal abscess). Other complications were mild. Bleeding was moderate in one case (late, percutaneous tracheostomy). Postoperative infection rate was low. Mortality of all causes was also low.
Early tracheostomy may have favorable effects in patients with acute traumatic SC. Both techniques, percutaneous and surgical tracheostomy, can be performed safely in the ICU.
Spinal cord injuries; Cervical; Thoracic; Mechanical ventilation; Tracheostomy; Percutaneous; Surgical; Complications; Spine surgery
Thyroglossal cysts are one of the most common midline neck masses. They usually present as midline painless cystic neck mass in the first three decades of life. These anomalies are very rare in elderly patients and may pose difficult diagnostic and therapeutic challenges. Here, we report a case of giant thyroglossal cyst in a 72-year-female patient who presented with stridor, hoarseness of voice, and vocal cord paresis with gross distortion of normal airway anatomy secondary to pressure effect of the mass. The gross distortion and displacement of airway along with respiratory distress in this patient posed a difficult situation in securing the airway. The airway was secured by a unique way of orotracheal intubation with the help of a ventilating airway exchange catheter. The cyst was excised in toto under general anaesthesia. The stridor completely resolved after surgery and tracheostomy was avoided.
Thirty-four intensive care patients who received elective tracheostomies were studied to determine the incidence and nature of complications associated with tracheostomies. Indication for tracheostomy was long-term ventilation. Adverse consequences occurred in 47% of the patients. The most frequent problem was pneumonia. There were no intraoperative complications. Two deaths occurred due to delayed haemorrhage. Some complications of tracheostomy were influenced by the preceding period of endotracheal intubation. In patients requiring prolonged mechanical ventilation, tracheostomy carries a considerable risk. Optimal airway care only will reduce the incidence of complications.