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1.  Submental intubation in patients with panfacial fractures: A prospective study 
Indian Journal of Anaesthesia  2011;55(3):299-304.
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.
doi:10.4103/0019-5049.82685
PMCID: PMC3141161  PMID: 21808409
Airway management; panfacial fractures; submental intubation
2.  Airway Management in Maxillofacial Trauma: Do We Really Need Tracheostomy/Submental Intubation 
Background: There are various techniques available for airway management in patients with maxillofacial trauma. Patients with panfacial injuries may need surgical airway access like submental intubation or tracheostomy, which have their associated problems. We have been managing these types of cases by a novel technique, i.e, intraoperative change of nasotracheal to orotracheal intubation.
Aim: To review our experience about various techniques for the airway management in patient with maxillofacial trauma. To analyse the possibility of using nasotracheal intubation and intraoperative change of nasotracheal to orotracheal intubation in panfacial fractures.
Materials and Methods: In a tertiary care centre four hundred eighty seven patients of maxillofacial injuries, operated over a period of 2 years were reviewed in relation to age, sex, mode of injury, type of facial fractures, methods of airway management and their associated complications.
Results: Young patients with male predominance is the most common affected population. Panfacial fracture is the most common type of injury (39.83%) among facial fractures. Airway was managed with intraoperative change of nasotracheal to orotracheal intubation in 33.05% of the patients whereas submental intubation or tracheostomy was done in 8.62% of the patients.
Conclusion: Nasal route for endotracheal intubation is not a contraindication in the presence of nasal fractures, base of skull fractures and CSF leak. By changing the nasotracheal intubation to orotracheal intubation intraoperatively in cases panfacial fractures, most of the tracheostomies and submental intubations can be avoided.
doi:10.7860/JCDR/2014/7861.4112
PMCID: PMC4003693  PMID: 24783087
Maxillofacial trauma; Airway management; Naso-tracheal intubation; Oro-tracheal intubation
3.  Submental Orotracheal Intubation: An Alternative to Tracheotomy in Transfacial Cranial Base Surgery 
Skull Base  2003;13(4):189-195.
ABSTRACT
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.
doi:10.1055/s-2004-817694
PMCID: PMC1131851  PMID: 15912177
Intubation; submental intubation; chordoma
4.  Submental Intubation: An Alternative and Cost-Effective Technique for Complex Maxillofacial Surgeries 
Introduction
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.
Technique
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.
Discussion
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.
Conclusion
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.
doi:10.1007/s12663-010-0084-x
PMCID: PMC3177441  PMID: 22190802
Submental intubation; Maxillofacial surgery; Tracheostomy; Nasoethmoidal injury
5.  Submental orotracheal intubation: Our experience and review 
Introduction:
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.
Aims:
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.
Results:
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.
Conclusions:
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.
doi:10.4103/2231-0746.83154
PMCID: PMC3591038  PMID: 23482892
Panfacial trauma; submental orotracheal intubation; tracheostomy; transmylohyoid intubation
6.  Submental intubation for airway management of patients with complex caniomaxillofacial injuries: Our experience 
Context:
There is paucity of data regarding the role of submental intubation (SI) in the airway management of patients with craniomaxillofacial trauma from India.
Aims:
To study the characteristics of patients presenting with craniomaxillofacial injuries requiring submental intubation, the duration of SI procedure and complications of this technique.
Settings and Design:
Tertiary level, teaching institute, retrospective, observational study.
Materials and Methods:
Forty patients requiring submental intubation between June, 2007 and December, 2009. The primary outcome measure was the time required for submental intubation defined as starting from the completion of the orotracheal intubation to the fixation of the submental tube. The secondary outcome measures included characteristics of patients with craniomaxillofacial injuries, intraoperative and postoperative complications of the SI technique.
Statistical Analysis Used:
Data are presented as mean± standard deviation and frequency and percentages, where relevant.
Results:
Most of the patients were young (average age = 35.15 ± 12.02 years), males (75%) and sustained craniomaxillofacial injuries due to road traffic accidents (85%). The 40 patients included in this audit had 56 injuries recorded at the time of admission including, orthopedic injuries in 65% and head injuries in 55% of patients. The mean time required for completion of SI was 8.90 min. The complications observed included, intraoperative tube migration, development of extra oral fistula, and sialocele, in one patient each.
Conclusions:
Submental intubation is a simple, safe, quick, and relatively harmless alternative to tracheostomy for securing the airway in selected patients with craniofacial trauma. Familiarity with the submental intubation technique will help the anesthesiologist to avoid tracheostomy in selected patients with craniofacial trauma who do not require long-term mechanical ventilation.
doi:10.4103/0259-1162.108301
PMCID: PMC4173446
Complications; maxillofacial injuries; submental intubation; tracheostomy
7.  Submental intubation: An option of airway management for rhinoplasty and rhytidectomy 
Context:
For rhinoplasty, full control of facial symmetry will improve the aesthetic results. During rhinoplasty, the nasal intubation is contraindicated while oral intubation may interfere with surgical procedure. Hence an alternative airway option of the submental intubation was planned to study the efficacy of the procedure.
Aims:
The submental intubation may improve the aesthetic results of rhinoplasty and facial symmetry.
Setting and Design:
This is a prospective cohort observational study.
Materials and Methods:
Fifteen adult consented patients of ASA grade I and II of either gender aged 20 to 38 years who met the inclusion criteria were enrolled. After induction, orotracheal intubation was done with flexometallic tube, followed by a 1.5-cm skin incision in the submental region, adjacent to lower border of mandible;then endotracheal tube was taken out through this incision. At the end of surgery, the procedure was reversed and submental wound was stitched. Patients were extubated after proper suctioning of oral cavity. No intraoperative and postoperative complications have occurred.
Results:
The submental intubation was performed in 15 patients by medial approach without any difficulty. The average time taken to perform the procedure was 7.27±0.63 min. No anesthetic and surgical complications were encountered in any patients. The submental scar was almost invisible after 2 months.
Conclusion:
Submental intubation offers a secure airway, efficient ventilation, and uninterrupted operating field to the plastic surgeon. Lack of anesthesia and surgical complications encouraged us to present the advantages of submental intubation on the basis of our own experience.
doi:10.4103/0259-1162.84195
PMCID: PMC4173372
Aesthetic scar; flexometallic endotracheal tube; rhinoplasty; submental intubation
8.  Submental tracheal intubation in oromaxillofacial surgery 
Background:
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.
Results:
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.
Conclusion:
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.
doi:10.4103/0970-0358.41105
PMCID: PMC2739561  PMID: 19753195
Avoiding tracheostomy; oromaxillofacial surgery; intubation
9.  Submental Intubation in Maxillofacial Surgery: A Prospective Study 
We designed a prospective study with the objective to evaluate the efficacy, indications and our experience of submental intubation in different types of maxillofacial surgeries. From May 2008 to August 2010, 23 patients with different conditions were intubated by submental route of tracheal intubation and patients were evaluated on different parameters during and after surgery to find its efficacy, indications and utilization in maxillofacial surgeries. All the patients were managed well with this technique of intubation with no significant difference in intubation and extubation time. We did not face any uneventful complication. There was only one reported complication that is rupture of the bulb of cuffed flexometallic tube but was managed well by changing tube. We found skull base access surgery as a new indication for submental intubation. The submental route for endotracheal intubation may be utilized as an alternative to blind nasal intubation or tracheostomy in the surgical management of patients involving complex maxillofacial surgeries. We hypothesized that the submental intubation should not be used where long term ventilation support is needed. We did a technique modification to deliver the endotracheal tube out from the submental region to avoid pilot cuff damage. Our study proposes that skull base access surgery is a safe and potential indication for submental intubation. In our experience submental intubation is a simple, secure and effective procedure for operative airway control in major maxillofacial surgeries.
doi:10.1007/s12663-012-0432-0
PMCID: PMC3777045  PMID: 24431850
Submental; Maxillofacial surgery; Intubation
10.  Submental Intubation with Reinforced Tube for Intubating Laryngeal Mask Airway 
Yonsei Medical Journal  2005;46(4):571-574.
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.
doi:10.3349/ymj.2005.46.4.571
PMCID: PMC2815845  PMID: 16127785
LMA-Fastrach™ETT; maxillofacial trauma; submental intubation
11.  Current Perspectives in Intra Operative Airway Management in Maxillofacial Trauma 
Objective
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.
Methodology
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.
Results
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.
Conclusion
Intubation of any form performed in a maxillofacial trauma patient is complex and requires both sound judgement and considerable experience.
doi:10.1007/s12663-011-0316-8
PMCID: PMC3386414  PMID: 23730059
Maxillofacial trauma; Nasal intubation; Submental intubation; Retromolar technique; Tracheostomy; Intermaxillary fixation
12.  Submental/Transmylohyoid Route for Endotracheal Intubation in Maxillofacial Surgical Procedures: A Review 
Patients with severe panfacial injuries usually require long-term airway management. Nasal intubation may be contraindicated in case of nasoorbitoethmoidal fractures and also there may be a need for intraoperative and short-term postoperative intermaxillary fixation to achieve optimum reduction of fractures. The need for unobstructed access to the perinasal area during bimaxillary orthognathic procedures is felt many a time and to avoid a tracheostomy with its attending morbidity, many techniques have evolved that involve a submandibular/transmylohyoid or submental approach for temporary oroendotracheal intubation. In this article, we present our experience of patients by using submental/transmylohyoid route for endotracheal intubation. technique gives the surgeon and the anesthetist comfortable control over their respective domains, is easy to learn and implement in the operating protocol with no added costs. How to cite the article: Prakash VJ, Chakravarthy C, Attar AH. Submental/transmylohyoid route for endotracheal intubation in maxillofacial surgical procedures: A review. J Int Oral Health 2014;6(3):125-8.
PMCID: PMC4109242  PMID: 25083048
Intubation; orthognathic surgery; panfacial trauma; submental; tracheostomy; transmylohyoid
13.  A novel method using Seldinger's technique for submental intubation in major craniomaxillofacial fractures: A case series 
Indian Journal of Anaesthesia  2014;58(1):48-50.
Airway management is a challenge to anesthesiologists particularly in maxillofacial surgeries. The oral tracheal tube is unsuitable because it interferes with the surgical field and prevents dental occlusion. Nasotracheal intubation may not always be possible due to structural deformity or trauma to the nasal bones. Tracheostomy and submental intubation have their drawbacks. To overcome these shortcomings we used Percutaneous Dilatational Tracheostomy Kit (PDTK) to modify the technique of submental intubation. Serial dilatations were performed over the guide wire before passing the tracheal tube by submental route, using the PDT kit in four patients. Submental intubation could be achieved in all the four cases with this technique and there were no associated complications. Seldinger's technique is a simple and easy technique with minimal bleeding, imperceptible scar, and more importantly anesthesiologists feel more comfortable because of their familiarity with the Seldinger technique.
doi:10.4103/0019-5049.126795
PMCID: PMC3968651  PMID: 24700899
Maxillofacial surgeries; percutaneous dilatational tracheostomy kit; seldinger's technique
14.  Submental intubation: A journey over the last 25 years 
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.
doi:10.4103/0970-9185.98320
PMCID: PMC3409936  PMID: 22869933
Adult; intubation; intratracheal methods; maxillofacial injuries/surgery; oral/methods; surgery
15.  Submental orotracheal intubation: A better alternative to tracheostomy in panfacial fractures 
Surgical repair of complex maxillofacial trauma presents a challenge to the surgeon and anaesthetist. Submental intubation is an alternative where oral and nasal intubation cannot be used. We present a case where tracheostomy was avoided in a patient with multiple maxillofacial fractures by opting for sub-mental endotracheal intubation technique. Time required for intubation, accidental extubation, postoperative complications, and the healing of intraoral and submental scars were evaluated. The technique avoids the complications associated with tracheostomy.
doi:10.4103/0259-1162.123278
PMCID: PMC4173555
Complex maxillofacial trauma; intubation; submental intubation; tracheostomy
16.  Submental intubation: our experience 
Introduction
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.
Material
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.
Results
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.
Conclusion
Submental intubation demands certain technical skills but it is simple, rapid and may avoid tracheostomy in selected patients.
doi:10.1007/s12663-010-0018-7
PMCID: PMC3453707  PMID: 23139571
Midfacial fractures; Submental intubation; Maxillofacial injuries
17.  Transmylohoid/Submental Endotracheal Intubation in Pan-facial Trauma: A Paradigm Shift in Airway Management with Prospective Study of 35 Cases 
The present study was planned to assess the efficacy, utility and complications of transmylohoid intubation in facial polytrauma patients, by setting and design: prospective study. This study was conducted between May 2008 and May 2011 and 35 patients of facial polytrauma were included irrespective of sex, caste and religion. All the selected 35 patients were male and the age of patients ranged between 15 to 45 years (mean age 31 years). All the patients were intubated with transmylohoid, orotracheal intubation using an armoured endotracheal tube (ETT). Average time to perform transmylohoid intubation was 15.51 + 1.85 min (mean + standarad deviation). Average time for drawing the ETT transmylohoid from the submental incision was 49.7 + 24.8 s. Mean duration for which the ETT was kept indwelling was 0.37 + 1.03 days. Accidental extubation of ETT was noted in two patients. Minor post operative complications like swelling in the submental area (2 patient), dehiscence of the submental incision (2 patient) and minor infection at the site of submental incision (3 patients) were noticed, which were found to be statistically insignificant. The transmylohoid intubation allowed simultaneous reduction and fixation of all the facial fractures and intraoperative control of dental occlusion without interference from the tube during the surgery without interfering in the maintenance of the anesthesia and air way.
doi:10.1007/s12070-012-0505-x
PMCID: PMC3696155  PMID: 24427577
Transmylohoid; Intubation; Submental; Airway; Maxillofacial trauma; Facial Polytrauma
18.  Submental intubation: An alternative to tracheostomy when nasoendotracheal intubation is unsuccessful – A case report 
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.
PMCID: PMC2827288  PMID: 21119832
Facial fractures; Maxillomandibular fixation; Maxillofacial reconstruction; Submental intubation
19.  Submental Intubation Including Extubation: Airway Complications of Maxillomandibular Fixation 
Case Reports in Anesthesiology  2012;2012:841051.
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.
doi:10.1155/2012/841051
PMCID: PMC3530757  PMID: 23304563
20.  Submental Intubation in Maxillofacial Trauma Patients 
Introduction:
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.
Results:
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.
Conclusion:
Submental intubation is a very useful technique in the management of maxillofacial trauma patients, with a low complication rate.
PMCID: PMC3846236  PMID: 24303414
Intubation; Jaw fracture; Submental
21.  Incidence and predictors of difficult nasotracheal intubation with airway scope 
Journal of Anesthesia  2014;28(5):650-654.
Purpose
The airway scope (AWS) improves views of the larynx during orotracheal intubation. However, the role of the AWS in routine nasotracheal intubation has not been studied adequately.
Methods
One hundred and three patients undergoing dental and maxillofacial surgery that required general anesthesia and nasotracheal intubation were enrolled. The study was approved by our Institution Review Board, and written informed consent was obtained from all patients. We evaluated the success rate of AWS intubation and the incidence of difficult nasotracheal intubation using a modified intubation difficulty scale (IDS) to examine preoperative characteristics and intubation profiles. Categories were difficult intubation (IDS ≥5), mildly difficult (IDS = 1–4), and intubation without difficulty (IDS = 0). We also assessed the incidence of the use of Magill forceps or cuff inflation (the cuff of endotracheal tube is inflated with 10–15 ml air) to guide the endotracheal tube into the glottis.
Results
AWS nasotracheal intubation was 100 % successful. The cuff inflation technique was used in 37 patients. Neither Magill forceps nor other devices were needed for any patient during AWS use. The incidence of difficult nasotracheal intubation was 10 % (n = 10). Of the patients, 61 % (n = 63) had mildly difficult intubation and 29 % (n = 30) had no difficulty. Patients with difficult intubation were more likely to be male and to have a larger tongue and a higher Cormack grade than in the other two groups. Complications, involving minor soft tissue injury, were observed in only 1 patient (1 %).
Conclusion
The AWS achieves a high success rate for nasotracheal intubation with cuff inflation in patients undergoing dental and maxillofacial surgery.
doi:10.1007/s00540-013-1778-2
PMCID: PMC4194022  PMID: 24435879
Airway scope; Video laryngoscope; Difficult nasotracheal intubation
22.  Combating Nasal Septum Deviation in Le Fort 1 Orthognathic Surgery Complications, with Submental Intubation 
Introduction: Orthognathic Le Fort 1 osteotomy, a surgical procedure performed to correct the aesthetics of mid face. Some of the complications of this surgery are hemorrhage, loss of sensation due to facial nerve damage, nasal septum deviation leading to crooked nose and snoring. Nasal septum deviation is the most common complication and one of the most noticeable complications that is developed during the Le Fort 1 osteotomy.
Aim: To ascertain that Submental Intubation in Orthognathic Le Fort 1 Osteotomy combats Nasal septum Deviation.
Materials and Methods: Medical records and clinical data of 32 patients who underwent orthognathic Le Fort 1 Osteotomy under submental orotracheal intubation were analyzed to understand if nasal septum deviation and other complications of Le Fort 1 Osteotomy occurred in such cases based on 6 parameters.
Results: No complications of nasal septum deviation or other complications that’s associated with orthognathic Le Fort 1 Osteotomy were found in the 32 cases that were analyzed.
Discussion: The surgeon needs to have a non-obtrusive nasal canal so as to determine the extent to which the nasal septum needs to be reduced so that it does not cause nasal septum deviation post the procedure. Submental oratracheal intubation provides the surgeon with an excellent view of the operating field, enough space for intra oral manipulation of the bone and septum for intra oral operation and control of dental occlusion.
Conclusion: Submental intubation is a better method of intubation during Le Fort 1 osteotomy as it does not cause nasal septum deviation or other associated complications.
doi:10.7860/JCDR/2014/8735.4497
PMCID: PMC4129313  PMID: 25121064
Le Fort 1 ostotomy; Nasal septum deviation Submental intubation
23.  Effective Use of Bronchial Blockers in Lung Isolation Surgery: An Analysis of 130 Cases 
The Ochsner Journal  2013;13(3):389-393.
Background
One-lung ventilation (OLV) is necessary for selected surgical settings and medical conditions. Different methods have been described and used to isolate 1 lung, including the double-lumen endotracheal tube (DLT) and a variety of bronchial blockers (BBs). This selection is often based on the preferences and experiences of the anesthesiologist and surgeon. Complications associated with OLV isolation tubes have been previously described, but complications specifically associated with the Cohen BB (CBB) (Cook Medical, Bloomington, IN) have not been investigated. The purpose of this retrospective review was to determine the incidence of vocal cord injury, tracheobronchial injury, and hoarseness in adult patients who underwent OLV with the CBB.
Methods
We reviewed electronic anesthesia records, operative dictation, and inpatient progress notes to collect information about vocal cord injury, bronchial injury, hoarseness, and sore throat for adults who underwent surgical and diagnostic procedures requiring OLV. Secondary endpoints were types of surgical procedures, degree of difficulty with orotracheal intubation, ability of the patient to tolerate extubation in the operating room, and whether the thoracic surgeon deemed the lung separation adequate. P<0.05 was considered significant.
Results
Of 130 patients, 113 underwent OLV with a CBB, and 17 patients underwent OLV with a DLT. The thoracic surgeon deemed the lung isolation adequate in all cases. Airway injury occurred in 2 patients with a CBB and none with a DLT (P=0.86). Both airway injuries were attributed to surgical technique. Two cases of postoperative hoarseness occurred in the CBB group (P=0.86). One injury was attributed to vagus nerve transection, and the other injury was diagnosed as vocal cord paralysis of unknown etiology. In 1 case, orotracheal intubation with a DLT was unsuccessful because of intubation difficulty and required conversion to a regular endotracheal tube and CBB for successful lung isolation.
Conclusion
This study demonstrates that the use of CBB can be successful in a wide variety of thoracic operations, has minimal complications, eliminates the need for tracheal tube exchange when postoperative mechanical ventilation is required, and effectively isolates the lungs of critically ill patients.
PMCID: PMC3776516  PMID: 24052770
Bronchi; intubation–intratracheal; one-lung ventilation; thoracic surgical procedures
24.  Submental intubation: A useful adjunct in panfacial trauma 
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.
doi:10.4103/0975-5950.69159
PMCID: PMC3304183  PMID: 22442557
Difficult intubation; submental intubation; Maxillofacial injury
25.  Pyriform Sinus Localization-Assisted Blind Intubation: Comparison with Laryngoscopic Intubation 
Background
Conventional endotracheal intubation requires laryngoscopy for a direct view of the glottis. However, laryngoscopy is associated with many potential complications. The aim of the present study was to compare the efficacy and safety of pyriform sinus localization-assisted blind orotracheal intubation with those of conventional laryngoscopic orotracheal intubation.
Material/Methods
A randomized, patient-blind, prospective study of 300 patients who underwent various operations was performed. One hundred patients were assigned to the laryngoscopic intubation group (laryngoscopy group), and 200 patients were assigned to the blind intubation group (blind group).
Results
The total intubation success rate in the blind group was similar to that in the laryngoscopy group (100% vs. 99%, respectively; p=0.33). Oxygen saturation by pulse oximetry in both groups was maintained at >98%. The intubation time was significantly shorter in the blind group than in the laryngoscopy group (9.7±3.4 s vs. 23.0±5.8 s, respectively; p<0.001). Postoperative complication rates were significantly lower in the blind group than in the laryngoscopy group. Recovery time from these symptoms was significantly shorter in the blind group than in the laryngoscopy group (p=0.004).
Conclusions
Pyriform sinus localization-assisted blind orotracheal intubation was shown to be more effective than conventional laryngoscopic orotracheal intubation in terms of success rate, intubation time, and postoperative complication rate. Moreover, it is less affected by common risk factors; thus, this method may be more beneficial in patients with difficult airways.
doi:10.12659/MSM.892195
PMCID: PMC4186215  PMID: 25252964
Blindness; Intubation; Intratracheal; Laryngoscopy; Pyriform Sinus

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