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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.
PMCID: PMC3141161  PMID: 21808409
Airway management; panfacial fractures; submental intubation
2.  Midline Submental Orotracheal Intubation in Maxillofacial Injuries: A Substitute to Tracheostomy Where Postoperative Mechanical Ventilation is not Required 
Maxillofacial fractures present unique airway problems to the anaesthesiologist. Nasotracheal intubation is contraindicated due to associated Lefort I, II or III fractures. The requirement for intraoperative maxillomandibular fixation (MMF) to re-establish dental occlusion in such cases precludes orotracheal intubation. Tracheostomy has a high complication rate and in many patients, an alternative to the oral airway is not required beyond the perioperative period. Hernandez1 in 1986 first described “The submental route for endotracheal intubation”. Later some workers faced difficult tube passage, bleeding, and sublingual gland involvement with this approach. They modified this to strict midline submental intubation and there were no operative or postoperative complications in their cases.67&8. Therefore we used mid line approach for submental orotracheal intubation in this study to demonstrate its feasibility and reliability and that it can be used as an excellent substitute to short term tracheostomy.
Patients & Methods:
We used midline submental intubation in 25 cases selected out of 310 consecutively treated patients with maxillofacial trauma over a 3 year period. After induction orotracheal intubation was done with spiral re-inforced tube. A 1.5-2.0 cm skin incision was made in the submental region in the midline 2.0 cm behind the symphysis and endotracheal tube was taken out through this incision in all the cases. At the end of the surgery the procedure was reversed, the submental wound was stitched; all the patients could be extubated & none of them required post-operative mechanical ventilation.
There were no significant operative or postoperative complications. Postoperative submental scarring was acceptable[6]. We conclude that midline submental intubation is a simple and useful technique with low morbidity. It can be chosen in selected cases of maxillofacial trauma and is an excellent substitute to tracheostomy where postoperative mechanical ventilation is not required.
PMCID: PMC3087271  PMID: 21547178
Submental orotracheal intubation; Maxillofacial injury; Tracheostomy
3.  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.
PMCID: PMC3968651
Maxillofacial surgeries; percutaneous dilatational tracheostomy kit; seldinger's technique
4.  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.
PMCID: PMC2815845  PMID: 16127785
LMA-Fastrach™ETT; maxillofacial trauma; submental intubation
5.  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
6.  Submental intubation: our experience 
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.
PMCID: PMC3453707  PMID: 23139571
Midfacial fractures; Submental intubation; Maxillofacial injuries
7.  Current Perspectives in Intra Operative Airway Management in Maxillofacial Trauma 
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.
PMCID: PMC3386414  PMID: 23730059
Maxillofacial trauma; Nasal intubation; Submental intubation; Retromolar technique; Tracheostomy; Intermaxillary fixation
8.  Submental tracheal intubation in oromaxillofacial surgery 
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.
PMCID: PMC2739561  PMID: 19753195
Avoiding tracheostomy; oromaxillofacial surgery; intubation
9.  Submental orotracheal intubation: Our experience and review 
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.
PMCID: PMC3591038  PMID: 23482892
Panfacial trauma; submental orotracheal intubation; tracheostomy; transmylohyoid intubation
10.  Submental Orotracheal Intubation: An Alternative to Tracheotomy in Transfacial Cranial Base Surgery 
Skull Base  2003;13(4):189-195.
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.
PMCID: PMC1131851  PMID: 15912177
Intubation; submental intubation; chordoma
11.  Submental Intubation in Maxillofacial Trauma Patients 
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.
PMCID: PMC3846236  PMID: 24303414
Intubation; Jaw fracture; Submental
12.  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.
PMCID: PMC3530757  PMID: 23304563
13.  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.
PMCID: PMC3409936  PMID: 22869933
Adult; intubation; intratracheal methods; maxillofacial injuries/surgery; oral/methods; surgery
14.  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.
PMCID: PMC3304183  PMID: 22442557
Difficult intubation; submental intubation; Maxillofacial injury
15.  Management of a Perforated Endotracheal Tube During Orthognathic Surgery 
Anesthesia Progress  1988;35(4):158-159.
Oral and maxillofacial procedures require nasotracheal intubation that often obscures the anesthesiologist's direct vision of the surgical field. Premature extubation of a damaged endotracheal tube frequently requires replacement and poses a potential risk to the patient. This case illustrates a technique for replacing a damaged endotracheal tube using a nasogastric tube inserted within the damaged tube to suction secretions, insufflate oxygen, and serve as a guide for placement of a new endotracheal tube.
PMCID: PMC2167961  PMID: 3166353
16.  Parker Flex-Tip and Standard-Tip Endotracheal Tubes: A Comparison During Nasotracheal Intubation 
Anesthesia Progress  2010;57(1):18-24.
The placement of endotracheal tubes in the airway, particularly through the nose, can cause trauma. Their design might be an important etiologic factor, but they have changed little since their introduction. Recently Parker Medical (Bridgewater, Conn ) introduced the Parker Flex-Tip (PFT) tube, suggesting that it causes less trauma. This study aimed to compare the PFT endotracheal tube to a side-beveled, standard-tip endotracheal tube (ETT) for nasotracheal intubation (Figures 1 and 2). Forty consecutive oral surgery patients requiring nasotracheal intubation were randomized to receive either a standard ETT or the PFT tube. Intubations were recorded using a fiber-optic camera positioned proximal to the Murphy eye of the tube. This allowed visualization of the path and action of the tube tip as it traversed the nasal, pharyngeal, laryngeal, and tracheal airway regions. Video recordings made during intubation and extubation were evaluated for bleeding, trauma, and intubation time. Both bleeding and trauma were recorded using a visual analogue scale (VAS) and by 3 different evaluators. The PFT received significantly better VAS values than the standard tubes from all 3 raters (P < 0.05) in both the extent of trauma and bleeding. Since the intubations were purposefully conducted slowly for photographic reasons, neither tube displayed a time advantage. This study suggests that the PFT tube design may be safer by causing less trauma and bleeding than standard tube designs for nasotracheal intubation.
PMCID: PMC2844234  PMID: 20331335
Nasotracheal intubation; Parker Flex-Tip tube; Endotracheal intubation; Endotracheal tube; Fiber-optic intubation
17.  Airway Management in Croup and Epiglottitis 
Western Journal of Medicine  1977;126(3):184-189.
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.
PMCID: PMC1237501  PMID: 349884
18.  Comparative study of percutaneous dilatational tracheostomy and conventional tracheostomy in the intensive care unit 
Objective: Tracheostomy is a one of the earliest described surgical procedure dating back to 2000 B.C. Percutaneous tracheostomy is becoming increasingly popular as an alternative method for conventional tracheostomy in the intensive care unit. In this study we compare the results of the use of these 2 techniques in 32 patients who underwent elective tracheostomy in the intensive care unit.Study Design: Prospective randomized comparative study.Setting: Tertiary care hospital.Patients: Adult intubated patients selected randomly in the intensive care unit with normal cervical soft tissue, laryngeal framework, palpable cricoid cartilage and normal coagulation parameters.Results: 17 patients underwent conventional tracheostomy and 15 patients underwent percutaneous dilatational tracheostomy. Demographic data and duration of intubation comparable between two groups. The mean operative time, blood loss and complications were lower in percutaneous than in conventional tracheostomy.Conclusions: PDT is quicker to perform and has lower blood loss and complication rates compared to conventional tracheostomy. However percutaneous tracheostomy is not indicated in emergencies and in children. The cost of the percutaneous kit and use of bronchoscopy adds to the cost. It is a good alternative to conventional tracheostomy in properly selected patients.
PMCID: PMC3451352  PMID: 23120172
percutaneous dilatational tracheostoury; intensive care unit
19.  AB 63. Management of complex benign post-tracheostomy tracheal stenosis with bronchoscopic insertion of silicon tracheal stents, in patients with failed or contraindicated surgical reconstruction of trachea 
Journal of Thoracic Disease  2012;4(Suppl 1):AB63.
Tracheal stenosis is a potentially life-threatening condition. Tracheostomy and endotracheal intubation remain the commonest causes of benign stenosis, despite improvements in design and management of tubes. Post-tracheostomy stenosis is more frequently encountered due to earlier performance of tracheostomy in intensive care units, while the incidence of post-intubation stenosis has decreased with application of high-volume low-pressure cuffs. We present tracheal stenting in complex post-tracheostomy stenoses.
Patients and methods
We inserted tracheal silicone stents (Dumon) under general anaesthesia through rigid bronchoscopy in two patients with benign post-tracheostomy stenoses: a 39-year old woman treated for acute respiratory failure (dyspnoea, hemoptysis, alveolar bleeding, attributed to seronegative lung vasculitis) who initially underwent surgical resection and end-to-end anastomosis, but developed restenosis (anastomotic granulation/scarring), and suffered continuous relapses after multiple bronchoscopic interventions, underwent silicone stenting (length 4.5 cm, diameter 12 mm). A 20-year old man treated for severe head trauma after a car accident developed a long tracheal stricture involving the subglottic larynx (lower posterior part), having inflamed tracheostomy site tissues (positive for methicillin resistant staphylococcus aureus), underwent silicone stenting (length 7 cm, diameter 14 mm).
The airway was immediately re-establish, without complications (tracheal rupture/pneumomediastinum, bleeding). At 15 and 10 months follow-up (respectively) there was no stent migration, luminal patency was maintained without: adjacent structure erosion, secretion adherence inside the stents, granulation at the ends. Tracheostomy tissue inflammation was resolved (2nd patient), new infection was not noted. The patients maintain good respiratory function and will be evaluated for scheduled stent removal.
In symptomatic benign tracheal stenosis the gold standard is surgical reconstruction (often after interventional bronchoscopy). Stenting is reserved for symptomatic tracheal narrowing deemed inoperable due to local or general reasons: inflammation, long strictures, previous failed operation, poor respiratory, cardiac or neurological status. When stenting is decided, silicone stent insertion is considered treatment of choice in the presence of inflammation and/or when removal is desirable. Silicone stents are removable, resistant to microbial colonization and are associated with minimal granulation. In benign post-tracheostomy stenosis silicone stenting was safe and effective in re-stenosis after surgery and multiple bronchoscopic interventions, and in long stenosis in the presence on inflammation and poor neurological status.
PMCID: PMC3537415
20.  Oral reconstruction with submental flap 
Annals of Maxillofacial Surgery  2013;3(2):144-147.
Submental flap is a useful technique for reconstruction of medium to large oral cavity defects. Hair bearing nature of this flap in men makes it less appropriate. Therefore, deepithelialized variant is introduced to overcome the problem of hair with this flap. Recently, application of this flap has been introduced in maxillofacial trauma patients.
Materials and Methods:
Deepithelialized orthograde submental flap is used for the reconstruction of oral cavity mucosal defects.
Four cases including two trauma patients and two squamous cell carcinomas (SCCs) of oral cavity were treated using deepithelialized orthograde submental flap. There were no complications in all four patients and secondary epithelialization occurred in raw surface of the flap which was exposed to oral cavity.
Deepithelialized orthograde submental flap is very effective in reconstruction of oral cavity in men. The problem of hair is readily solved using this technique without jeopardizing flap blood supply.
PMCID: PMC3814662  PMID: 24205473
Avascular necrosis; papillary squamous cell carcinoma; submental flap
21.  Comparison of the effects of remifentanil andalfentanil on cardiovascular response to nasotracheal intubation: A prospective, randomized, double-blind study 
Nasotracheal intubation is often necessary in patients undergoingelective or emergency maxillofacial surgery. Previous studies have suggested that the increase in blood pressure after nasotracheal intubation is significantly greater than the increase after orotracheal intubation. Many drugs, including narcotic analgesics, are effective in modifying cardiovascular responses to orotracheal intubation.
The effects of remifentanil and alfentanil on the cardiovascularresponses to nasotracheal intubation were compared in healthy patients scheduled to undergo surgery.
This prospective, randomized, double-blind study was conductedat the Department of Anesthesiology and Reanimation, Faculty of Medicine, Dicle University, Diyarbakir, Turkey. Patients aged 16 to 65 years scheduled to undergo elective maxillofacial surgery and who were American Society of Anesthesiologists status I or 11 were randomly assigned to receive remifentanil 1 μg/kg in 10 mL saline over 30 seconds followed by an infusion of 0.5 μg/kg · min, or alfentanil 10 μg/kg in 10 mL saline over 30 seconds followed by an infusion of saline. Anesthesia was then induced with propofol, cisatracurium, and 1% isoflurane with 66% nitrous oxide in oxygen. Heart rate (HR) and systolic and diastolic arterial pressures (SAP and DAP, respectively) were measured noninvasively at 2 minutes before general anesthesia induction (baseline); 2 minutes after induction; and 1, 3, and 5 minutes after nasotracheal intubation. Patients were monitored for cardiac changes using electrocardiography.
Forty consecutive patients were enrolled in the study. Twenty patients (11 males, 9 females; mean [SD] age, 27.7 [12.6] years) received remifentanil, and 20 patients (12 males, 8 females; mean [SD] age, 31.5 [17.2] years) received alfentanil. Two minutes after anesthesia induction, mean (SD) arterial pressures decreased significantly from baseline in the remifentanil group (changes, 22 [8]/11 [6] mm Hg) and the alfentanil group (changes, 10 [9]/12 [8] mm Hg) (both, P < 0.05). Changes in SAP and DAP followed a similar pattern in both groups, but SAP was significantly lower in the remifentanil group compared with that in the alfentanil group throughout the study period (all, P < 0.05). After 1 minute of intubation, DAP was significantly lower in the remifentanil group compared with that in the alfentanil group (66 [9] mm Hg vs. 73 [20] mm Hg; P < 0.05). Compared with baseline, HR was decreased significantly in both groups throughout the study (all, P < 0.05). Except SAP in the alfentanil group, SAP, DAP, and HR were increased 1 minute after intubation compared with preintubation values. However, SAP, DAP, and HR remained significantly lower compared with baseline values throughout the study period in both groups (all, P < 0.05) except DAP at 1 minute after incubation in the alfentanil group. Five patients in the remifentanil group and 2 patients in the alfentanil group required treatment of hypotension. None of the patients in either group required treatment of bradycardia.
In this study in healthy surgical patients aged 16 to 65 years, remifentanil 1 μg/kg given over 30 seconds, followed by a remifentanil infusion of 0.5 μg/kg · min, was similarly effective compared with alfentanil 10 μg/kg in attenuating the pressor response to nasotracheal intubation, but the incidence of hypotension in patients administered remifentanil was high.
PMCID: PMC3964577
remifentanil; alfentanil; cardiovascular responses; nasotracheal intubation
22.  Emergency Percutaneous Tracheostomy in a Severely Burned Patient with Upper Airway Obstruction and Circulatory Failure  
Airway inaccessibility is one of the most dreaded situations in emergency medicine. Surgical tracheostomy is not indicated in emergency situations because it takes a long time and can result in death if respiratory support cannot be provided during the procedure. Emergency percutaneous tracheostomy (PCT) was widely regarded as absolutely counterindicated. Recently, however, a number of studies have appeared on the safety and feasibility of PCT in situations regarded as presenting relative contraindications. We describe the life-saving action of Griggs' PCT in a patient with upper airway obstruction resulting from burns, smoke injuries, and unsuccessful tracheal intubation attempts. Emergency PCT using the Griggs technique was immediately performed without aseptic care, and a 9-mm internal diameter tracheostomy tube was successfully inserted in less than one minute. Griggs' PCT is a quick technique that secures an airway when tracheal intubation fails. The feasibility - in selected cases - of using an emergency Griggs' PCT, in experienced hands, rather than cricothyroidotomy or surgical tracheostomy, is recommended.
PMCID: PMC3188149  PMID: 21991172
23.  Evaluation of Inter Incisal Mouth Opening for Airway Maintenance in Oral Submucous Fibrosis 
Determination of difficult airway maintenance preoperatively holds a great significance in different intubation techniques and also surgical exploration of airway. No data is available for relation of airway maintenance and preoperative interincisal mouth opening in oral submucous fibrosis patients.
20 oral submucous fibrosis patients were evaluated pre operatively for general anaesthesia. Direct nasotracheal intubation, fiberoptic laryngoscopy guided intubation or awake blind nasal intubation technique, or combination of above techniques were used.
Mean pre operative inter incisal mouth opening for direct nasotracheal intubation (nine patients) is 15.44 mm, fiberoptic guided laryngoscopy (six patients) is 9.0 mm and blind nasal intubation (five patients) is 5.2 mm.
Benefits of avoiding a surgical exploration of airway was significant.
PMCID: PMC3428452  PMID: 23997480
Pre operative inter incisal mouth opening; Direct nasotracheal intubation; Fiberoptic guided laryngoscopy; Awake blind nasal intubation; Oral submucous fibrosis
24.  Anaesthesia for trans-sternal thymectomy in myasthenia gravis. 
A retrospective review is presented of the thirty patients who underwent trans-sternal thymectomy for myasthenia gravis in our unit from 1980-85. The clinical status of these patients is contrasted to that of more severely debilitated patients described by other authors. The problems encountered by the anaesthetist in the perioperative care of patients with mild myasthenia gravis are discussed. Management of the perioperative anticholinesterase regime is described and a case presented for the use of suxamethonium for intubation. A less invasive postoperative regime is advocated in which tracheostomy and nasotracheal intubation are avoided, and anticholinesterase therapy is re-introduced orally as soon as possible after surgery.
PMCID: PMC2498543  PMID: 3426096
25.  Ultrasound of the airway 
Indian Journal of Anaesthesia  2011;55(5):456-462.
Currently, the role of ultrasound (US) in anaesthesia-related airway assessment and procedural interventions is encouraging, though it is still ill defined. US can visualise anatomical structures in the supraglottic, glottic and subglottic regions. The floor of the mouth can be visualised by both transcutaneous view of the neck and also by transoral or sublinguial views. However, imaging the epiglottis can be challenging as it is suspended in air. US may detect signs suggestive of difficult intubation, but the data are limited. Other possible applications in airway management include confirmation of correct endotracheal tube placement, prediction of post-extubation stridor, evaluation of soft tissue masses in the neck prior to intubation, assessment of subglottic diameter for determination of paediatric endotracheal tube size and percutaneous dilatational tracheostomy. With development of better probes, high-resolution imaging, real-time picture and clinical experience, US has become the potential first-line noninvasive airway assessment tool in anaesthesia and intensive care practice.
PMCID: PMC3237144  PMID: 22174461
Airway; ultrasonography; upper respiratory tract

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