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 Table of Contents  
Year : 2023  |  Volume : 2  |  Issue : 1  |  Page : 65-66

Submental intubation in a patient with panfacial fracture for bilateral intermaxillary fixation and occlusion

1 Department of Anaesthesiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
2 Department of Craniomaxillofacial Surgery, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

Date of Submission21-Mar-2023
Date of Decision07-Apr-2023
Date of Acceptance08-Apr-2023
Date of Web Publication25-May-2023

Correspondence Address:
Dr. Sunil Rajan
Department of Anaesthesiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jica.jica_5_23

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How to cite this article:
Rajan S, Mathew J, Raveendran SD, Krishnadas A, Padappayil S. Submental intubation in a patient with panfacial fracture for bilateral intermaxillary fixation and occlusion. J Ind Coll Anesth 2023;2:65-6

How to cite this URL:
Rajan S, Mathew J, Raveendran SD, Krishnadas A, Padappayil S. Submental intubation in a patient with panfacial fracture for bilateral intermaxillary fixation and occlusion. J Ind Coll Anesth [serial online] 2023 [cited 2023 Oct 1];2:65-6. Available from: https://www.jicajournal.in//text.asp?2023/2/1/65/377602

Dear Editor,

Patients with pan-facial fractures pose unique challenges to anesthetists since such surgeries may require the avoidance of oral and nasal endotracheal tubes (ETTs). A 32-year-old male patient presented with bilateral Lefort 1 and 2 fractures with displaced nasal bone fracture following a road traffic accident which was sustained 1 week back. He was posted for bilateral intermaxillary fixation and occlusion, bilateral zygomatic buttress plating, and closed reduction of nasal bone fracture. He was conscious and oriented with diffuse swelling on both sides of the face with stable vitals. Submental intubation was planned for the control of the airway. Before induction of general anesthesia, the flexometallic ETT was prepared by inserting the tip of a mosquito forceps between the connector and the tube and glided it around the whole circumference [Figure 1]a for easily detaching the connector during the procedure.[1] Following intravenous induction with propofol and neuromuscular blockade, he was intubated orally with the prepared 8.0-mm cuffed flexometallic ETT. Anesthesia was maintained using sevoflurane in air oxygen mixture with mechanical ventilation.
Figure 1: (a) Detaching connector, (b) Submental intubation

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A 2 cm long paramedian skin incision (2 cm medial to the lower border of the mandible and 2 cm lateral to the midline from the chin) was made up to subcutaneous tissue. Then using tonsil artery forceps, blunt dissection was carried out along the lingual aspect of the mandible scraping the bone. The dissection was done till the tip of the forceps entered the oral cavity at the junction between canine and premolar teeth at the gingiva on the same side. The patient was ventilated with 100% oxygen and the pilot balloon was deflated and caught with the tip of tonsil forceps and pulled out through the skin incision. The tonsil artery forceps was then reintroduced into the oral cavity through the same track. The circuit was disconnected and the connector was detached from ETT. The proximal tip of the tube was then curved to the tip of the forceps, caught firmly, and pulled out extraorally through the skin incision [Figure 1]b. The connector was reattached, proper tracheal position was confirmed with auscultation, and appearance of regular end-tidal carbon dioxide (ETCO2) waveforms and ventilation was resumed. The procedure of submental intubation took approximately 4 min from skin incision to exteriorization of the ETT extraorally through skin incision with subsequent appearance of ETCO2.

The ETT was secured by suturing to the skin using silk stitches. The surgery lasted for 8 h. Intraoperative period was uneventful. At the end of the surgery, ETT and pilot balloon were pulled back to the oral cavity and the skin wound was sutured to provide an esthetic scar. He was extubated on the table after reversing neuromuscular blockade when fully awake with the return of protective airway reflexes. The postoperative period was unremarkable.

In craniofacial trauma, oral ETT cannot be used when reconstruction of facial fractures requires intermaxillary fixation to assess for correct alignment of both dental occlusion and fracture fragments. Nasal ETT is also contraindicated in patients with skull base fractures and combined maxillary and nasal fractures.[1] Although tracheostomy meets all the requirements of such surgeries, it is not recommended due to significant complications, and hence, submental intubation is considered a safe alternative.[2],[3] The incidence of immediate complications following tracheostomy is 6%–8% and that of delayed complications is 60%. The immediate complications of tracheostomy include surgical emphysema, pneumothorax, pneumomediastinum, recurrent laryngeal nerve palsy, and bleeding. The delayed complications are 60% and include stomal and respiratory tract infection, tube blockage, dysphagia, difficulty with decannulation, tracheal erosion, tracheal stenosis, tracheoesophageal fistula, and a prominent visible scar.[4],[5]

Only minor complications are reported following submental intubation and include mostly superficial skin infections. Other rare but reported complications are ranula formation, hypertrophic scarring, orocutaneous fistula, lingual nerve injury, bleeding, hematoma, and infection.[6],[7] Submental intubation carries 100% success rate, and the average time required is 9.9 min.[7] Flexometallic ETT is preferred to prevent kinking. Serious complications are collapse or kinking of ETT, accidental extubation, endobronchial intubation and injury to the salivary duct, marginal mandibular, and lingual nerves.[8] It is concluded that submental intubation is a safe alternative to tracheostomy in panfacial trauma patients for intraoperative control of the airway.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Surman K, Duffy N, Anwar Z, Basyuni S, Santhanam V. Submental intubation in craniomaxillofacial surgery. Anaesth Crit Care Pain Med 2021;40:100796.  Back to cited text no. 1
Vashishta A, Sharma S, Chugh A, Jain D, Gupta N, Bihani U. Submental intubation: A useful adjunct in panfacial trauma. Natl J Maxillofac Surg 2010;1:74-7.  Back to cited text no. 2
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Kaiser A, Semanoff A, Christensen L, Sadoff R, DiGiacomo JC. Submental intubation: An underutilized technique for airway management in patients with panfacial trauma. J Craniofac Surg 2018;29:1349-51.  Back to cited text no. 3
Banjare M, Sharma DK. Submental route of endotracheal intubation; a better solution in cases of multifacial fractures. Sri Lankan J Anaesthesiol 2012;20:100-3.  Back to cited text no. 4
Banjare M, Ningawal BK, Nema A, Arora KK. A study to evaluate the efficacy of submental intubation in panfacial trauma. Indian J Clin Anaesth 2020;7:483-9.  Back to cited text no. 5
Rahpeyma A, Khajeh Ahmadi S. Submental intubation in maxillofacial trauma patients. Iran J Otorhinolaryngol 2013;25:17-22.  Back to cited text no. 6
Jundt JS, Cattano D, Hagberg CA, Wilson JW. Submental intubation: A literature review. Int J Oral Maxillofac Surg 2012;41:46-54.  Back to cited text no. 7
Yadav SK, Deo G. Submental intubation including extubation: Airway complications of maxillomandibular fixation. Case Rep Anesthesiol 2012;2012:841051.  Back to cited text no. 8


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