A Prospective, Randomized Comparison of the Classical Altemir’s Method With the Newer Seldinger’s Technique of Submental Intubation

Abstract

BACKGROUND: Submental intubation performed using the classical Altemir’s technique is a well-accepted, safe technique for providing optimal operating field to the maxillofacial surgeon, in cases where either nasotracheal or orotracheal intubation is impossible. We propose a new, percutaneous Seldinger’s technique of submental intubation as an interesting alternative to the classical Altemir’s technique, wherein a percutaneous dilatational tracheostomy kit is used to dilate the submental tract, instead of bluntly dissecting it. We hypothesized that Seldinger’s technique would be associated with reduced procedure time and minimal scar formation in patients with maxillofacial fractures. METHODS: We enrolled 60 patients scheduled to undergo maxillofacial injury fixation under general anesthesia. After consent, the cohort was randomly allocated to undergo submental intubation by either the classical Altemir’s technique or Seldinger’s technique. As our primary objective, we noted the time taken to complete the procedure of submental intubation. Our secondary objectives were the components of primary outcome, such as disconnection/apnea time, bleeding, and technical difficulties during the procedure. We also observed for complications such as presence of salivary fistula/infection at hospital discharge and scar characteristics at 1- and 3-month follow-up. RESULTS: The median time for performing submental intubation in the Seldinger group was significantly lower than that in the Altemir group (170.5 [136.5–256.0] seconds vs 220.0 [205.5–289.0] seconds; P value, .040). The median disconnection time was also significantly lower in the Seldinger group (12.0 [10.8–20.0] seconds vs 19.0 [15.0–23.0] seconds; P value, .036). Furthermore, significant bleeding was absent in nearly 53.8% of the study participants in the Seldinger group as compared to 25.9% in the Altemir group. At follow-up, there was no evidence of differences in scar characteristics between the 2 groups. CONCLUSIONS: Seldinger’s technique is associated with shorter procedure time and reduced apnea time due to easier and better tract formation, thus minimizing the effort required to exteriorize the endotracheal tube. Furthermore, as dilation reduces tissue damage, Seldinger’s technique is associated with significantly less procedural bleeding. Thus, Seldinger’s technique can be safe, easy, and faster to perform compared with the classical Altemir’s technique of submental intubation in patients with maxillofacial trauma.

Use of Griggs forceps for submental intubation: A modification of Seldinger’s technique

“…[ 2 , 3 ] Seldinger’s technique is a recently described and exciting alternative to the classical Altemir’s technique, wherein a percutaneous dilatational tracheostomy kit is used to dilate the submental tract instead of bluntly dissecting it. [ 4 , 5 ] However, this kit is expensive and may not always be available. Thus, we modified this technique and used Griggs forceps, instead of a dilator, to dilate the oro-cutaneous tract.…”