Facial fractures and submental tracheal intubation

Abstract

SummarySubmental tracheal intubation is a simple, quick and effective alternative to oral and nasal tracheal intubation or tracheostomy in the surgical management of selected patients with craniomaxillofacial injuries. It has a low morbidity and it does not impede the surgical field, allowing for temporary maxillo-mandibular fixation (jaw wiring) intra-operatively, and nasal assessment, manipulation and bone grafting, either simultaneously or as an independent procedure. We report 12 cases utilizing this technique in this retrospective study, this includes 11 patients with midfacial fractures and associated base of skull fractures, and one patient who underwent an elective Le Fort III advancement. The techniques and indications for submental tracheal intubation are described.Keywords Anaesthesia: equipment; tubes tracheal. Intubation tracheal: submental; complications. Correspondence to: Mr M. Amin E-mail: michaelamin@doctors.org.uk Accepted: 6 February 2002 There are specific problems associated with airway management in patients with midface or panfacial fractures and possible base of skull fractures. Nasal tracheal intubation in these patients is controversial, particularly if performed without the benefits of a fibreoptic bronchoscope, because of the potential complications, including cranial intubation, epistaxis and intracranial or sinonasal infection [1][2][3][4]. Furthermore, comminuted midface or naso-orbito-ethmoidal complex fractures may cause a physical obstruction to the passage of a nasal tube and the tube may interfere with the assessment and reduction of these fractures [5]. It is often necessary during the reduction of facial fractures to establish dental occlusion and perform temporary maxillo-mandibular fixation (jaw wiring) intra-operatively. This precludes the use of an oral tube at this point in the procedure and may therefore necessitate a tube change.Tracheostomy is still considered the treatment of choice for patients with extensive craniomaxillofacial injuries and multisystem trauma and those who require long-term ventilatory support. However, it is associated with significant morbidity and complications such as haemorrhage, surgical emphysema, tube blockage, recurrent laryngeal nerve injury, tracheal stenosis and poor scar appearance [6].An alternative method of establishing an airway in patients who require maxillofacial surgery but who do not require long-term ventilatory support is to perform submental tracheal intubation, the technique being originally described by Hernández Altemir in 1986 [7]. This provides a secure airway and allows unimpeded surgical access to the oral cavity and midface, whilst avoiding the potential complications associated with nasal intubation and tracheostomy. MethodsTo perform this technique, the patient's trachea is intubated orally using an armoured tracheal tube. Prior to this the universal connector must be removed or cut off and replaced with a removable connector to allow easy detachment. Patients who are already intubated must have Anaesthesia, ...

Efficacy and complications of submental tracheal intubation compared with tracheostomy in maxillofacial trauma patients

“…Reported complications include accidental extubation (17,18), detachment of the pilot balloon (19) or its damage during externalization (20), damage to the cuff of the tracheal tube (15), skin infection (15,21), scar formation (22), tube dislodgement (17), lingual nerve paresthesia, venous bleeding (23), salivary fistula (21,24), and mucocele formation (25). In the present study, minor complications included dislodgement, skin infection, and scar formation.…”

Endotracheal Intubation Using Submandibular Approach for Maxillofacial Trauma Patients: Report of 2 Cases

“…Thus, replacement with oral endotracheal intubation might be proper for prolonged mechanical ventilation, but care is needed as disruption of operation site may occur due to patient's biting of the orotracheal tube [16]. Submandibular approach is a variation from submental approach, and it is well applicable to make a tunnel as the area has better ways around the anatomical structures.…”

“…Extubation after the surgery sometimes is not proceded with the tube remaining, and intermaxillary fixation at this state may cause dangerous situation in airway security due to swelling of tissue. Thus, further studies recommend intermaxillary fixation after the extubation process, and rigid fixation may elimination requirement of intermaxillary fixation [16].…”

Submental Intubation: An Alternative and Cost-Effective Technique for Complex Maxillofacial Surgeries

“…Very low rates of complications have been reported. Many trials have shown the submental route to be simple, quick and safe approach to airway management [1,4,5,7].…”

“…Tracheostomy remains an excellent procedure for establishing a formal surgical airway although this procedure may involve a significant risk of iatrogenic complications, such as tracheal stenosis, internal emphysema, damage to laryngeal nerves, tracheoesophagal fistula, and scarring [1,13]. However, this technique involves very meticulous and professional post operative care, and thus prolonged stay in the hospital is required [14].…”