Intubation Techniques: Preferences of Maxillofacial Trauma Surgeons

Abstract

Objective To evaluate the clinical outcomes of alternative techniques of intubation in patients sustaining maxillofacial injuries, where nasotracheal intubation (NTI) is best avoided. Material and Methods Alternative techniques to standard naso-tracheal intubation like submental intubation, orotracheal intubation-retrotuberosity/retromolar and missing dentition were used and variables of clinical outcome recorded.Results Submental intubation provides an unobstructed intraoral surgical field, avoids intraoperative and postoperative complications of tracheostomy, and overcomes the disadvantages of NTI. In our experience with submental intubation (6 cases), we only had complication related to tube apparatus like damage to pilot balloon. With retrotuberosity intubation (5 cases) we did not encounter any complications and the only limitations were bulbous maxillary tuberosity. Retromolar intubation (4 cases) a safe noninvasive technique has disadvantages like tube interference within the surgical field and not feasible in case of limited retromolar space. Orotracheal-missing dentition intubation (4 cases) is of great advantage i.e. it can be used in cases where NTI is contraindicated, no specialized skill required, no added cost, avoids the need for tracheostomy, no extra-oral procedures required and does not interfere with occlusion/MMF; with disadvantage of occasional tube interference within the surgical field. Conclusion Preferred techniques of securing an airway like orotracheal, nasotracheal may not always be applicable, thus a trauma surgeon-anesthesist team should always have alternative techniques in their armamentarium to reduce the morbidity associated with these patients without interference with occlusion, which is prime goal in jaw fracture reduction. We have used these techniques in a country with limited resources and found them equally effective and convenient to use.

Awareness among anesthesia residents pertaining to various intubation techniques in craniofacial surgery: A questionnaire study

“…[ 17 ] The mortality rate of tracheostomy has been reported to range from 0.5% to 2.7%. [ 13 ] The results of this study show that 17.94% of the participants have not seen submental intubation clinically during their residency period and 14.10% of the participants felt that they need the surgeon's help for dissection for placing a submental tube.…”

“…Blunt or penetrating injury to the larynx, trachea, hyoid structure, and facial bones would unquestionably result in difficulty in managing the airway. [ 13 ] FOI is considered the ideal option for management of difficult airways. Even though FOI can be performed in an unconscious individual, it is particularly suited to the awake patient.…”

Experiencia en intubación submandibular en pacientes con fracturas panfaciales

“…Aun así, esta técnica se ha reportado también como rápida y segura. Puede requerir además extracción de tercer molar u osteotomía semilunar retromolar solo para acomodar el tubo, lo que aumentaría el tiempo quirúrgico y afectaría la anatomía ósea [13], [14], [15].…”

Securing the Airway in Maxillofacial Trauma Patients: A Systematic Review of Techniques

“…26 When standard nasotracheal intubation is complicated by the presence of blood or secretions in the nasal passages, or by variations in patient anatomy, image-guided nasotracheal intubation, including fiber-optic-guided, lightwand-guided intubation, and newer video-assisted laryngoscopy techniques, can be used. 25,27 It is best to first position the nasotracheal tube cephalically toward the head of the bed to remove it from the surgical field. The tube can be anchored by taping it across the forehead, or by suturing it through the nasal septum and placing a Merocel (Medtronic Inc.), between the tube and soft tissue triangle to prevent necrosis of the nasal tip (Figure 7).…”

“…22 Retromolar intubation also affords a route to the airway in patients with trismus or patients requiring intraoperative mandibulomaxillary fixation (MMF). [23][24][25] Of note, if a surgeon plans on performing MMF during the case, consideration must be taken for resecuring an airway that becomes dislodged intraoperatively, as this may require expedient removal of the MMF to visualize and replace a dislodged endotracheal tube.…”