Journal of

Vol. 6, No. 2, 68-71 Lifestyle

Case Report https://doi.org/10.15280/jlm.2016.6.2.68
Medicine

Submental Intubation in Patients with Complex

Maxillofacial Injuries
Yuseon Cheong1, Seong Sik Kang1, Minsoo Kim1,*, Hee Jeong Son1, Jaewoo Park1, Jeong-Mo Kim2
1
Department of Anesthesiology and Pain Medicine, Kangwon National University Hospital, Chuncheon, 2Department of Oral and
Maxillofacial Surgery, Kangwon National University Hospital, Chuncheon, Korea

Airway management in patients with complex maxillofacial injuries is a challenge to anesthesiologists. Submental in-
tubation is a useful technique that is less invasive than tracheostomy in securing the airways where orotracheal and
nasotracheal intubation cannot be performed. This procedure avoids the use of tracheostomy and bypasses its associated
morbidities. A flexible and kink-resistant reinforced endotracheal tube with detachable universal connector is com-
monly used for submental intubation. Herein, we report cases involving submental intubation using a reinforced endo-
tracheal tube with a non-detachable universal connector in patients with complex maxillofacial injuries.

Key Words: Intubation, Submental, Maxillofacial injuries

INTRODUCTION tubation was first introduced to avoid tracheostomy in 1986

and has some advantages. We present two cases of sub-
Patients with complex maxillofacial injuries usually re- mental intubation using a reinforced endotracheal tube with
quire general anesthesia for surgical reduction of fractures. non-detachable universal connector in patients with complex
Orotracheal intubation is not suitable for assessing the den- maxillofacial trauma. The indications, contraindications, ad-
tal relationship and occlusion, and nasotracheal intubation vantages, and complications of submental intubation are
is contraindicated in patients with nasoorbitoethmoidal frac- discussed.
tures or fractures of the base of the skull owing to potential
complications such as cerebrospinal fluid leakage and CASE REPORT
meningitis. Tracheostomy provides an alternative, surgical
1. Case 1
intervention, but can be associated with increased post-oper-
ative care, complication rates, and morbidity. Submental in- An 18-year-old male patient (60 kg, 170 cm) was sched-
uled for open reduction and internal fixation of a nasoorbi-
Received: June 15, 2016, Accepted: July 21, 2016
toethmoidal fracture (Fig. 1). Preliminary investigations in-
*Corresponding author: Minsoo Kim
dicated that he was otherwise healthy, with preanesthetic
Department of Anesthesiology and Pain Medicine, Kangwon National
University Hospital, 156 Baengnyeong-ro, Chuncheon, Gangwon-do evaluation being unremarkable except for signs of sinus bra-
24289, Republic of Korea
Tel: 82-33-258-9423, Fax: 82-33-258-9099
dycardia (41 bpm). As intra-operative assessment of dental
E-mail: [email protected] occlusion was required, orotracheal intubation was not in-
This is an Open Access article distributed under the terms of the Creative dicated, with nasotracheal intubation also being in-
Commons Attribution Non-Commercial License (http://creativecommons.org/
appropriate due to his nasoorbitoethmoidal fracture. In order
licenses/by-nc/4.0) which permits unrestricted noncommercial use, dis-
tribution, and reproduction in any medium, provided the original work is to avoid tracheostomy, submental intubation was planned.
properly cited.
Yuseon Cheong, et al : Submental Intubation for Complex Maxillofacial Injuries

Fig. 1. Three-dimensional reconstructed image of the patient in Fig. 2. The patient with submental intubation.
case 1.

The patient was monitored with pulse oximetry, electro-

cardiography, and noninvasive blood pressure measurements.
Before anesthetic induction, atropine (0.5 mg) was given
intravenously. After preoxygenation with 100% oxygen for
3 minutes, anesthesia was induced with propofol (100 mg)
and fentanyl (100 μg). After successful ventilation with a
facial mask, rocuronium (50 mg) was administered intraven-
ously. Prior to intubation, the universal connector of a re-
inforced endotracheal tube (ETT) was detached gently from
the tube and reattached so that it could be easily dis- Fig. 3. Reinforced endotracheal tube with detached universal
connector.
connected during the procedure (Fig. 2). Orotracheal in-
tubation was performed using a 7.5-mm-internal diameter
reinforced ETT (Lo-Contour Oral/Nasal Tracheal Tube then grasped by the tip of the Kelly forceps and pulled out
Cuffed, Mallinckrodt, Ireland). Anesthesia was maintained through the tunnel of the sub-mental incision, followed by
with sevoflurane and 100% oxygen to increase the apneic the pilot balloon. After the ETT was shifted, the connecter
reservoir during the procedure. Approximately 3 cm lateral was then reattached, and the tube was reconnected to the
to the mandibular midline, a submental horizontal incision ventilator. Then, the ETT was repositioned using Magill for-
(of 1.5 cm) was placed a fingerbreadth below the man- ceps, and a stay suture was applied with silk in order to fix
dibular inferior border. Blunt dissection toward the mouth the tube to the skin to prevent accidental extubation (Fig.
floor was performed using a thin mosquito hemostat, form- 3).
ing an orocutaneous tunnel. A Kelly forceps was then in- At the end of the surgery, the stay suture was removed,
troduced through the tunnel from the outside to widen it. and the ETT with a pilot balloon was retracted from the
At that moment, the ETT was disconnected from the ven- oral cavity, removed via the mouth, and brought back to
tilator circuit, and its connector was removed. The ETT was the orotracheal position. The submental incision was lay-

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Journal of Lifestyle Medicine Vol. 6, No. 2, September 2016

er-sutured, and wet gauze dressing was applied at the site tients with complex maxillofacial injuries, particularly for
of the wound at the mouth floor to facilitate secondary those who need prolonged intubation. However, the proce-
healing. Following the procedure, extubation was per- dure is associated with the risk of hemorrhage, pneumo-
formed, and the patient was transferred to the post-anes- thorax, infection, and tracheal stenosis [3,4].
thetic care unit. The post-operative period was un- Submental intubation was first described by Hernandez
remarkable, and there was negligible submental scarring at Altemir [5] in 1986. Since its introduction, it has been used
two months post-operation. as an attractive option for intra-operative airway control in
specific, complex maxillofacial injuries. Maxillofacial trau-
2. Case 2
ma is the most common indication for submental intubation
A 48-year-old male patient (65 kg, 175 cm) sustained bi- [6]. Submental intubation is also applied to bimaxillary or-
lateral orbital wall and maxillary fractures with a skull-base thognathic surgeries with simultaneous rhinoplasty or or-
fracture after a motor vehicle accident. He was scheduled thognathic surgeries in patients with large pharyngeal flaps
to undergo surgical intervention for the fractures. He had or other anatomic anomalies precluding nasotracheal in-
undergone brain surgery for epidural hematoma removal 11 tubation [7,8]. Other possible indications for this technique
days prior. As his level of consciousness was alert, in- are certain base of skull procedures [9] or cancrum oris
tubation following the operation was unnecessary. As an al- [10]. Submental intubation is contraindicated in patients
ternative to tracheostomy, submental intubation was who have severe neurological defects or those who require
planned. long-term airway support and maintenance [7,8]. In these
The patient was monitored with pulse oximetry, electro- cases, tracheostomy should be considered. In patients with
cardiography, and noninvasive blood pressure measurements. a history of severe keloid formation, this technique can be
After preoxygenation with 100% oxygen for 3 minutes, an- contraindicated. In the first case, endotracheal intubation
esthesia was induced with propofol (80 mg) and rocuronium was not indicated because of circumstances that prevented
(50 mg). Following orotracheal intubation with a reinforced the intra-operative assessment of dental occlusion, with na-
ETT (internal diameter, 7.5 mm), the tube was removed sotracheal intubation also being inappropriate due to his na-
through the submental area using the aforementioned soorbitoethmoidal fracture. As he was healthy, with the ex-
method. ception of his nasoorbitoethmoidal fracture, and did not re-
After the operation, the patient was transferred to the in- quire prolonged ventilatory support, the decision to choose
tensive care unit and was extubated at post-operative day 1. submental intubation over tracheostomy had greater
significance. In the second case, the patient had a traumatic
DISCUSSION epidural hematoma. Nevertheless, submental intubation was
chosen because of his alert mental status in addition to his
Airway management in patients with complex max- unrequired use of long-term airway support.
illofacial injuries is a challenge to anesthesiologists. Flexible and kink-resistant ETT is required to maintain
Although orotracheal intubation is the most frequently used airway patency despite the acute angle of the airway, partic-
route in securing the airway, it interferes with the surgical ularly in the submental route. Ball et al. [11] reported sub-
field and disturbs intra-operative assessment of dental mental intubation using the flexible tracheal tube supplied
occlusion. As an alternative to orotracheal intubation, naso- with the intubating laryngeal mask (ILM, Intavent, UK).
tracheal intubation is commonly used in oral and max- This tube has an advantage that its connector is easy to de-
illofacial surgeries. However, nasotracheal intubation is con- tach and reattach. However, it is rare in the market and ex-
traindicated in cases of skull-base trauma due to the in- pensive compared to our reinforced tube (Lo-Contour
cidence of accidental intracranial placement [1], possible Oral/Nasal Tracheal Tube Cuffed, Mallinkrodt, Ireland).
cerebral spinal fluid leakage, and/or meningitis [2]. The universal connector of a standard reinforced ETT,
Tracheostomy is a good route to secure the airway in pa- which we used, is bounded firmly to the tube to prevent

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Yuseon Cheong, et al : Submental Intubation for Complex Maxillofacial Injuries

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