Open Journal of Anesthesiology, 2019, 9, 221-226

https://www.scirp.org/journal/ojanes
ISSN Online: 2164-5558
ISSN Print: 2164-5531

Submental Intubation with LMAFastrach™

Endotracheal Tube in Maxillofacial Trauma:
A Case Report

Daphne Moo1*, Elizabeth Tan1, Juen Bin Lai2, Soo Toon Chan1

Departmentof Anaesthesia and Surgical Intensive Care, Changi General Hospital, Singapore
1

Department of Oral & Maxillofacial Surgery, Changi General Hospital, Singapore

2

How to cite this paper: Moo, D., Tan, E., Abstract

Lai, J.B. and Chan, S.T. (2019) Submental
Intubation with LMAFastrach™ Endotra- Securing a definitive airway in patients who require surgical fixation of com-
cheal Tube in Maxillofacial Trauma: A Case plex maxillofacial fractures is an integral part of their perioperative manage-
Report. Open Journal of Anesthesiology, 9,
ment. For the ease of surgical access, an orotracheal tube is usually not pre-
221-226.
https://doi.org/10.4236/ojanes.2019.912022 ferred by surgeons. The presence of a base of skull or nasal bone fractures
would also contraindicate nasotracheal intubation. Therefore, a tracheostomy
Received: November 18, 2019 may be the only option left to secure the airway in these patients who require
Accepted: December 9, 2019
surgical fixation. Submental intubation has been used as a safe and effective
Published: December 12, 2019
alternative method in patients who require intubation for maxillofacial re-
Copyright © 2019 by author(s) and construction since it was first reported by Hernandez Altemir F in 1986.
Scientific Research Publishing Inc. Many modifications to the original technique have been documented over the
This work is licensed under the Creative
years, but there has been no consensus to support the use of a single method
Commons Attribution International
License (CC BY 4.0). or device. In this case report, we described our experience with submental
http://creativecommons.org/licenses/by/4.0/ intubation using an LMAFastrach™ endotracheal tube (ETT) to facilitate the
Open Access surgical fixation of bilateral Le Fort II fractures. We conclude that the LMA-
Fastrach™ ETT is a suitable device for submental intubation. This technique
should be included in airway workshops and courses for anaesthesia residents
as it is a simple yet secure alternative to tracheostomy in the intraoperative
airway management of maxillofacial trauma.

Keywords
Submental Intubation, LMAFastrach™, Maxillofacial Trauma

1. Introduction
The submental route for endotracheal intubation was first described in 1986 [1]

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D. Moo et al.

as an alternative airway maneuver for maxillofacial procedures. This technique

involves exteriorizing the endotracheal tube (ETT) from the oral cavity into the
submental space, thereby allowing the surgeons unhindered access to the oral
cavity. It also eliminates the risks associated with nasotracheal intubation, and
avoids a tracheostomy which would otherwise be the conventional method of
airway control [2]. Since its first description by Altemir, several case studies have
been published reporting the efficacy of this approach [3] [4]. The LMAFa-
strach™ ETT has been reported to be an ideal device for this technique in view of
certain unique design features [5]. In this case report, we document a successful
submental intubation using the LMAFastrach™ ETT.

2. Case Report
The patient was a 34-year-old, 65 kg male who required surgical fixation of bila-
teral Le Fort II facial fractures,which he sustained from an unwitnessed fall.
There was no radiological evidence of brain or cervical spine injuries. He had no
other significant medical history.
In view of his Le Fort II facial fractures, nasotracheal intubation was contrain-
dicated. Besides a marginally reduced mouth opening, the patient otherwise dis-
played no signs of a difficult airway. A decision was then made with the surgeon
to perform a submental intubation in order to avoid a tracheostomy.
A rapid sequence induction was performed after all standard monitors were
applied. A C-MAC video laryngoscope was used, revealing a Grade 1 laryngos-
copic view. The patient was intubated easily with a 7.0 mm internal diameter
reinforced Mallinkrodt (Covidien) cuffed ETT. A submental tract was then
created under general anaesthesia. First, a 2.5 cm left submental incision was
made, followed by blunt dissection to the oral mucosa, then a 1cm mucosa inci-
sion. The tract was then further dilated using a #8.0 nasopharyngeal airway.
We proceeded to detach the connector of the reinforced MallinkrodtETT but
realized that the connector was fixed to the tube. Decision was then made to
change to a Fastrach™ ETT by railroading it over a Bougie, after ensuring that
the connector of the Fastrach™ ETT was easily detachable. A direct laryngoscopy
was done subsequently to ensure that the cuff was beyond the vocal cords. Tube
placement was confirmed with capnography and equal bilateral breaths sounds.
The pilot balloon was first brought out through the submental tunnel by a pair
of artery forceps. The connector of the Fastrach™ ETT was then removed and the
tube was exteriorized. After reconnection, endotracheal position reconfirmed
with capnography and patency of the ETT was ensured by smooth passage of a
suction catheter. Anaesthesia was initially maintained with 100% oxygen and
Desflurane until submental intubation was completed. Subsequently, the frac-
tion of inspired oxygen (FiO2) was kept at 0.3.
The marking seen at the submental skin incision was initially at 26 cm. How-
ever, a leak was subsequently noted. This was resolved with advancement of the
ETT to the point where the connector was (Figure 1). Direct laryngoscopy was

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D. Moo et al.

repeated to confirm that the position of the cuff was beyond the vocal cords, be-
fore the ETT was finally secured to the skin with sutures.
Throughout the surgery, there were multiple episodes of air leak from the
mouth despite adequate cuff pressure. The leak improved each time by advanc-
ing the ETT deeper into the patient’s oral cavity or closing the patient’s jaw. At
the end of the surgery, we noticed that fluid from the surgical field had entered
the space between the connector and the interior wall of the tube, most likely
due to the fact that the connector was inside the submental tunnel throughout
the surgery. This made the detachment of the connector, which was a necessary
step for conversion back to orotracheal intubation, very challenging. Using a
pair of artery forceps, we eventually managed to detach the connector. The pa-
tient maintained excellent oxygenation despite this unforeseen difficulty.
After mucosal and submental skin closure, the patient was extubated awake.
He was monitored in the postanaesthesia care unit, followed by transfer to the
high dependency ward. He was discharged four days later. An examination of
the submental wound on postoperative day (POD) eight showed no signs of in-
fection (Figure 2). The patient subsequently defaulted follow up.

3. Discussion
Submental intubation has been described as a safe and effective technique for
intraoperative airway control for surgical fixation of complex panfacial fractures,
as it avoids the risks and complications of nasotracheal intubation, and tra-
cheostomy [6].

Figure 1. Submental intubation completed. Universal

connector was embedded in submental tunnel.

Figure 2. Submental wound at POD 8.

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D. Moo et al.

Since 1986, several publications have attested to the efficacy and low morbidi-
ty of this technique. In a study involving 25 patients [7], two patients had endo-
bronchial intubation, and one patient suffered infection at the submental inci-
sion site. Another study involving 13 maxillofacial surgical patients [8] reported
two patients with endobronchial migration which was readily detected and cor-
rected, as well as two patients with superficial wound infection which responded
well to local treatment. Other major complications have been proven to be un-
common based on trials conducted over the past 30 years [9].
However, it is not uncommon to find that patients with complex facial frac-
tures often have concomitant neurological deficits or a compromised pulmonary
status, which makes postoperative mechanical ventilation necessary. In such pa-
tients, a tracheostomy would be the preferred choice [10]. Submental intubation
was suitable in our patient as he only required intraoperative airway manage-
ment.
Majority of the cases reported in the literature [9] chose a reinforced ETT for
its flexibility. However, as illustrated in our case, it is crucial to confirm the abil-
ity to remove the universal connector before commencing, as not all armoured
tubes come with a freely detachable connector. Fewer reports documented suc-
cess with a non-reinforced ETT, as these standard tubes are usually prone to
kinking and associated with increased peak airway pressures [11]. Altemir also
went on to describe the use of the Combitube SA in two patients, with no com-
plications reported [12]. Unfortunately, no large-scale studies supporting the use
of a particular technique or device have been published so far.
The structural design of the Fastrach™ ETT confers many benefits in submen-
tal intubation [13]. On top of being a wire-reinforced tube that allows it to be
positioned in acute angles without kinking, the connector is intended to be easily
detached and reattached without damaging the tube. It is designed to withstand
the shearing forces when being pulled through the airway tube of the intubating
LMA, hence the pilot balloon and its connecting tubing are described to be
tougher than that of a conventional ETT [13], making it less prone to damage
during exteriorization.
Use of an unsuitable ETT due to our lack of experience could have resulted in
the loss of airway and hypoxic consequences. We also faced another problem
where there was insufficient length of the tube beyond the exit point due to the
need for repeated advancement of the ETT into the patient’s mouth to circum-
vent an air leak. Dislodgement was excluded with laryngoscopy and the pilot
balloon was not leaking. We postulated that our problem occurred because the
Fastrach™ ETT is shorter in length when compared to the Mallinkrodt reinforced
tube of the same diameter, and we did not exclude coiling of the ETTintraorally
before fixing the tube [7]. This resulted in the universal connector being em-
bedded in the submental tunnel throughout surgery, rendering it difficult to re-
move at the end of the procedure.
A literature review [9] done on submental intubation reported a procedure
time averaging at 9.9 minutes. Success rate was 100%. Minor complications oc-

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D. Moo et al.

curred in merely 7% of patients. No major complications associated with sub-

mental intubation have been reported, and none of the studies demonstrated
hypoxia during disconnection of the ETT. Besides the consensus among reports
that the complications are minimal and minor, submental intubation also re-
quires no specialized equipment, and results in an aesthetically better tolerated
scar [9] than a tracheostomy. Elective use of submental intubation has also been
described as a valuable maneuver in elective orthognathic surgery [14] and
transfacial cranial base surgery [15].

4. Conclusion
Although the level of evidence is low, we conclude that submental intubation is
an effective yet underutilized technique for establishing a definitive airway while
providing uninhibited intraoral surgical access during maxillofacial reconstruc-
tive surgery. We recommend the use of the LMAFastrach™ ETT for this tech-
nique in view of certain design features. In order to further improve its safety
profile, we also believe that more emphasis should be given to this simple pro-
cedure during airway workshops for residents, with the aim to avoid the pitfalls
we faced due to the lack of experience.

Informed Consent
Informed consent was obtained from the patient for their anonymized informa-
tion to be published in this article.

Conflicts of Interest
The authors declare no conflicts of interest regarding the publication of this pa-
per.

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