Louis A et al. Submental Intubation in Complex Maxillofacial Trauma.

Review Article
Submental Intubation in Complex Maxillofacial Trauma: An Overview
Archana Louis, Indraniil Roy, Vikas Dhupar, Francis Akkara, Omkar Shetye

Department of Oral and Maxillofacial Surgery, Government Dental College and Hospital,
Goa, India

Abstract:
Management of Airway in patients with complex maxillofacial trauma is challenging due to
disruption of components of upper airway. Submental intubation is a simple, quick and effective
alternative to oral and nasal intubation or tracheostomy.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. This article is an overview of
the procedure and discusses the technique, scope, advantages, disadvantages and modifications
of submental intubation.
Keywords: Airway management, Submental intubation, Tracheostomy

Corresponding Author: Dr. Indraniil Roy, Address-D-102, Socorro Gardens, Porvorim, Goa,
India. Email: [email protected]
This article may be cited as: Louis A, Roy I, Dhupar V, Akkara F, Shetye O. Submental
Intubation in Complex Maxillofacial Trauma: An Overview. J Adv Med Dent Scie Res 2015;3(1):66-
70.

I NTRODUCTION:
Panfacial fractures refers to simultaneous
fracture of multiple bones in the upper ,
middle and lower thirds of the face.1 The
management of panfacial fracture is complex
Tracheostomy in such situations is
conventional and time-tested; however, it has
life-threatening complications, it needs
special postoperative care, lengthens hospital
stay, and adds to expenses. Submental
because of the lack of reliable landmarks. intubation is an attractive alternative which
Early reconstruction and restoration of overcomes the disadvantages of
occlusion of patients with panfacial fractures tracheostomy.
by open reduction and rigid internal fixation A Spanish faciomaxillary surgeon, Francisco
is now the standard of care. However, Hernandez Altemir in 1986, first described
mantainance of airway in patients with “The submental route for endotracheal
faciomaxillary injuries is challenging. Neither intubation”.5 He proposed it as an alternative
nasal nor orotracheal intubation is possible. to short-term elective tracheostomy, where
Nasotracheal intubation in patients with nasal both oral and nasal route for endotracheal
fractures can result in meningitis or the tube intubation were not feasible. This provides a
can be passed intracranially in patients with secure airway and allows unimpeded surgical
frontobasillar fractures.2,3 Orotracheal tube access to the oral cavity and midface, whilst
interferes with intraoperative intermaxillary avoiding the potential complications
fixation and thus cannot be used.4 associated with nasal intubation and

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Journal of Advanced Medical and Dental Sciences Research |Vol. 3|Issue 1| January-March 2015
Louis A et al. Submental Intubation in Complex Maxillofacial Trauma.

tracheostomy. This article discusses the with 2-0 heavy silk. A throat pack is placed
technique, scope, advantages, disadvantages during manipulation of the mandible. At the
and modifications of submental intubation. end of the surgery, the stay sutures are
removed, followed by throat pack. Tracheal
TECHNIQUE: extubation is done through the submental
The conventional submental intubation route, when the patient is awake and
technique essentially involves creation of an maintaining airway reflexes. The submental
orocutaneous tunnel and diverting the incision is sutured using silk or nylon whereas
proximal end of the armoured ETT through the mucosal incision is left to heal by
anterior floor of the mouth.5An appropriate- secondary intention. Skin sutures are removed
sized flexometallic ETTs is selected and made after 5–7 days.
easily detachable from the universal
SCOPE:
connector. General anesthesia and intubation
Indications of submental intubation include
via the oral route is done with the armoured
panfacial fractures with associated fractures
ETT in conventional way.
of nasal bone and skull base,6 repair of post
The entire submental region is scrubbed and
cancrum oris defects,7 oronasal fistula,8
prepared with 10% povidone iodine solution
selected cleft lip and palate surgeries, repair
and is draped. The proposed site is infiltrated
of congenital malformations,9 skull base
with 2% lignocaine with adrenaline. Skin
surgery,10 transfacial oncologic procedures of
incision measuring about 1.5cm is made in
the cranial base, and pediculated craniofacial
the right submental region parallel to the
surgeries. The scope of this technique has
inferior border of the mandible. The
extended far beyond the realm of
advantage of right-sided incision is that it
faciomaxillary surgeries and it has been
permits better visualization of the ETT orally
successfully used in orthognathic surgeries
by a left handed laryngoscopy. However, the
and elective aesthetic face surgeries as there is
side of incision may be altered based on the
minimal distortion of the nasolabial soft
site of injury and mandible fracture. Blunt
tissue.11 Submental intubation is
dissection is carried out with a medium-sized
contraindicated in patients who don’t give
curved artery forceps along the lingual
consent, with bleeding diasthesia, injury to
surface of the mandible through subcutaneous
laryngo-tracheal airway, history of keloid
tissue, platysma, investing layer of deep
formation, long term airway maintenance
cervical fascia, and the mylohyoid muscle. A
desired and gunshot injuries in maxillofacial
paramedian oral incision is made over the
region.12,13
tented mucosa created by the tip of the artery
forceps. The patient is ventilated with 100% ADVANTAGES:
oxygen and 1% isoflurane for 5 min, after Submental intubation combines the best
which the breathing circuit is disconnected features of both nasotracheal intubation and
and universal connector is detached from the orotracheal intubation, and also avoids the
tube. The tip of the pilot balloon cuff is first complications associated with tracheostomy.
pulled through the submental incision This technique allows free intraoperative
followed by the distal end of the ETT in a access to the dental occlusion and the nasal
similar fashion. The connector is reattached pyramid. It also allows adequate access to
and the ETT reconnected with the breathing frontonasal fractures. Risk of iatrogenic
circuit. The position of the tube is confirmed meningitis or trauma of the anterior skull base
by chest auscultation, and capnography. The as seen with naso-tracheal intubation are
ETT is secured to the skin using stay suture avoided.14 Complications associated with

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Journal of Advanced Medical and Dental Sciences Research |Vol. 3|Issue 1| January-March 2015
Louis A et al. Submental Intubation in Complex Maxillofacial Trauma.

tracheostomy such as tracheal stenosis, injury exteriorizing the ETT as this minimized the
to cervical vessels or the thyroid gland are chance of injury to the associated
also avoided using this technique.15 structures. 25 Anwer et al suggested that
placement of a 1.5-cm skin incision, 1 inch
DISADVANTAGES: below and 0.5 inch anterior to the angle of the
Disavantages of submental intubation include mandible is found to be more advantageous as
accidental dislodgement of the tube during posterior placement of the tube assures
pulling of the tube end through the unobstructed surgical field.26
track,16,17abscess formation in the floor of Mahmood and Lello performed submental
mouth, infection of the submental wound.18,19 intubation using preformed Sheridan tube.
Formation of salivary fistula and development The preformed curvature helps in positioning
of mucocele have also been reported of the tube as it conforms to the anatomy of
following submental intubation.20,21 Facial the region.27 The use of Combitube SA (Tyco-
scarring is another disadvantage , as this is an Kendall, Mansfield, MA) through the wide
extraoral procedure. However, by following submental incision or the external injury site
proper surgical technique and placing the makes provision for adequate dental
incision in the submandibular region scars can occlusion, unimpeded surgical access, and
be concealed.22 ease of ventilation in severe maxillofacial
MODIFICATIONS: injuries. Moreover, the inflated proximal
After the first description of Submental balloon helps to allay pain and minimizes
intubation in 1986 by Altemir5, this technique bleeding by spontaneous reduction of fracture
has come a very long way. All modifications fragments.28
have been proposed with an expectation of
improved outcome. Most authors are of the CONCLUSION:
opinion that subperiosteal placement of the Submental intubation serves as an attractive
tube as described by Altemir is not necessary. and adaptive option for intraoperative airway
In compound communited fractures of the control in complex panfacial injuries. It
mandible stripping of the periosteum for the combines the advantages of the nasotracheal
placement of the tube can jeopardize blood and orotracheal intubation by allowing access
supply.17,23,24 to the interdental occlusion and nasal
Gadre and Waknis considered transmylohyoid pyramid, respectively. It provides a safe and
as a more appropriate terminology, as in this reliable route for airway management and
technique the endotracheal tube passes avoids the difficulties and morbidity of
through the mylohyoid muscle anywhere nasotracheal intubation and tracheostomy. It
between the first mandibular molars of either presents a low incidence of operative and
side anterior to the massetor muscle.24 postoperative complications. The simplicity
Greene and Moore described the use of 2 of the technique lies in the fact that no
endotracheal tubes (one anterograde and the specialized equipment or technical expertise
other retrograde) as there is less chance of is required.
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Source of Support: None

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