Submental Intubation Versus
Tracheostomy in Maxillofacial
Trauma Patients
Petr Schütz, and Hussein H. Hamed
J Oral Maxillofac Surg 66:1404-1409, 2008
O A definitive airway is defined as the cuffed tube placed below the
vocal cords
O Oro- tracheal intubation is the most reliable and time proven method
of securing airway even for trauma victims
O Nasotracheal intubation is most commonly performed
Indications of NTI
O Head and neck surgery
1. Intra-oral and oropharyngeal surgery
2. Complex intra-oral procedures involving segmental
mandibulectomy or mandibular osteotomy and mandibular
reconstructive procedures
3. Rigid laryngoscopy and microlaryngeal surgery
4. Dental surgery
Indications of NTI
O General indications
1. Intubation of patients with intra-oral pathology including
obstructive lesions, structural abnormalities and trismus
2. Intubation of patients with cervical spine instability or
marked degenerative cervical spine disease
3. Intubation of patients with obstructive sleep apnoea
syndrome
O Base of the skull fracture O Bleeding diathesis
O Laryngeal trauma with tracheal O Patients on anti- platelet
seperation therapy
O Apnea O Cardiac valvular abnormalities
O C- Spine injuries, major upper or prostheses
airway injuries
O Upper airway foreign body
Nasotracheal intubation for head and neck surgery
C. E. J. Hall and L. E. Shutt A E
Anaesthesia, 2003, 58, 249–256
O Epistaxis O Avulsion if inferior turbinate
O Incidence of 17% O Bacteremia due to abrasions on
O Avulsion of nasal polyps, nasal mucosa
adenoids, tonsils O Superficial necrosis of nasal ala
O Damage to posterior O Oedema around the ostium or
pharyngeal wall Eustachian tube
Nasotracheal intubation for head and neck surgery
C. E. J. Hall and L. E. Shutt A E
Anaesthesia, 2003, 58, 249–256
O The diameter of tube that can be inserted via the nasal passage is
necessarily smaller than that which can be passed orally.
O Nasal tubes are also longer
O Hagen–Poiseuille equation
Nasotracheal intubation for head and neck surgery
C. E. J. Hall and L. E. Shutt A E
Anaesthesia, 2003, 58, 249–256
O In such surgery there is a frequent need for maxillo-mandibular
fixation (MMF)
O Intra-operative need for the establishment of occlusion (as in the
cases of Le Fort II and III fractures), or the impossibility of nasal
intubation due to septonasal disorders, may necessitate alternative
solutions in addition to those already known
O Different intubation techniques used in maxillofacial speciality
O Sub- mental intubation
O Retrograde intubation
O Cricothyroidotomy
O Tracheostomy
O Can be traced back to 3000 BC
O Rig veda- 2000 BC
O Asclepiades in the first century BC- relief of upper airway obstruction,
the principal indication for the next 2000 years
Techniques of surgical tracheostomy:
P.A. Walts et al.
Clin Chest Med 24 (2003) 413– 422
O Hieronymus Fabricius 1671, Habicot 1620 provided the first
technical descriptions of the surgical procedure
O Heister 1781- Tracheotomy
O Negus 1938- Tracheostomy
O Until 19th century , tracheostomy was widely condemned
O A surge in the performance of tracheostomy in the eighteenth and
nineteenth centuries during the diphtheria after the publication by
Bretonneu and Trousseu
O Chevealier Jackson 1909, is credited with the establishment of the
modern tracheostomy
O Toy and Weinstein, 1969 introduced the percutaneous tracheostomy
Techniques of surgical tracheostomy:
P.A. Walts et al.
Clin Chest Med 24 (2003) 413– 422
INDICATIONS CONTRAINDICATIONS
O Upper airway obstruction
O Cricothyrotomy can be
O Major laryngeal trauma performed more safely
O Expanding haematomas of
neck
O Laryngeal foreign body or
pathology that prohibits
cricothrotomy
O Prolonged ventilation
O Oncologic resections
O Cricoid cartilage and first tracheal ring must not be injured
O Incision into trachea should not extend below 4 th tracheal ring
O Before late 19th century “Semislaughter” and the “Scandal of
surgery”
O 28 successful cases in procedures performed before 1825
O Incidence of complications – 6% to 48%
O Perioperative O Postoperative
O Plugging of tube
O Haemorrhage
O Haemorrhage
O Pneumothorax
O Infection
O Subcutaneous emphysema O Tracheoesophageal fistula
O Esophageal injury O Tracheal stenosis, erosion
O Tracheomalacia
O False passage
O Injury to recurrent laryngeal nerve
O Aspiration
O Vocal cord palsy
Submental Intubation Versus
Tracheostomy in Maxillofacial
Trauma Patients
Petr Schütz, and Hussein H. Hamed
J Oral Maxillofac Surg 66:1404-1409, 2008
O Purpose:
To evaluate the indications and outcomes of airway
management by submental intubation or tracheostomy in
patients with maxillofacial trauma, and to describe the
technique of submental intubation in detail and discuss its
latest refinements
O 356 patients admitted from January 2004 through September 2007
with maxillofacial trauma
O 222 were operated on under general anesthesia.
O 8 patients- urgent or elective tracheostomy
O 8 patients - submental intubation
O 206 patients- intubated either orally or nasally
“Submental endotracheal intubation is an extremely
useful technique with very low morbidity and is suitable to
replace tracheostomy in selected cases of maxillofacial trauma,
where NTI is impossible or contraindicated and long term
ventilation support is not required”
O Accidental passage of the tracheal tube into the cranial cavity during
nasal intubation
First described by Martinelle et al in 1974.
33 additional cases have been reported in the
international literature
Inadvertent Intracranial Placement of a Nasogastric
Tube in a Patient With Severe Craniofacial Trauma: A
Case Report
Genu et al.,
Oral Maxillofac Surg 62:1435-1438, 2004
O More frequent obstacle to NTI is an associated nasal bone fracture,
which cannot be properly managed in the presence of a nasal tube
The incidence of sports-related faciail trauma in children
Perkins, Dayan et al.,
ENT-Ear, Nose & Throat Journal - August 2000
O Facial surgery, and particularly maxillofacial surgery, presents peculiar
features in relation to general anesthesia
O Prime reqisite to achieve a stable relation between the maxilla and
mandible; dental occlusion as a basic parameter
O Simultaneous surgical access for checks of dental occlusion and of the
nasal region, exchanging nasotracheal for orotracheal intubation
becomes necessary
O Submental endotracheal intubation is a method of securing the airway
without interference with the intraoral operative field and
maxillomandibular fixation.
O Technically easier
O Less time consuming
O Accompanied by lower morbidity than tracheostomy
O In a case of multiple facial fractures, tracheostomy was avoided by the
use of submental endotracheal intubation technique.
O In selected group of patients with severe maxillofacial trauma,
submental endotracheal intubation is a useful and relatively harmless
alternative to tracheostomy for securing airway
Submental endotracheal intubation: A useful alternative to
tracheostomy
Malhotra, Bhardwaj, Chari
Indian J. Anaesth. 2002; 46 (5) : 400-402
O When simultaneous surgical access to oral and nasal regions is
needed, switching the tube from nasal to oral route may lead to-
O Risk of aspiration
O Interfere with surgical procedure
O The use of the submental orotracheal method offers an alternative
that the surgeon can use successfully
Submental method for orotracheal intubation in treating facial trauma
Manganello-Souza LC, Tenorio-Cabezas N, Piccinini L.
Rev Paul Med 1998;116(5):1829-32
O Antonio Figueiredo Caubi, Belmiro Cavalcanti do Egito Vasconcelos
et al.,
Submental intubation should be chosen whenever possible in cases
of purely maxillofacial trauma
It presents a low incidence of operative and postoperative
complications and eliminates the risks and side effects of
tracheotomy
It demands a certain surgical skill, but it is simple, safe and quick to
execute.
Submental intubation in oral maxillofacial surgery: review of the literature
and analysis of 13 cases
Med oral patol oral cir bucal. 2008 mar1;13(3):e197-200
O Used sub- mental intubation as an adjunct in the management of
orthognathic surgery in a series of 44 patients
Allows precise assessment of changes to the nasolabial complex,
midlines, cants, and incisal display in patients having maxillary
orthognathic surgery
Submental intubation in orthognathic surgery: initial experience
A. Chandu et al.
British Journal of Oral and Maxillofacial Surgery 46 (2008) 561–563
Garg et al.,
O 10 patients were intubated via submental route
Disconnection of tube from the circuit per-operatively
Submental wound infection
O Conclusion:
Low incidence of operative and postoperative complication,
eliminates drawbacks of tracheostomy
Submental intubation in panfacial injuries: our experience
Garg et al.,
Dental Traumatology 2010; 26: 90–93
O Shenoi, et al.
Uneventful extubation
1 patient out of the 7 intubated via sub- mental route experienced
post-operative infection
O Conclusion:
Submental endotracheal intubation is a simple technique with very
low morbidity and can be used as an alternative to tracheostomy in
selected cases of maxillofacial trauma.
Submental orotracheal intubation: Our experience and review
Shenoi et al.,
Annals of Maxillofacial Surgery 2011 , 1 (1): 37 - 41
O The use of transtracheal ventilation as a routine method of ventilation
during anaesthesia for 60 patients with gross pathology requiring oral
surgery was reported
O There were no serious complications in this series.
O The technique is recommended as a simple and safe alternative to
blind nasal intubation
Transtracheal ventilation in oral surgery
P R Layman
Annals of the Royal College of Surgeons of England
(1983) vol. 65
Utilization of Tracheostomy in Craniomaxillofacial Trauma at a Level-1
Trauma Center
Holmgren et al,
J Oral Maxillofac Surg 65:2005-2010, 2007
P.A. Walts et al,
O Variations in technique and expertise have led to a wide range of
reported procedural related morbidity and rarely mortality
O The risk-benefit ratio of prolonged translaryngeal intubation versus
tracheostomy begins to weigh heavily in favor of surgical
tracheostomy
Techniques of surgical tracheostomy
P.A. Walts et al.,
Clin Chest Med 24 (2003) 413–422
O Consensus show that high morbidity is asssociated with tracheostomy
O But, tracheostomy was performed to maintain airway in comorbid
conditions,
O The death toll was due to the associated injuries rather than the
complications of tracheostomy persay
O Submental intubation can be performed in controlled conditions after
securing airway, but cannot be performed in an emergency setup
O Tracheostomy – in emergency set up
O Submental intubation- elective or non-
emergency cases
O Submental intubation versus tracheostomy in maxillofacial trauma
patients. Petr Schütz, and Hussein H. Hamed J Oral Maxillofac Surg
66:1404-1409, 2008
O Nasotracheal intubation for head and neck surgery C. E. J. Hall and
L. E. Shutt A E Anaesthesia, 2003, 58, 249–256
O Techniques of surgical tracheostomy: P.A. Walts et al. Clin Chest
Med 24 (2003) 413– 422
O Inadvertent Intracranial Placement of a Nasogastric Tube in a Patient
With Severe Craniofacial Trauma: A Case Report Genu et al., Oral
Maxillofac Surg 62:1435-1438, 2004
O The incidence of sports-related faciail trauma in children Perkins,
Dayan et al., ENT-Ear, Nose & Throat Journal - August 2000
O Submental endotracheal intubation: A useful alternative to
tracheostomy Malhotra, Bhardwaj, Chari Indian J. Anaesth. 2002; 46
(5) : 400-402
O Submental method for orotracheal intubation in treating facial trauma
Manganello-Souza LC, Tenorio-Cabezas N, Piccinini L. Rev Paul
Med 1998;116(5):1829-32
O Submental intubation in oral maxillofacial surgery: review of the
literature and analysis of 13 cases Med oral patol oral cir bucal. 2008
mar1;13(3):e197-200
O Submental intubation in orthognathic surgery: initial experience A.
Chandu et al. British Journal of Oral and Maxillofacial Surgery 46
(2008) 561–563
O Submental intubation in panfacial injuries: our experience Garg et al.,
Dental Traumatology 2010; 26: 90–93
O Submental orotracheal intubation: Our experience and review Shenoi
et al., Annals of Maxillofacial Surgery 2011 , 1 (1): 37 – 41
O Transtracheal ventilation in oral surgery P R Layman Annals of the
Royal College of Surgeons of England (1983) vol. 65
O Utilization of Tracheostomy in Craniomaxillofacial Trauma at a
Level-1 Trauma Center Holmgren et al, J Oral Maxillofac Surg
65:2005-2010, 2007
