Submental intubation, maxillofacial trauma, wound infection, polytrauma. Full text submental intubations in panfacial fractures. A simple and reliable submental intubation technique for. Submental intubation allows intraoperative dental occlusion and is an acceptable option, especially when longterm postoperative ventilation is not planned. The average reported time to complete a submental intubation was 9. This procedure avoids the use of tracheostomy and bypasses its associated morbidities. This pdf download is supported by maquet the makers of flowi advancing anesthesia. Submental intubation is an interesting alternative when shortterm postoperative control of airway is desirable with the presence of undisturbed access to oral as well as nasal airways and good dental occlusion in maxillofacial trauma and.
Since that time, several case studies have been performed demonstrating the efficacy of the submental approach. When all the conventional modalities to secure airway seem unsuitable then submental route offers an excellent alternative to manage airway in such patients. Seven male patients with panfacial fractures underwent submental intubation. This procedure consists of exteriorizing an oral endotracheal tube through the floor of the mouth and submental triangle. Submental intubation is now a known alternative to tracheostomy to secure airway in the management of severe maxillofacial injuries. Farhad ardeshirpour, md, division of facial plastic and reconstructive surgery, department of head and neck surgery, loma linda university medical center, 11234 anderson st, room 2587a, loma linda, ca 92354. To improve the selection of patients and clinical outcomes we have explored published papers on submental intubation in oral and maxillofacial surgery, and included a proposal for a decision pathway.
Tracheal intubation via the submental route was first described by altemir in 1986. Pdf submental intubation in maxillofacial trauma patients. Submental intubation was described by altemir 1 almost 20 years ago and is now a recognised technique of airway control in the management of severe maxillofacial injuries. Upon open reduction and internal fixation, which was now conveniently done in a single stage surgery, when the. This method was recently implemented in the case of a patient with altered nasal anatomy who sustained a mandibular fracture necessitating. A 20yearold man was scheduled for sagittal split ramus osteotomy. After sterile painting and draping of chin and mouth, lignocaine 2% with 1. Submental intubation is a viable alternative to tracheostomy. Submental intubations in panfacial fractures ccide. Submental intubation is a lowrisk alternative to tracheostomy when nasotracheal or orotracheal intubation is not appropriate. Submental orotracheal intubation severe facial and anterior skull base trauma present particular challenges to the surgeon and anesthesiologist.
Submental orotracheal intubationa technique for airway. We report a new modification for soi to minimize the risk of apnea. This leaves the facial bones, mandible, and skull base untouched. Pdf submental orotracheal intubation for maxillofacial. Submental intubation in oral maxillofacial surgery. Submental intubation provides intraoperative airway control, avoids use of oral and nasal route, with minimal complications. This technique should be included in airway workshops and courses. Hernandez first described the submental route for endotracheal intubation in 1986 as an alternative airway maneuver for maxillofacial procedures. Submental tracheal intubation was performed in cases needing intermaxillary fixation complicated by a nasal. Thus, submental intubation is a simple, safe, with low morbidity technique for operative. Anaesthesia and common oral and maxillofacial emergencies. Indications for submental intubation are maxillofacial injuries with associated fractures of nasal bone and skull base or use of temporary.
Submental intubation in oral and maxillofacial surgery a. Submental intubation in oral and maxillofacial surgery. It contains one or two lymph glands, the submental lymph nodes and some small veins. In patients in whom a tracheal tube cannot be inserted through the nostrils due to multiple facial trauma or hypoplasty of the nose, submental orotracheal intubation soi is performed to avoid tracheostomy.
A variety of methods have been described for airway management in cases of panfacial trauma. A 40 year old male patient, reported to our casuality department who had met with a road traffic accident. We conclude that the lmafastrach tm ett is a suitable device for submental intubation. The choice of anaesthetic technique will again be influenced by the airway evaluation and the difficulties anticipated. It is a versatile technique which allows intubation of patients in the presence of polytrauma and allows maxillamandibular fixation along with simultaneous access to nasal pyramid fractures. Submental orotracheal intubation smoti avoids the risks, morbidity, and hindrance associated with nasotracheal intubation, orotracheal intubation, or tracheostomy. This paper reports a case of maxillofacial injury, operated using submental intubation technique. We have described successful use in a patient with severe facial deformities, as a result of underlying thalassaemia major. Submental intubation can be chosen whenever possible, as it is easy, takes little time and followup is simple, does not result in bleeding or other complications and more importantly does not.
Submental intubation in patients with complex maxillofacial injuries. Panfacial fractures or concomitant nasoethmoidal injuries. This technique involves passing an endotracheal tube through the anterior floor of the mouth, and then down the airway. Submental intubation permitted reduction and fixation of all the fractures without the interference of the tube during surgical procedure in all of the patients. Herein, we describe a refined technique based on altemirs original procedure. In addition, submental intubation allows proper access to oronasal airways and occlusion during intraoperative management. Submental intubation in maxillofacial trauma patients. Fig 1, 2 fig 1, submental intubation fig 2 submental intubation case 2. Either a nasal or oral tube would have been in the way of the surgical field. Pdf submental endotracheal intubation cassiano pereira. Submental intubation in patients with panfacial fractures. Mar 19, 2018 it is safe an effective option for pan fasciomaxillary trauma.
On admission patient was conscious, with a glasgow coma score. Submental orotracheal intubation for maxillofacial surgery. Evidence based report submental intubation in patients with. Alternative technique of intubation retromolar, retrograde. The submental triangle or suprahyoid triangle is a division of the anterior triangle of the neck. Submental tracheal intubation was performed in cases needing intermaxillary fixation complicated by. A useful alternative method of managing the airway intraoperatively is submental endotracheal intubation, where, the tube is passed through a submental skin incision into the mouth. Sep 30, 2016 tracheostomy is a good route to secure the airway in patients with complex maxillofacial injuries, particularly for those who need prolonged intubation. Tracheostomy is a good route to secure the airway in patients with complex maxillofacial injuries, particularly for those who need prolonged intubation. In conclusion, the submental method is a novel, but under utilized, technique for tracheal intubation and has only previously been described in patients with craniofacial trauma. It avoids retromolar intubation tracheostomy and its disadvantages.
Submental intubation is an effective and less invasive alternative to tracheostomy during intraoperative airway management where orotracheal and nasotracheal intubation are not appropriate options. Submental intubation is a safe, effective and time efficient method for securing an airway when increased surgical. Photo of the patient with orotracheal intubation and the submental incision. The submental intubation is a very good alternative to nasotracheal intubation in the patients undergoing bimaxillary surgeries or maxillary surgeries. Clinical evaluation of submental intubation as an alternative. It is safe an effective option for pan fasciomaxillary trauma. Submental intubation in patients with complex maxillofacial.
After orotracheal intubation and establishment of the submental tract, the free end of the endotracheal tube was pulled through a submental incision and reconnected to the anesthetic circuit. Paetkau and others published submental orotracheal intubation for maxillofacial surgery find, read and cite all the research you need on researchgate. The submental intubation was successfully done in all patients with minimal obvious postoperative complications. Alternative technique of intubation retromolar, retrograde, submental and other technique 1. Submental intubation with midline incision has been used in 10 cases from october 2008 to march 2010 in. Submental intubation technique for airway during surgery. Submandibular approach for tracheal intubation in patients. The endotracheal tube can be seen externally in the oral cavity through a tunnel in the submental region. A flexible and kinkresistant reinforced endotracheal tube. Submental intubation, thus as an alternative to tracheostomy, can be used when shortterm control of airway is desirable with the presence of undisturbed access to oral as well as nasal airways and a good dental occlusion. The potential indications for submental intubation extend beyond craniomaxillofacial trauma to include orthognathic surgery and elective craniomaxillofacial. Paetkau and others published submental orotracheal intubation for maxillofacial surgery find, read and cite all. Due to the extensive existing fracture, the preferred airway approach would be through a tracheostomy or a.
A simple and reliable submental intubation technique for max. Here we describe our experience with submental intubation technique in 10 patients with panfacial injuries over a period of two years. Submental intubation allowed simultaneous management of all the fractures nasal as well as jaw fractures and. The patient was painted and draped as usual, with full access to the facial bones and occlusion. The orotracheal intubation was then converted to a submental endotracheal intubation by using the following procedure. Submental intubation with lmafastrachtm endotracheal tube. A comparison of different techniques of airway access in complex maxillofacial injury is. Submental intubation technique for airway during surgery of. The submental approach to intubation allows imf to be used without resort to nasal intubation or tracheotomy. Submental intubation, a less invasive alternative to tracheostomy, was. We describe a modification of the original technique which is applicable to any reinforced tracheal tube and which does not compromise the airway. There are technical problems with the original technique described.
Alternative technique ofintubation retromolar, retrograde, submental and other technique under the guidance assistant prof dr. The mode of trauma for majority of cases of panfacial fracture who underwent submental intubation was road traffic accident 69. Clinical evaluation of submental intubation as an alternative airway management technique in midface osteotomy. However, the procedure is associated with the risk of hemorrhage, pneumothorax, infection, and tracheal stenosis 3,4. Submental intubation steps of the procedure explained. The need for a throat pack, postoperative intermaxillary fixation, and facial nerve monitoring should also be discussed. It allows short term, nonobstructed access to the maxillofacial skeleton, particularly when nasal intubation is contraindicated, allowing intermaxillary fixation without compromise to the. It provides added advantage of control of occlusion during the panfacial trauma management.
Submental intubation is a simple, safe, useful and effective method to secure airway in major maxillofacial trauma, where oral and nasal endotracheal intubation cannot be performed. Smoti secures the endotracheal tube and provides uninhibited access to craniofacial injuries. The contraindications of submental intubation are patients refusal, bleeding diathesis, laryngotracheal disruption, infection at the proposed site, gunshot injuries in the maxillofacial region, longterm airway maintenance, tumor ablation in maxillofacial region, and history of keloid formation. Introduction management of airway is a significant issue in. Submental intubation was first described by hernandez altemir in 1986. A comparison of different techniques of airway access in complex.
After completion of submental intubation the anticipated procedure was carried out. Submental orotracheal intubationa technique for airway management in severe facial trauma. Journal of stomatology, oral and maxillofacial surgery. Nov, 2012 hernandez first described the submental route for endotracheal intubation in 1986 as an alternative airway maneuver for maxillofacial procedures. In patients who require intubation for maxillofacial. Sep 25, 2015 submental intubation steps of the procedure explained 1.
Full text submental intubations in panfacial fractures ccide. A new modification for safer submental orotracheal intubation. Submandibular intubation is a modification of submental intubation, first described by hernandez altemir 8 in 1986 as an alternative method for shortterm tracheostomy, when both orotracheal and nasotracheal intubation are contraindicated, impossible, or may interrupt the surgical access or techniques. Submental intubation in patients with panfacial fractures medind. Thus,submental intubation is a simple, safe, with low morbidity technique for operative. Feb 07, 20 alternative technique of intubation retromolar, retrograde, submental and other technique 1. In such cases submental intubation smi is a recognized technique in practice. Evidence based report submental intubation in patients. Submental intubation an alternative to tracheostomy in. In contrast, the submental route for endotracheal intubation represents a fast and lowmorbidity alternative to tracheostomy. Submental intubation europe pmc article europe pmc. Submental intubation is an interesting alternative to tracheostomy, especially when shortterm postoperative control of airway is desirable with the presence of undisturbed access to oral as well as nasal airways and a good dental occlusion.
This method was recently implemented in the case of a patient with altered nasal anatomy who sustained a. Material and methods from july 2003 to february 2005, patients benefited from submental intubation table 1. Submental intubation offers an adequate, easy and minimally invasive alternative for polytrauma patients though patients with comorbidities should be screened to avoid complications. Submental intubation is a reliable single and safe technique allowing an onestage surgical treatment in case of complex association of fractures without using tracheotomy. At the end of the procedure, the stay sutures around the ett were removed and the deflated pilot tube cuff and the ett were pulled in reverse order from the tunnel to the oral cavity and thus submental intubation transformed into orotracheal intubation. Submental intubation for a midface odontogenic tumor.
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