Nasal tube switch: Converting from a nasal to an oral endotracheal tube without extubation

The choice of intubation for a patient with maxillary/mandibular fracture concomitant with nasal bone fracture is submental or retromolar intubation or tracheostomy. These methods facilitate unhindered surgical access to the fracture sites for reduction and fixation as well as to perform Inter Maxillary Fixation to achieve ideal occlusion. This article presents a new technique of using a pre-fabricated “Splint with Port for Endotracheal Tube” (SPET) as an effective modality to achieve oral intubation which permits surgical manipulation of the naso-maxillomandibular complex while ensuring ideal dental occlusion.

The conventional endonasal intubation would not allow precise intra-operative assessment of the changes to the nasolabial soft tissue complex. Submental intubation allows accurate measurement of nasolabial soft tissue complex with no interference with the occlusion.

A clinical prospective study was carried on 20 patients visiting the Oral and Maxillofacial Surgery department diagnosed of dentofacial deformity requiring orthognathic surgery. The patient were intubated by the submental route of anaesthesia. Intraoperatively time taken to perform intubation and bleeding during the surgery was noted. Post-operatively infection, presence or absence of any complications were noted along with the measurement of scar by Vancouver scar scale.

Out of 20 patients 17 patients required only maxillary osteotomies whereas 3 patients required bimaxillary osteotomy. The mean time taken for intubation was 5.68 ± 1.257 minutes. In all the cases the scar was measured as minimum. 2 patients showed infection at the site of submental intubation after 7th day while after 14th day there was no infection present. No other complication was noted. 19 out of 20 cases showed no interference during the procedure whereas in 1 case mild interference during mandibular movement.

The submental intubation is a very good alternative to nasotracheal intubation in the patients undergoing bimaxillary surgeries or maxillary surgeries. Submental intubation can be chosen whenever possible, as it is easy, takes little time and follow-up is simple, does not result in bleeding or other complications and more importantly does not result in any unaesthetic scar after 3rd month follow up.

Soft tissue changes secondary to Maxillary orthognathic surgery are many fold. The alar flare is one among them, which affects the appearance of the patient. Cinch suture has been used to prevent alar flare; but the presence of anaesthetic tube hinders cinching. So, the study was aimed to assess an efficacy of modified nasal to oral tube switch technique for modified alar cinching to prevent alar flare after orthognathic and nasal corrective surgeries.

Patients were randomly allocated in each group, who underwent modified alar base cinching with and without nasal to oral tube switch. Changes in alar base width, upper lip length was measured with Digital Vernier Caliper and nasolabial angle (Cotg-Sn-Ls) on lateral cephalogram at 1st, 3rd, 6th, and 12th months after surgery. The time taken and ease of tube switch were noted. The data obtained were tabulated and interpreted using a test of significance.

Study results showed no statistical significant difference in perinasal soft changes among both groups. But tube switch appears to be beneficial to prevent alar flare.

Modified alar base cinching was performed effectively in patients with a modified tube switch technique. It increased positive results in comparison with non-shift. The technique of tube switch used is effective in prevention of alar flare. Because of small sample size and limited period of follow up, our study suggests multi centre, randomized studies to know the technical difficulties of tube switch for cinching and aesthetic results with varying anaesthetist and the surgeon’s experience.

To evaluate the outcome of airway management in patients with complex maxillofacial fracture by submental intubation, time required for intubation, accidental extubation, and postoperative complications.

Retrospective study.

University-affiliated hospital.

The medical records of the 10 patients who underwent submental intubation from December 2008 to June 2011 were reviewed.

At the end of the procedure, all 10 patients were extubated without any complications. Postoperatively, only one patient presented with superficial infection of the submental wound.

Submental endotracheal intubation is a simple technique with very low morbidity, and may be used as an alternative to tracheostomy in selected cases of maxillofacial trauma.

Hernandez⁵, in 1986, published the first paper on “The submental route for endotracheal intubation”. The technique was developed to avoid tracheostomy, particularly in maxillofacial trauma cases, where short-term intermaxillary fixation was required. Gordon & Tolstunov⁴ published 2 cases utilizing the technique. Our initial experience with the technique as presented was less than satisfactory. The technique was modified to utilize a strict midline approach. Fifteen cases utilizing this modified technique are reported, including 14 cases of craniomaxillofacial trauma and one complex orthognathic surgery case. There have been no operative or postoperative complications. Postoperative submental scarring has been acceptable.