Submental Intubation Versus Tracheostomy in Maxillofacial Trauma Patients

doi:10.1016/j.joms.2007.12.027

Journal of Oral and Maxillofacial Surgery

Volume 66, Issue 7, July 2008, Pages 1404-1409

https://doi.org/10.1016/j.joms.2007.12.027 Get rights and content

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.

Patients and Methods

Of 356 patients admitted from January 2004 through September 2007 with maxillofacial trauma, 222 were operated on under general anesthesia. Eight patients underwent urgent or elective tracheostomy; 8 patients underwent submental intubation.

Results

Seven patients with submental intubation were extubated at the end of the procedure. One patient received elective tracheostomy 3 days later. We did not encounter any complications in the tracheostomy group, while 1 case of slight damage to the endotracheal tube occurred in the submental intubation group.

Conclusions

Submental endotracheal intubation is a simple technique with very low morbidity and can replace tracheostomy in selected cases of maxillofacial trauma without indication for prolonged ventilation support.

Section snippets

Surgical Procedure

After the induction of general anesthesia, the patient's trachea is intubated orally by standard direct laryngoscopy with a reinforced, spiral embedded, tracheal tube (Fig 1). It is important to release the sealed connector from the proximal end of the tube before intubation so that it can be easily disconnected during the procedure. Patients already intubated by other types of tubes must have their tubes replaced.

The oral route of intubation is converted into the transcutaneous

Discussion

An often-stated reason for avoidance of NTI in maxillofacial trauma patients is the danger of accidental passage of the tracheal tube into the cranial cavity during nasal intubation.2, 3 However, this is a rare incident and thinner gastric tubes are incomparably more prone to such a complication, as has been reported multiple times in the literature.¹⁶ A much more frequent obstacle to NTI is an associated nasal bone fracture, which cannot be properly managed in the presence of a nasal tube.

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Cited by (51)

Submental intubation in oral and maxillofacial surgery: a systematic review 1986–2018
2020, British Journal of Oral and Maxillofacial Surgery
Citation Excerpt :
Two of them did not report sample size.24,25 Three studies on tracheostomy (n = 27) and submental intubation (n = 38) reported data on tracheostomy complications.26–28 No data were reported for 166 cases (7%).
Submental intubation is a low-risk alternative to tracheostomy when nasotracheal or orotracheal intubation is not appropriate. 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. Systematic searches of PubMed, Scopus, and Cochrane databases for papers published between 1986 and 2018 yielded 116 eligible articles (one randomised controlled trial, 61 case series, 40 case reports, six surgical techniques, and eight letters) that included 2 229 patients. Measured outcomes were the indications, techniques, devices used, time taken to complete the procedure, and complications. Indications were trauma (81%), orthognathic surgery (15%), disease (2%), and cosmetic surgery (1%). Technical preferences were for a one-tube (84%) over a two-tube technique (6%), and a paramedian (52%) over a median incision (33%). The preferred device was a reinforced endotracheal tube (85%). The mean (range) intubation time was 10 (2–37) minutes. The complication rate was 7% (n = 152), the most common being superficial skin infection (n = 54), hypertrophic scarring (n = 18), and damage to the tube apparatus (n = 15). Submental intubation has minimal complications, takes a short time to do, and it is a useful alternative to tracheostomy in some oral and maxillofacial operations. More robust evidence regarding the selection of patients, modifications to the technique, and a comparison of risk with that of tracheostomy, are needed for further evaluation of its feasibility.
The Characteristics and Cost of Le Fort Fractures: A Review of 519 Cases From a Nationwide Sample
2019, Journal of Oral and Maxillofacial Surgery
The aims were to report the characteristics of Le Fort fractures and to quantify the associated hospital costs.
From October 2015 to December 2016, the National Inpatient Sample was searched for patients admitted with a primary diagnosis of a Le Fort fracture. Predictor variables were drawn from demographic, admission, and injury characteristics. The outcome variable was hospital cost. Summary statistics were calculated and compared among Le Fort patterns. Univariate comparisons and multivariate regression analyses were conducted to determine predictors associated with cost.
A total of 519 patients were identified in this cohort. Associated injuries included skull fractures (28%), intracranial hemorrhage (13%), cervical spine injury (9.8%), and concussion (9.1%). Seventy-three percent of patients received open reduction and internal fixation (ORIF) for their facial fractures during their admission, 13% received a tracheostomy, and 10% were mechanically ventilated for at least 1 day. The ventilation (P < .01) and tracheostomy (P < .01) rates increased with Le Fort complexity, as did length of stay (LOS; P < .01), costs (P < .01), and charges (P < .01). The mean costs of treating Le Fort I, II, and III fractures were $25,836, $28,415, and $47,333, respectively. Increased cost was independently associated with younger age, male gender, African-American ethnicity, Le Fort II and III patterns, motor vehicle accident etiology, mechanical ventilation requirement, tracheostomy, ORIF, transfer to an outside facility, and increased LOS.
The prevalence of head injuries and the need for respiratory support substantially increased with Le Fort complexity. Hospital costs were not markedly influenced by the diagnosis and management of associated injuries. Instead, costs were predominantly driven by fracture complexity and the need for necessary procedures, such as ORIF, tracheostomy, and mechanical ventilation.
Thirty years of submental intubation: a review
2018, International Journal of Oral and Maxillofacial Surgery
Submental intubation has been used as an alternative to conventional intubation in the field of oral and maxillofacial surgery since its introduction by Francisco Hernández Altemir in 1986. A review of submental intubation was performed using data from all case reports, case-series, and prospective and retrospective studies published between 1986 and 2016. The indications, variations in incision length, incision sites, types of endotracheal tube used, methods of exteriorization, and complications were recorded and analyzed. A total of 70 articles reporting 1021 patients were included. The main indication was maxillofacial trauma (86.9%, n = 887), followed by orthognathic surgery (5.8%, n = 59), skull base surgery (2.8%, n = 29), and rhinoplasty and rhytidectomy (1.5%, n = 15). The complication rate was relatively low: 91.0% of patients (n = 929) were complication-free. The most common complication was infection, occurring in 3.5% (n = 36) of the total number of patients, followed by scarring (1.2%, n = 12) and formation of an orocutaneous or salivary fistula (1.1%, n = 11). In summary, submental intubation is a good alternative airway with minimal complications.
Can Submandibular Tracheal Intubation Be an Alternative to Tracheotomy During Surgery for Major Maxillofacial Fractures?
2017, Journal of Oral and Maxillofacial Surgery
Citation Excerpt :
If not performed properly, damage to the Wharton duct openings may occur. Moreover, close positioning of the tube in the paralingual sulcus may be compromised.2 Toledo et al12 found that the main morbidities reported in the literature were skin infection (42%), salivary fistula (22%), tube-related accidents (16%), unaccepted scars (12%), bleeding (4%), and abscesses in the floor of the mouth.
During surgery for major maxillofacial fractures, orotracheal intubation can interfere with some surgical procedures and nasal intubation can be contraindicated or impossible. That is why tracheotomy is presented as a solution, although it carries a relatively high incidence of complications. In this study, the use of submandibular tracheal intubation is basically evaluated as an alternative to tracheotomy in such circumstances.
This prospective study was performed in patients undergoing surgery for major maxillofacial fractures in which oral intubation and/or nasal intubation have been unsuitable, impossible, or contraindicated. The technique of submandibular intubation was assessed intraoperatively and in the postoperative period. The outcomes and complications are presented.
The study included 26 patients aged between 14 and 57 years. All patients had mandibular fractures, with 19 midface fractures (73.1%), 11 nasal bone fractures (42.3%), 10 zygomatic bone fractures (38.5%), 9 naso-orbito-ethmoidal fractures (34.6%), and 9 frontobasilar fractures (34.6%). The procedure time ranged from 5 to 12 minutes (mean, 7 minutes 4.6 seconds). Delayed extubation was performed in 15 cases (57.7%) in which the tube was left in place for a period ranging from 8 to 50 hours (mean, 30 hours 24 minutes). The technique has proved to be straightforward and satisfactory. A postoperative superficial infection occurred in 2 patients, whereas hypertrophic scars occurred in another 2 patients.
Submandibular endotracheal intubation is straightforward, safe, and quick to carry out. It can be an alternative to tracheotomy as it allows operative techniques and postoperative airway protection without the risks and side effects of tracheotomy.
Stoll's submandibular intubation: A safety alternative to Altemir's submental technique and traditional tracheostomy
2016, Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology
Selection of the method of intubation during complex facial surgeries is a difficult task for the anesthetist because of airway is sharing area and oral or nasal intubation is not preferable, even though, tracheostomy is a worthy alternative; however, it has serious complications. Altemir FH introduced the ‘submental technique’ as a substitute for tracheostomy but it has demonstrated the complications of ‘lingual nerve damage’ and ‘Wharton's duct injuries’. So, the Stoll's approach is the safest option in this scenario. The purpose of the present study was to evaluate ‘Stoll's submandibular method’ as a safest choice to Altemir's technique.
The study was conducted prospectively in a sample of 42 patients for intra-operative airway management in complex facial surgeries during the period of six years from 2008 to 13 by considering the following objectives: duration of the procedure, and intra-operative and postoperative complications.
The average time taken for this procedure was 9 min. The complications encountered were superficial skin wound infection in a total of three patients (7%), partial extubation in one case (2%), cuff leakage in one case (2%) and dislodgement of the tube in one case (2%).
The results of the present study have provided the evidence of Stoll's technique as a safest choice both for Altemir's and tracheostomy in justifiable circumstances because of simple, quick technique associated with negligible complications. So, anesthetist should consider this underutilized technique in complex facial surgeries and it is a valuable option in patients, who underwent tracheostomy in previous surgeries.
Otorhinolaryngology trainees and the alternatives to surgical tracheostomy: A survey study
2015, Journal of Taibah University Medical Sciences
Alternatives to surgical tracheostomy (AST) including submental (SMENI), submandibular (SMAN) and retromolar intubation (RMI) are fairly new and innovative airway procedures intended to avoid the complications of traditional surgical tracheostomy (ST). The study aimed to document the responses of junior Otorhinolaryngologists , regarding the awareness and training of AST as well as dealing with its complications when performed by other specialty. According to our knowledge there is no similar survey in the English literature.
Otorhinolaryngology residents/registrars in Ryad, Jeddah and Taif were surveyed between March 2013 and June 2014, enrolled and non-enrolled in Otorhinolaryngology-Head and Neck Surgery (ORL-HNS) training programs doctors were included, Consultants and Senior Consultants were excluded. it is a qualitative and cross sectional study. Senior consultants were excluded from this qualitative and cross-sectional survey.
A total of 59 participants responded to the questionnaire. Fifty-six (94.9%) were not familiar with AST, 52 (88.13%) supported the concept of AST, and 57 (96.6%) agreed the inclusion of AST in the ORL training programs. Thirty (50.8%) thought that AST will have a negative effects on ORL training, 47 (79.7%) would participate in any AST procedure, while 27 (45.8%) agreed to deal with AST complication if the procedure done by other specialty.
The majority of the surveyed ORL residents and registrars were not familiar with AST, nevertheless, agreed to undergo further training and to included it in the training programs. However, reserved dealing with related complications once done by other specialty we recommend that the supervising training body training body consider including AST in the curriculum.

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Basic and patient-oriented researchSubmental Intubation Versus Tracheostomy in Maxillofacial Trauma Patients

Purpose

Patients and Methods

Results

Conclusions

Section snippets

Surgical Procedure

Discussion

J Emerg Med

J Oral Maxillofac Surg

Oral Surg Oral Med Oral Pathol Oral Radiol Endod

Br J Anaesth

J Craniomaxillofac Surg

Ann Emerg Med

J Oral Maxillofac Surg

J Craniomaxillofac Surg

Br J Oral Maxillofac Surg

J Clin Anesth

J Craniomaxillofac Surg

Nasotracheal intubation for head and neck surgery

Anaesthesia

Complication from a nasopharyngeal airway in a patient with basilar skull fracture

Anesthesiology

Complications of emergency and elective tracheostomy: A retrospective study of 150 consecutive cases

Ann R Coll Surg Engl

Changing indications for tracheostomy in maxillofacial trauma

J Oral Maxillofac Surg

Basic and patient-oriented research
Submental Intubation Versus Tracheostomy in Maxillofacial Trauma Patients