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