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Table of Contents  
Year : 2013  |  Volume : 7  |  Issue : 3  |  Page : 415-417  

Submental orotracheal intubation: A better alternative to tracheostomy in panfacial fractures

1 Department of Oral and Maxillofacial Surgery, RKDF Dental College and Research Centre, Bhopal, Madhya Pradesh, India
2 Department of Oral and Maxillofacial Surgery, S.M.B.T. Dental College, Sangamner Taluka, Maharashtra, India
3 Department of Oral and Maxillofacial Surgery, King Khalid University, Abha, Saudi Arabia

Date of Web Publication18-Dec-2013

Correspondence Address:
Fareedi Mukram Ali
Department of Oral and Maxillofacial Surgery, S.M.B.T. Dental College, Sangamner Taluka, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0259-1162.123278

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Surgical repair of complex maxillofacial trauma presents a challenge to the surgeon and anaesthetist. Submental intubation is an alternative where oral and nasal intubation cannot be used. We present a case where tracheostomy was avoided in a patient with multiple maxillofacial fractures by opting for sub-mental endotracheal intubation technique. Time required for intubation, accidental extubation, postoperative complications, and the healing of intraoral and submental scars were evaluated. The technique avoids the complications associated with tracheostomy.

Keywords: Complex maxillofacial trauma, intubation, submental intubation, tracheostomy

How to cite this article:
Chandra PM, Ali FM, Singhai A, Mudhol A, Ustad F. Submental orotracheal intubation: A better alternative to tracheostomy in panfacial fractures. Anesth Essays Res 2013;7:415-7

How to cite this URL:
Chandra PM, Ali FM, Singhai A, Mudhol A, Ustad F. Submental orotracheal intubation: A better alternative to tracheostomy in panfacial fractures. Anesth Essays Res [serial online] 2013 [cited 2022 Sep 24];7:415-7. Available from:

   Introduction Top

Airway management in the presence of midface or panfacial injuries requires special consideration as the operating space is shared by Anesthetist and surgeon. Different methods of intubation and surgical airway management have been described in the literature. [1]

In most maxillofacial trauma, maxillomandibular fixation (MMF) is an important part of treatment and a critical indicator of reduction. MMF is important to re-establish dental occlusion for a normal functional result in dentate patients with fractures involving alveolar segments of the jaws. Nasotracheal intubation is often used, but is contraindicated in the presence of skull base fractures and has to be avoided in case of associated naso-orbital-ethmoidal complex fractures. Tracheostomy is a potent technique, but has high complication rate. The submental route for endotracheal intubation is an alternative to nasal intubation or tracheostomy in the surgical management of patients with complex cranio-maxillofacial injuries. It was first described by Hernαndez Altemir [2] in 1986, but has not gained extensive popularity among the Anesthetist and surgeons. We revisit this extremely useful technique by presenting a case report and review.

   Case Report Top

A 26-year-old boy with the history of road traffic accident presented to the casualty department with multiple maxillofacial injuries and history of the brief period of unconsciousness at the time of the accident. Clinical examination of patient revealed diffuse facial swelling with lacerations. Initial radiographic evaluation suggested fractures of parasymphysis of mandible and naso-ethmoidal complex. A multi-planar, contrast enhanced 3D computerized tomography scan confirmed the radiographic findings.

In pre-anesthetic evaluation, patient gave the history of loss of consciousness for a brief period of time probably as a result of brain concussion. Patient had no other significant medical illness. He was moderately built and nourished with stable vitals and good cardio-respiratory reserves. Airway assessment predicted difficult oral intubation due to multiple fracture of mandible with restricted mouth opening. All hematological and biochemical investigations were within the normal range.


Under meticulous aseptic protocol, oral intubation was carried out and connected to the ventilator. The patient was intubated with 7.0 mm internal diameter flexo-metallic cuffed endotracheal tube. The endotracheal tube placement and position was secured after confirmation by bilateral chest auscultation. The patient was scrubbed and draped. In the presented case, an incision was placed in the chin region including the laceration. Following the incision, blunt dissection was carried out through the superficial fascia, platysma and deep fascia and an opening was created in the floor of the mouth between the anterior belly of digastic and mylohyoid muscle. The opening into the oral cavity was made sufficiently large to pass an endotracheal tube. A straight hemostat was then inserted into the tract from the lower border of chin into the oral cavity [Figure 1]. The patient was well-ventilated then tracheal tube was disconnected from the circuit and its connector was removed. A hemostat was used to grasp the tip of the tube and pulled out through the submental incision and connected to the breathing circuit. The tube was secured to the skin using 2-0 mersilk in order to prevent accidental extubation.
Figure 1: Submental intubation in a panfacial trauma patient

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At the end of surgery, the stay suture was removed and endotracheal tube was pulled back in the oral cavity and brought out through the mouth and the circuit was connected back. The submental incision was sutured. After patient regained protective reflexes and consciousness, extubation was carried out.

   Discussion and Review Top

It is a war of operating spaces when the Anesthetist and a maxillofacial surgeon share the same space in management of complex maxillofacial injuries. Oral intubation is not the choice as it does not provide room for intermaxillary fixation to achieve ideal functional occlusion, which is considered the key to treat facial fractures. Nasal intubation is also contraindicated in naso-ethmoidal fractures. Anterior and middle cranial fossa, base of skull fractures may coexist in patients with craniomaxillofacial fractures and are generally a contraindication to the use of a nasal tube due to the small, but significant risk of intracranial penetration. Tracheostomy definitely allows an unobstructed surgical field for adequate reduction and fixation but a significant risk of iatrogenic complications, such as tracheal stenosis, internal emphysema, pneumomediastinum, tracheoesophageal fistula, damage to the laryngeal nerves and scarring. Though these complications are rare, but can be completely avoided with the use of submental intubation.

No consensus exists to date as to the best way of management of airway when orotracheal or nasotracheal intubations are contraindicated. Sir Hernαndez Altemir in 1986 first described the technique of submental intubation. Indications for submental intubation include midfacial and pan-facial fractures, with the base of skull involvement, orthognathic surgery, facial aesthetic surgery and rhinoplasty. [2],[3],[4],[5],[6]

Submental intubation technique takes less time, is easy and risk of damage to the structures such as the submandibular glands, lingual nerve, Wharton's duct and structures of the floor of the mouth is very low. [7]

The risk associated with this technique includes reduced oxygen saturation during the change over from oral intubation to submental intubation and vice versa. While, passing the tube through the incision difficulty may be encountered. [8]

Other complications include accidental extubation, tube obstruction and tube leaking, which are more difficult to manage in submental route. The technique has the risk of infection of the submental wound, trauma to the submandibular and sublingual glands and ducts, damage to the lingual nerve, fistula formation and scarring. Most of the complications can be avoided by careful blunt dissection and a good knowledge of anatomy.

   References Top

1.Meyer C, Valfrey J, Kjartansdottir T, Wilk A, Barrière P. Indication for and technical refinements of submental intubation in oral and maxillofacial surgery. J Craniomaxillofac Surg 2003;31:383-8.  Back to cited text no. 1
2.Hernández Altemir F. The submental route for endotracheal intubation. A new technique. J Maxillofac Surg 1986;14:64-5.  Back to cited text no. 2
3.Taicher S, Givol N, Peleg M, Ardekian L. Changing indications for tracheostomy in maxillofacial trauma. J Oral Maxillofac Surg 1996;54:292-5.  Back to cited text no. 3
4.Amin M, Dill-Russell P, Manisali M, Lee R, Sinton I. Facial fractures and submental tracheal intubation. Anaesthesia 2002;57:1195-9.  Back to cited text no. 4
5.Caron G, Paquin R, Lessard MR, Trépanier CA, Landry PE. Submental endotracheal intubation: An alternative to tracheotomy in patients with midfacial and panfacial fractures. J Trauma 2000;48:235-40.  Back to cited text no. 5
6.Biglioli F, Mortini P, Goisis M, Bardazzi A, Boari N. Submental orotracheal intubation: An alternative to tracheotomy in transfacial cranial base surgery. Skull Base 2003;13:189-95.  Back to cited text no. 6
7.Caubi AF, Vasconcelos BC, Vasconcellos RJ, de Morais HH, Rocha NS. Submental intubation in oral maxillofacial surgery: Review of the literature and analysis of 13 cases. Med Oral Patol Oral Cir Bucal 2008;13:E197-200.  Back to cited text no. 7
8.Gordon NC, Tolstunov L. Submental approach to oroendotracheal intubation in patients with midfacial fractures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;79:269-72.  Back to cited text no. 8


  [Figure 1]

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