submental intubation is a new technique for intubating patients with severely compromised nasal and oral airways

1. GOOD MORNING

2. JOURNAL CLUB
BY
REHANA SULTANA

3. Submental
intubation…….
A literature Review
J.S.Jundt, D.Cattano, C.A.Hagberg, J.W.Wilson
Int. J. Oral Maxillofac. Surg. 2012; 41: 46–54

4. First reported by
Francisco Hernandez
Altemir in 1986
Procedure that could
avoid tracheostomy and
allow for the concomitant
restoration of occlusion
and reduction of facial
fractures in patients
ineligible for nasotracheal
intubation

5. Airway management in a pt with
pan facial fractures:
Treatment options:
 tracheostomy
 nasotracheal intubation
 retromolar intubation
 submentotracheal intubation.

6. Tracheostomy:
 Elective short-term tracheostomy is the conventional and
time-tested method for airway access in these patients
 associated with immediate and late complications
 difficult in obese patients, children, and patients with
thyroid swelling

7. Retro molar intubation
 Bonfils first documented the use of retromolar space for
endotracheal intubation.
 Patients with Le Fort II fracture with both occlusal
changes and nasal fractures

8.  Nasotracheal intubation is not recommended in presence
of panfacial fracture, cervical spine injury, skull base
fracture with or without cerebrospinal fluid rhinorrhea,
systemic coagulation disorders, distorted nasal anatomy
and when nasal packing is indicated.

9. Submental intubation
 Proximal end of ETT diverted through orocutaneous tunnel
at anterior floor of mouth.
 Effective for short-term airway maintenance for surgeries
precluding use of oral & nasal passages
Altemir FH. J Maxillofac Surg 1986; 14: 64-5.

10. Submental intubation. Schematic
view of the tube position

11. Submental intubation-anatomical
relevance

12. Submental intubation-Indications
• Faciomaxillary surgeries
requiring MMF & IMF, &
with nasal injury/#
• Orthognathic surgery
• Aesthetic surgeries
involving both oral &
nasal passages

13.  maxillofacial injuries with associated fractures of nasal
bone and skull base
 Repair of congenital malformations, skull base surgery,
multiple or complex facial osteotomies, transfacial
oncologic procedures of the cranial base, and
pediculated craniofacial surgeries

14. Contra indications:
 patients’ refusal
 bleeding diathesis
 laryngotracheal disruption
 infection at the proposed site
 gunshot injuries in the maxillofacial region
 long-term airway maintenance
 tumor ablation in maxillofacial region
 and history of keloid formation.

15. Anaesthesiologist’s Concerns
• Disruption of components of upper airway
• Surgery- in and around upper airway
• Airway edema-difficult airway situation
• Dental occlusion-orotracheal intubation
• Nasal #/pack-nasotracheal intubation
• Adult patients—retromolar difficult, destructive,
time consuming

16. Contd.
• Tracheostomy- conventional, not without
complications
• Submental intubation allows dental occlusion
Technically easy
Low complication rate
 Cosmetically acceptable scar

17. Preparation
Antibiotics
Antisialogogue
Aspiration prophylaxis
Universal connector
Emergency airway access

18. Technique
Conventional orotracheal
intubation
Prepped & draped
Local infiltrated
Incision

19. Technique
Blunt dissection
Oral mucosal incision
Denitrogenation
Cuff deflation
Disconnection of circuit

20. Technique
Tip of Pilot balloon cuff
Proximal end of ETT
Intraoral part of ETT stabilised

21. Reattachment of
breathing circuit
Confirmation of position
Markings at skin exit
Stay sutures
Technique

22. Technique
Transparent adhesive
dressing
Throat pack
Capnography, Airway
pressure

23. Technique
Extubation
Incision closed in layers
Postoperative Antibiotic &
Antiseptics
Combined retrograde & submental in a patient
with limited mouth opening

24. Results
 Intraop. airway maintenance successful in all cases
 Delay in anterior submandibular approach changed to
strict midlineearly retrieval (mean duration 5.13±1.58
minutes)
 Minor bleeding in 2 cases responded to pressure

25. Results (contd.)
 Accidental partial extubation in 1 patient-corrected early
 No event of desaturation
 2 patients extubated at PACU after 6 & 22 hrs respectively
with no complications
 Minor skin infection in one patient
 Healthy aesthetic scar
 Acceptable to surgeon

26. A literature review

27. Technique and the modifications:
 Altemir sequence’
 Green and Moore sequence’ involves two endotracheal
tubes
 Retrograde submental intubation and utilized a
pharyngeal loop technique

28. Devices used:
 Reinforced spiral embedded endotracheal tubes
 non-reinforced endotracheal tubes
 reinforced laryngeal maskairway
 Combitube
 Fibre or metal reinforced tubing

30. Discussion
 Successful intraop. airway
control
 Difficulty in retrieval of ETT
& more bleeding with ant.
Submandibular approach
 Strict midline approach
preferableless cramped &
avascular
•MacInnis E. Int J Oral Maxillofac Surg 1999; 28(5): 269-72.

31. Discussion(contd.)
 Bleeding reduced with change of site
 Skin infection treated with continuation of antibiotics &
local care
 Prevention of infection by perop. Antibiotics, oral
hygiene, not so tight closure
 Study results corroborated with studies of MacInnis et al,
Amin et al & related studies

32. Why submental?
 Efficient in short-term airway control
 Technically easy
 Less invasive than tracheostomy
 Minimal chances of major bleed
 Minimal chance of aspiration & other major
complications of tracheostomy
 Aesthetic acceptable scar

33. Submental Intubation Tube Exchanger
Submental incision
Free end of the ETT pulled through
it
Tube exchanger
Damaged tube is pulled out
Replaced with the new ETT. Drolet P et al. Anesth Analg 2000; 90: 222.

34. Percutaneous dilatation set
alternative to blunt dissection
Minimal scar
Biswas BK et al. Anesth Analg 2006; 103:1055.
Percutaneous Dilational Tracheostomy
Kit: An Aid to Submental Intubation

35. Altemir FH et al. Journal of Cranio-Maxillofacial Surgery 2000; 28: 343-4.
The Submental Route Revisited Using The
Laryngeal Mask Airway: A Technical Note

36. Problems
 Unfamiliarity
 Poor in prolonged ventilation and weaning
 Difficulty in suctioning
 Smaller tube
 Angulation-↑ airway pressure
 Increased risk of tube movement (Bronchial
intubation & extubation)

37. complications
 superficial skin infections
 Damage to the tube apparatus
 fistula formation
 Right mainstem bronchus tube dislodgement/obstruction
 hypertrophic scarring
 accidental extubation in paediatric
 excessive bronchial flexion
 transient lingual nerve paresthesia
 venous bleeding
 mucocele
 dislodgement of the throat pack sticker in the
submental wound

39. Conclusion
 Safe alternative
 Advantage of both orotracheal & nasotracheal
 No consensus of superiority
 Patient’s choice & cooperation, Experience of airway
managers, Liaison with the surgeons,
Single versus Multi-stage operation.

40. REFERENCES:
 Altemir FH. The submental route for
endotrachealintubation. A new technique. J
Maxillofac.Surg 1986;14:64–5.
 Altemir FH, Montero SH. The submental route revisited
using the laryngeal mask airway:a technical note. J
Craniomaxillofac Surg 2000;28:343–4.
 sub mental intubation-journey over last 25years J
Anaesthesiol Clin Pharmacol. 2012 Jul-Sep; 28(3): 291–
303.

41. THANK YOU