Carlos R. Degrandi Oliveira, MD, TSA
Santa Casa de Misericórdia de Santos
In the airway management of patients with multiple facial fractures, the tracheal tube in the oral cavity can interfere with the surgical procedure. It is therefore necessary for an alternative path to be used. When the patient does not require a long period of ventilation, one alternative is a submental tracheal intubation. The goal of this case report is to present a case of submental tracheal intubation for reconstructive surgery of maxillary and mandibular fractures.
The patient was a 24-year-old man, body weight 70 kg, American Society of Anesthesiologists physical status I, scheduled for reconstructive surgery of maxillary and mandibular fractures. We obtained peripheral venous access with a 16-gauge needle and the patient was monitored by pulse oximetry, cardioscope, and noninvasive blood pressure. After preoxygenation, anesthesia was induced using propofol, fentanyl, and cisatracurium.
The patient was intubated with a wired silicone 8 mm endotracheal tube (ETT). Correct placement was confirmed by capnography. Anesthesia was maintained with oxygen, nitrous oxide, and isoflurane. A submental incision was made on the right side of the patient. Soft tissues were divulsed until the floor of the mouth was reached. The distal part of the tube without the connector was clamped and exteriorized through the submental access (Figure). The ETT connector was temporarily disconnected so the body of the tube could be pulled through the floor of the mouth by artery forceps and exteriorized through the submental opening. The tube was reconnected to the breathing system and surgery continued without complications. At the end of the procedure, the patient was extubated and the submental incision was sutured.
This technique provides a secure airway while allowing for an unobstructed surgical field for adequate reduction and fixation of midface and panfacial fractures. Submental tracheal intubation also avoids the potential complications associated with nasal intubation and tracheostomy, and obviates the need for a tube change during the operation. In addition to facial trauma where temporary intermaxillary fixation (jaw wiring) is required intraoperatively, submental tracheal intubation may also be indicated in patients undergoing simultaneous elective mandibular orthognathic surgery and rhinoplasty procedures, and in cleft lip and palate patients undergoing orthognathic surgery where nasal obstruction may preclude the use of a nasal tube.
The submental access is a simple procedure and technique that has excellent results. Good communication between the surgeon and the anesthesiologist is essential to minimize potential complications. Complications are rare because the area does not have any large vessels or nerves. This provides a clear surgical field and the ability to treat all the injuries in a single surgery. Using this technique, it is possible to perform an intermaxillary fixation without the need for a tracheostomy. In summary, submental tracheal intubation is a useful alternative for airway management in selected patients with complex craniomaxillofacial injuries.