Submento-submandibular intubation: is the subperiosteal passage essential? Experience in 107 consecutive cases

A Prospective, Randomized Comparison of the Classical Altemir's Method With the Newer Seldinger's Technique of Submental Intubation

BACKGROUND

Submental intubation performed using the classical Altemir's technique is a well-accepted, safe technique for providing optimal operating field to the maxillofacial surgeon, in cases where either nasotracheal or orotracheal intubation is impossible. We propose a new, percutaneous Seldinger's technique of submental intubation as an interesting alternative to the classical Altemir's technique, wherein a percutaneous dilatational tracheostomy kit is used to dilate the submental tract, instead of bluntly dissecting it. We hypothesized that Seldinger's technique would be associated with reduced procedure time and minimal scar formation in patients with maxillofacial fractures.

METHODS

We enrolled 60 patients scheduled to undergo maxillofacial injury fixation under general anesthesia. After consent, the cohort was randomly allocated to undergo submental intubation by either the classical Altemir's technique or Seldinger's technique. As our primary objective, we noted the time taken to complete the procedure of submental intubation. Our secondary objectives were the components of primary outcome, such as disconnection/apnea time, bleeding, and technical difficulties during the procedure. We also observed for complications such as presence of salivary fistula/infection at hospital discharge and scar characteristics at 1- and 3-month follow-up.

RESULTS

The median time for performing submental intubation in the Seldinger group was significantly lower than that in the Altemir group (170.5 [136.5-256.0] seconds vs 220.0 [205.5-289.0] seconds; P value, .040). The median disconnection time was also significantly lower in the Seldinger group (12.0 [10.8-20.0] seconds vs 19.0 [15.0-23.0] seconds; P value, .036). Furthermore, significant bleeding was absent in nearly 53.8% of the study participants in the Seldinger group as compared to 25.9% in the Altemir group. At follow-up, there was no evidence of differences in scar characteristics between the 2 groups.

CONCLUSIONS

Seldinger's technique is associated with shorter procedure time and reduced apnea time due to easier and better tract formation, thus minimizing the effort required to exteriorize the endotracheal tube. Furthermore, as dilation reduces tissue damage, Seldinger's technique is associated with significantly less procedural bleeding. Thus, Seldinger's technique can be safe, easy, and faster to perform compared with the classical Altemir's technique of submental intubation in patients with maxillofacial trauma.

Factors associated with complications of submental intubation in 339 patients with facial fractures: A German retrospective cohort study

PURPOSE

For nearly four decades, submental intubation (SI) has been introduced and employed to avoid tracheostomy in facial trauma cases where nasal/oral intubation is infeasible or associated with possible risks. The purposes of this study were to estimate the frequency and to identify variables associated with complications of SI (CSI).

METHODS

The authors organised a retrospective cohort study and enrolled a group of patients with facial trauma and SI during a seven-year interval at two German level one trauma centres where SI has routinely been used in complex facial trauma cases. The predictor variables included demographic, medical, dental, fracture-related, operative, and postoperative parameters. The outcome variable was CSI. We used descriptive, bivariate, and multivariate analyses at the 0.05 significant level.

RESULTS

The sample included 339 patients (24.5% females, 9.4% had complications) with an average age of 58.2 ± 12.0 years (range, 17-89). Bivariate analyses revealed nine significant variables. However, forward stepwise multiple logistic regression modelling identified three variables statistically associated with CSI: smoking (OR, 691.8; 95% CI, 75.9 to 6303.9; P < 0.0001; number needed to harm [NNH], 6), moderate to high gingival inflammation (OR, 786.7; 95% CI, 66 to 9378.9; P = 0.002; NNH, 12), and postoperative use of chlorhexidine mouthwash (OR, 0.03; 95% CI, 0.001 to 0.77; P = 0.0003; number needed to treat [NNT], 2).

CONCLUSIONS

smokers and subjects with gingivitis were more likely to experience CSI. Postoperative chlorhexidine rinsing was the potentially modifiable, albeit low-OR, factor. These findings could help to draw an effective guideline against the CSI.

Submental Intubations in Panfacial Fractures

Introduction

Airway management in patients with panfacial fracture remains a challenge to anesthesiologists and surgeons. Submental intubation is an effective and less invasive alternative to tracheostomy during intraoperative airway management where orotracheal and nasotracheal intubation are not appropriate options. In addition, submental intubation allows proper access to oronasal airways and occlusion during intraoperative management.

Methods

The descriptive retrospective study was carried out and evaluated the outcomes of submental intubation in the management of panfacial fracture, complex maxillary or mandible fracture associated with nasal bone fracture and naso-orbito-ethmoid (NOE) fracture. The medical records of 23 patients who received submental endotracheal intubation were reviewed at UCMS College of Dental Surgery, Bhairahawa, Rupandehi, Nepal from March 2014 to December 2018. The following parameters were evaluated: mode of trauma, time required for intubation, accidental extubation, accidental perforation of the pilot balloon during its insertion, period of hospital stay, post-operative complications, such as the healing of submental scars both intraorally and extraorally.

Results

The submental intubation was successfully done in all patients with minimal obvious post-operative complications. The mode of trauma for majority of cases of panfacial fracture who underwent submental intubation was road traffic accident (69.56%). The mean time required for intubation was 8.43 (±0.84) minutes. No accidental extubations occurred. Accidental perforation of the pilot balloon was seen in one patient (4.35%) during tube manipulation which was managed successfully by changing the tube. The healing of submental scars was uneventful intraorally and extraorally in almost every case. The mean period of hospital stay in patients with submental intubation was 7.95 (±1.49) days.

Discussion

Submental intubation is an effective and safe method as it is not associated with complications of tracheostomy during management of panfacial fracture, NOE fracture and craniofacial fracture. In addition, it does not interfere with IMF during intraoperative period.

A Simple and Reliable Submental Intubation Technique for Maxillofacial Fractures

In 1986, Altemir first reported the use of submental intubation to avoid tracheotomy in patients with panfacial and midfacial fractures for whom intermaxillary fixation is necessary, but orotracheal and nasotracheal intubations are not recommended. This novel technique allowed intraoperative access to perform dental occlusion and reconstruction of the nasal pyramid in patients with skull base fractures. Herein, we describe a refined technique based on Altemir's original procedure. Seven male patients with panfacial fractures underwent submental intubation using our refined technique. The technique was developed after encountering a technical error with Altemir's original procedure. In this new technique, we employed a 2-0 silk suture guide to allow the passage of both the endotracheal and cuff-inflation tubes through the same tunnel created from the oral cavity to the submental area. The success rate of the refined technique was 100%, and there were no intraoperative or postoperative complications. There was 20 seconds of ventilation outage time in total. Endotracheal and cuff-inflation tubes were easily and quickly passed through the same submental tunnel. Our refined technique is simple, easy, safe, fast, inexpensive, and does not require specific materials. Submental scars were smaller and relatively inconspicuous in this study, compared to those reportedly associated with other modified techniques.

Submental Intubation in Cases of Panfacial Fractures: A Retrospective Study

Surgical treatment of panfacial fractures usually requires intraoperative temporary occlusion of the teeth and simultaneous access to the nasal pyramid. In such cases, the standard method of airway management is to perform a tracheostomy, but this may be associated with a significant number of perioperative and late complications. This study aimed to determine if submental endotracheal intubation (SEI) is a viable alternative to tracheostomy, especially when short-term postoperative control of the airway is foreseen. This was an observational retrospective study, carried out between 2012 and 2014, which involved 32 consecutive patients who sustained panfacial fractures and were surgically treated during a 3-year period in a level I trauma center hospital. Only those who required SEI were included in the sample. Four cases were excluded because of incomplete registries, follow-up period less than 4 months after hospital discharge, or other unrelated complications. The medical charts of all patients involved in the sample were carefully reviewed in order to qualify and quantify perioperative and postoperative complications related to anesthetic management. We hypothesized that SEI would not interfere with the surgical procedures and would present less morbidity and reduced complication rates. Twenty-eight patients, 24 male and 4 female, met all the inclusion criteria. The mean age was 29.5 ± 9.05 years (range, 18-56 years). The mean duration time of surgery was 8.07 ± 4.0 hours (range, 4-16 hours). There were no perioperative complications. Postoperatively, only 1 patient (3.57%) experienced a cutaneous infection at the submental region, which was easily treated. Additionally, only 1 case (3.57%) of hypertrophic scar was reported. SEI appears to be a safe, simple, and effective technique of immediate perioperative airway management in selected cases of panfacial fractures.

Thirty years of submental intubation: a review

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.

Anterior Submandibular Approach for Transmylohyoid Endotracheal Intubation: A Reappraisal with Prospective Study in 206 Cases of Craniomaxillofacial Fractures

Despite a paradigm shift in anesthesia and trauma airway management, the craniomaxillofacial fracture (CMF) patients continue to pose a challenge. A prospective study was planned between April 2007 and March 2015 to investigate the safety, efficacy, utility, and complications of anterior submandibular approach for transmylohyoid intubation (TMI) in CMFs using an armored endotracheal tube (ETT). Out of 1,207 maxillofacial trauma cases reported, this study recruited 206 patients (152 males and 54 females) aged between 21 and 60 years. No episode of oxygen desaturation was noted intraoperatively. Mean time to perform TMI was 6 ± 2 minutes. The mean transmylohyoid ETT withdrawal time/disconnection time from ventilator was approximately 1.5 minutes. Accidental partial extubation of ETT was noted in two patients (0.97%), and three patients (1.45%) developed abscess formations at anterior submandibular site which were managed by incision and drainage. The anterior submandibular approach for TMI was successfully used and provided stable airway in all elective CMF surgery cases, where oral or nasal intubations were not indicated/feasible and long-term ventilation support was not required. It permitted simultaneous dental occlusion-guided reduction and fixation of all the facial fractures without interference from the tube during the surgery with unhindered maintenance of the anesthesia and airway. The advantages include easy, swift, efficient, and reliable approach with a small learning curve.

Efficacy and complications of submental tracheal intubation compared with tracheostomy in maxillofacial trauma patients

Submental tracheal intubation is a technique for use in patients with maxillofacial trauma. The purpose of this retrospective study was to evaluate the efficacy and complications of this technique compared with tracheostomy. Twenty-five patients underwent submental tracheal intubation since 2001. Submental tracheal intubation was performed in cases needing intermaxillary fixation complicated by a nasal pyramid or anterior skull base fracture. No severe perioperative or long-term complications were noted. Intra- and postoperative complications were observed in three patients. In one case, the tube was accidentally dislodged into the right main bronchus during submental tracheal intubation. Two patients developed skin infections. Submental scarring was undetectable, except for one patient with slight scarring. Submental tracheal intubation avoids the complications associated with tracheostomy and the difficulty of nasal intubation during intubation and surgery. Therefore, submental tracheal intubation is useful in the intraoperative management of patients with complex maxillofacial trauma. (J Oral Sci 58, 23-28, 2016).

Can Submandibular Tracheal Intubation Be an Alternative to Tracheotomy During Surgery for Major Maxillofacial Fractures?

PURPOSE

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.

MATERIALS AND METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Submandibular intubation as an alternative for intra-operative airway management in maxillofacial fractures - our institutional experience

Background and Aims:

Airway management in anaesthesia for maxillofacial surgical procedures is tricky at times when the nasal/oral routes are contraindicated or are impossible. Tracheostomy as an alternative inherits its own complications. We present a case series of the submandibular route for tracheal intubation as an alternative.

Methods:

The procedure was performed in ten selected adult patients with maxillofacial/mandibular fractures associated with a fracture of skull base or nasal bone. All of them were medically stable with no need of intensive care or mechanical ventilation in post-operative period.

Results:

Submandibular intubation in all ten patients of panfacial fractures allowed uninterrupted surgical techniques with a secured airway. All patients were reverted to oro-tracheal tube at the end of surgery as immediate maxillomandibular fixation was not necessary. The patients were extubated after recovery from anaesthesia before they left the operating theatre. One patient in the post-operative period had a superficial infection of incision site that responded well to local treatment. No other complications were encountered in the intra-operative or post-operative period.

Conclusion:

In complex maxillofacial injuries, when oral or nasal intubation hampers surgeon's field of view, submandibular intubation offers an effective alternative to short-term tracheostomy along with small risk potential. There is a need to emphasise its regular application in such cases so that technique can be mastered by both surgeons and anaesthesiologist.

Assessment of the Efficacy of Submental Intubation in the Management of Midfacial and Panfacial Trauma Patients

INTRODUCTION

Securing an airway in maxillofacial injuries remains a challenge and is an important objective on the part of a maxillofacial surgeon to thoroughly understand its management.

PURPOSE

The aim of this study was to evaluate the efficacy and complications of submental intubation in the management of midfacial/panfacial trauma patients where oro-endotracheal or naso-endotracheal intubation is contraindicated and tracheostomy can be avoided.

PATIENTS AND METHODS

Twenty patients with maxillofacial injuries were selected for submental intubation who were admitted in Kamineni Hospital, Narketpally, Nalgonda during a 2 year period (2010-2012). The parameters used to assess the efficacy were; restoration of the occlusion, duration of the surgery, presence of scar, presence of infection, damage to vital structures or any post-operative salivary fistula.

RESULTS

Submental intubation allowed reduction and fixation of all fractures without the interference of the tube during surgical procedure in all of the patients. There were no intra-operative complications and none of the patients required post-operative ventilation. There were no significant post-operative complications. However, in one of the cases (case 4) infection of submental wound was seen and in another case (case 11) salivary fistula was formed. Both the cases were appropriately managed without any difficulty. The submental scar was well accepted by all the patients.

CONCLUSION

Submental intubation is a safe and extremely useful procedure in severe maxillofacial injuries. It presents a low incidence of operative and post operative complications. It allows both the surgeon and the anaesthetist to deliver a better quality of patient care.

Midline submental intubation might be the preferred alternative to oral and nasal intubation in elective oral and craniomaxillofacial surgery when indicated

PURPOSE

No consensus exists to date regarding the best method of controlling the airway for oral or craniomaxillofacial surgery when orotracheal and nasotracheal intubations are unsuccessful or contraindicated. The most commonly used method of tracheostomy has been associated with a high degree of morbidity. Therefore, the present study was conducted to determine the indications, safety, efficacy, time required, drawbacks, complications, and costs of the midline submental intubation (SMI) approach in elective oral and craniomaxillofacial surgical procedures.

MATERIALS AND METHODS

A retrospective case series study was used to evaluate the surgical, financial, and photographic records of all patients who had undergone oral or craniomaxillofacial operations at Sharda University School of Dental Sciences, Greater Noida, from April 2006 to March 2014. The indications, drawbacks, time required for the procedure, ability to provide a secure airway, intra- and postoperative complications, and additional costs associated with SMI were analyzed.

RESULTS

Of the 2,823 patients treated, the present study included 120 patients (97 men and 23 women, aged 19 to 60 years). The average time required for SMI was 10 ± 2 minutes. No episode of intraoperative oxygen desaturation was noted. One intraoperative complication, an injury to the ventral surface of the tongue, was encountered. Two patients developed infection at the skin incision site. No significant additional cost was incurred with the use of SMI.

CONCLUSIONS

SMI has been successfully used in elective oral and craniomaxillofacial surgical procedures for which oral and nasal intubations were either not indicated or not possible. The advantages include a quick procedure, insignificant complications, the ability to provide a stable airway, and no added costs, making SMI a quick, safe, efficient, and cost-effective alternative in such cases.

Submental intubation in maxillofacial surgery: a prospective study

We designed a prospective study with the objective to evaluate the efficacy, indications and our experience of submental intubation in different types of maxillofacial surgeries. From May 2008 to August 2010, 23 patients with different conditions were intubated by submental route of tracheal intubation and patients were evaluated on different parameters during and after surgery to find its efficacy, indications and utilization in maxillofacial surgeries. All the patients were managed well with this technique of intubation with no significant difference in intubation and extubation time. We did not face any uneventful complication. There was only one reported complication that is rupture of the bulb of cuffed flexometallic tube but was managed well by changing tube. We found skull base access surgery as a new indication for submental intubation. The submental route for endotracheal intubation may be utilized as an alternative to blind nasal intubation or tracheostomy in the surgical management of patients involving complex maxillofacial surgeries. We hypothesized that the submental intubation should not be used where long term ventilation support is needed. We did a technique modification to deliver the endotracheal tube out from the submental region to avoid pilot cuff damage. Our study proposes that skull base access surgery is a safe and potential indication for submental intubation. In our experience submental intubation is a simple, secure and effective procedure for operative airway control in major maxillofacial surgeries.

Submental intubation: a retrospective review of 45 cases

BACKGROUND

Airway management in patients undergoing maxillofacial surgery requires special consideration. A number of options including oro- or naso-tracheal intubation and tracheostomy are available. Submental intubation is now a recognised method of airway control during maxillofacial surgery. It provides a secure airway and does not interfere with maxillomandibular fixation or access to naso-orbito-ethmoid fractures. It avoids potential complications associated with nasotracheal intubation and tracheostomy in patients with multiple facial fractures, and obviates the need to alternate between oral and nasal intubation intra-operatively.

METHODS

This is a ten year retrospective review of patients who underwent submental intubation in a Regional Oral and Maxillofacial Surgery Department. The following variables were recorded: patient gender and age, preoperative diagnosis, duration of intubation, and complications associated with the intubation technique.

RESULTS

Submental intubation was performed 45 times on 45 patients. There were no complications relating to the submental intubation procedure.

CONCLUSION

Submental intubation should be considered as an option for airway management in selected cases of craniomaxillofacial surgery. It is a quick and safe technique with minimal morbidity and a low complication rate. It allows access to the maxillofacial skeleton intra-operatively and does not preclude the use of intermaxillary fixation.

Submental intubation: A journey over the last 25 years

Airway management in patients with faciomaxillary injuries is challenging due to disruption of components of upper airway. The anesthesiologist has to share the airway with the surgeons. Oral and nasal routes for intubation are often not feasible. Most patients have associated nasal fractures, which precludes use of nasal route of intubation. Intermittent intraoperative dental occlusion is needed to check alignment of the fracture fragments, which contraindicates the use of orotracheal intubation. Tracheostomy in such situations is conventional and time-tested; however, it has life-threatening complications, it needs special postoperative care, lengthens hospital stay, and adds to expenses. Retromolar intubation may be an option, But the retromolar space may not be adequate in all adult patients. Submental intubation provides intraoperative airway control, avoids use of oral and nasal route, with minimal complications. Submental intubation allows intraoperative dental occlusion and is an acceptable option, especially when long-term postoperative ventilation is not planned. This technique has minimal complications and has better patients’ and surgeons’ acceptability. There have been several modifications of this technique with an expectation of an improved outcome. The limitations are longer time for preparation, inability to maintain long-term postoperative ventilation and unfamiliarity of the technique itself. The technique is an acceptable alternative to tracheostomy for the good per-operative airway access.

Transmylohyoid orotracheal intubation: case series and review

STUDY OBJECTIVE

To evaluate the outcome of airway management in patients with complex maxillofacial fracture by submental intubation, time required for intubation, accidental extubation, and postoperative complications.

DESIGN

Retrospective study.

SETTING

University-affiliated hospital.

MEASUREMENTS

The medical records of the 10 patients who underwent submental intubation from December 2008 to June 2011 were reviewed.

MAIN RESULTS

At the end of the procedure, all 10 patients were extubated without any complications. Postoperatively, only one patient presented with superficial infection of the submental wound.

CONCLUSIONS

Submental endotracheal intubation is a simple technique with very low morbidity, and may be used as an alternative to tracheostomy in selected cases of maxillofacial trauma.

Current perspectives in intra operative airway management in maxillofacial trauma

OBJECTIVE

Maxillofacial trauma presents a complex problem due to the disruption of normal anatomy. In such cases, we anticipate a difficult oral intubation that may hinder intraoperative IMF. Nasal and skull base fractures do not advocate use of nasotracheal intubation. Hence, other anesthetic techniques should be considered in management of maxillofacial trauma patients with occlusal derangement and nasal deformity. This study evaluates the indications and outcomes of anesthetic management by retromolar, nasal, submental intubation and tracheostomy.

METHODOLOGY

Of the 49 maxillofacial trauma cases reviewed, that required intraoperative IMF, 32 underwent nasal intubation, 9 patients had tracheostomy, 5 patients utilized submental approach and 3 underwent retromolar intubation.

RESULTS

Among patients who underwent nasal intubation, eight cases needed fiberoptic assistance. In retromolar approach, though no complication was encountered, constant monitoring was mandatory to avoid risk of tube displacement. Consequently, submental intubation required a surgical procedure which could result in a cosmetically acceptable scar. Though invasive, tracheostomy has its benefits for long term ventilation.

CONCLUSION

Intubation of any form performed in a maxillofacial trauma patient is complex and requires both sound judgement and considerable experience.

Submental orotracheal intubation: Our experience and review

INTRODUCTION

In maxillofacial injuries, a choice has often to be made between different ways of intubation when surgical access to fractured nasal bone and simultaneous establishment of occlusion are required. We report our experience with submental intubation in the airway management of complex maxillofacial trauma patients.

AIMS

To evaluate the outcome of airway management in patients with complex maxillofacial fracture by submental intubation, time required for intubation, accidental extubation, postoperative complications, and to discuss indications, contraindications, advantages and disadvantages of submental intubation.

SETTINGS AND DESIGN

A retrospective study is designed.

MATERIALS AND METHODS

The medical records of seven patients who underwent submental intubation from December 2008 to June 2010 were reviewed and no statistical analysis was used.

RESULTS

At the end of the procedure all seven patients were extubated without any complications. Postoperatively only one patient presented with superficial infection of the submental wound.

CONCLUSIONS

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.

A review of intraoperative airway management for midface facial bone fracture patients

In craniofacial trauma patients, oral route endotracheal intubation may thwart the accuracy of dental occlusion and nasotracheal intubation carries the risk of intracranial invasion in skull base fracture cases. Between November 2005 and June 2006, patients receiving facial bone fracture operations at Kaohsiung Medical University Hospital were enrolled in this study. Intraoperatively, the endotracheal tube was pushed to either the retromolar space or the missing tooth space and secured by two 4.0 silk stitches. Then, surgeons could perform the usual procedure to explore the fracture sites, check the occlusion and correct the deviated nose without limitation. Also, for better understanding the time needed for various intubation techniques, a time-measuring study was performed. Ninety-one patients were treated by this method. Most of them were satisfied with the result of occlusion and nasal contour. Only 2 patients received second surgery to correct nasal deformity. One hundred seventeen anesthesia procedures were checked. In average, an experienced anesthesiologist could successfully intubate a patient in less than 105 seconds. The advantages and reported complications of different intubation methods were discussed. This retromolar position and tooth fixation technique allowed surgeons to correct the dental occlusion and nasal deformity simultaneously. It has served well for zygoma fracture, maxilla fracture, and Le Fort II fracture patients. It is worthy of consideration in management of middle face trauma patients involving occlusion change and nasal deviation.

The value of the maxillo-malar osteotomy in the treatment of Crouzon syndrome with exorbitism

Premature fusion of the cranial sutures along with midface hypoplasia, shallow orbits, and ocular proptosis are the principal features of Crouzon syndrome. Treatment varies according to the variable expressivity of the disease and usually begins during a child's first year with fronto-orbital advancement with cranial decompression. Subsequent development of midfacial hypoplasia needs correction. Procedures for this purpose include the Le Fort III osteotomy or its segmental variants, monobloc frontofacial advancement, or bipartition osteotomy. Adult Crouzon often presents with marked midface hypoplasia and exorbitism. We report an adult-diagnosed Crouzon syndrome case with typical facial features and exorbitism corrected by orbital decompression and zygomaticomaxillary advancement.

Submental intubation versus tracheostomy in maxillofacial trauma patients

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.

Utilization of tracheostomy in craniomaxillofacial trauma at a level-1 trauma center

PURPOSE

The decision to perform a tracheostomy on patients with maxillofacial trauma is complex. There is little data exploring the role of tracheostomy in facial fracture management. We sought to profile the utilization of tracheostomy in the context of maxillofacial trauma at our institution by comparing patients who required tracheostomy with and without facial fractures versus those with facial fractures not requiring tracheostomy.

MATERIALS AND METHODS

All patients admitted to the Trauma Service at Legacy Emanuel Hospital and Health Center (LEHHC), Portland, OR, from 1993 to 2003 that sustained facial fractures or underwent tracheostomy were identified and data were retrospectively reviewed using patient charts and the trauma registry. Variables such as age, gender, death, injury severity score (ISS), facial injury severity score (FISS), Glasgow coma score (GCS), intensive care days (ICU), hospital length of stay (LOS), facial fracture profile, and oral and maxillofacial surgery (OMFS) operative intervention were tabulated and analyzed. Data were divided into 3 groups for comparison: group 1 (ffxT) consisted of patients who underwent a tracheostomy procedure and repair of their facial fracture during the SAME operation by the OMFS department (N = 125); group 2 (ffxNT) were those patients who had repair of their facial fractures by OMFS and did not require a tracheostomy (N = 224); and group 3 (NffxT) were patients who did not have facial fractures but received a tracheostomy during their hospitalization (N = 259). Ten-year data were used to analyze the ffxT and 5-year data were used to analyze the ffxNT and NffxT. Analysis of variance and chi2 testing was used for statistical analysis.

RESULTS

A total of 18,187 patients were admitted to the trauma LEHHC Trauma Service during the study period, of which 1,079 (5.9%) patients sustained facial fractures and 788 (4.3%) required a tracheostomy. One hundred twenty-five patients (0.69% of total; 11.6% of facial fracture) received a tracheostomy at the same time as the facial fracture repair. All patients had their facial fractures successfully managed, regardless of the type of method used to stabilize the airway. There were no known cases of tracheal stenosis, severe bleeding requiring a return to the operating room, airway obstruction, or loss of secured airway. Males were the predominate gender in all 3 groups. The NffxT group (mean, 44.9 years) was much older compared with the ffxT (mean, 36.2 years) and ffxNT (mean, 30.9 years) groups. The incidence of death was higher in the tracheostomy groups compared with 0% with the non-tracheostomy group. The ffxNT group had a statistically significant higher GCS with an average of 12.4 when compared with the tracheostomy groups (ffxT = 6.8; NffxT = 6.7). ISS was nearly the same in the tracheostomy group (ffxT = 28.45; NffxT = 30.04), but higher when compared with the ffxNT (ISS = 17.33). All 3 groups were much different in terms of LOS and ICU days, in which the NffxT group had an average hospital LOS and ICU days of 34.4 and 16.56, respectively. This was higher when compared with the ffxT (LOS = 19.71 days; ICU = 7.21 days) and ffxNT (LOS = 6.82 days; ICU = 1.33 days) groups. The FISS averaged 6.22 in the ffxT group and was higher compared with an FISS of 3.16 in the ffxNT group. Overall, the fracture profile was different between the tracheostomy and non-tracheostomy groups. There was a higher prevalence of mandibular fractures, multiple mandibular fractures, and Le Fort III fractures in the ffxT group compared with the ffxNT group.

CONCLUSION

Tracheostomy is commonly performed in the context of multisystem trauma and is a safe method for airway stabilization in patients with craniomaxillofacial trauma. Multi-institutional collaboration and a prospective, randomized trial measuring outcome, resource utilization, and length of ICU stay is necessary to determine if tracheostomy is indeed of measurable benefit to patients with complex injuries.

Submandibular approach for tracheal intubation in patients with panfacial fractures

BACKGROUND

The oral route for tracheal intubation can interfere with some maxillofacial surgical procedures. At the same time, the nasal route can be contraindicated or impossible. Tracheostomy is the usual solution in these circumstances, but it carries a high incidence of complications. We tested the submandibular route for tracheal intubation as an alternative to tracheostomy in such situations.

METHODS

The procedure was performed in 13 patients suffering from panfacial fractures associated with a fracture of skull base or a displaced nasal fracture, and in one patient with post-caustic burn scar affecting most of the face including the nose and requiring a full thickness skin flap surrounding the mouth.

RESULTS

The technique was found easy and satisfactory for both the surgeon and the anaesthetist. It allowed uninterrupted surgical techniques and a secure airway. In six of the 13 patients, the submandibular tracheal tube was left in place for up to 44 h in the intensive care unit after the operation without complications or difficulties. Accidental dislodgement of the tube to the right main bronchus occurred in two patients while carrying out the procedure; it was rapidly detected and corrected. In another two patients, postoperative superficial infection occurred that responded well to local treatment. No other complications were encountered.

CONCLUSIONS

Submandibular tracheal intubation is a simple and effective technique for upper airway management in some maxillofacial surgical patients when both oral and nasal tracheal intubations are not convenient.