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Troise S, Committeri U, Barone S, Palumbo D, D'Auria D, Arena A, Romano A, Salzano G, Abbate V, Raccampo L, Sembronio S, Vaira LA, Dell'Aversana Orabona G, Califano L, Piombino P. Submental intubation in complex maxillofacial trauma: Pilot balloon protection. J Craniomaxillofac Surg 2024; 52:212-221. [PMID: 38143159 DOI: 10.1016/j.jcms.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 10/02/2023] [Accepted: 12/11/2023] [Indexed: 12/26/2023] Open
Abstract
AIMS This study aims to describe our refined technique of submental intubation to avoid the recorded intraoperative complications related to tube passage and pilot balloon rupture. CASE SERIES This is a retrospective case series of 21 patients with complex maxillofacial trauma who underwent submental intubation from January 2019 to January 2023. All the patients underwent to the same procedure with a new technique of pilot balloon protection: the pilot balloon was not deflated because, once the connector was removed, only the tube was curved and passed through the incision extraorally while the cuff remained inflated. The wire of the pilot balloon was passed behind the last tooth so as not to interfere with the maxillary-mandibular fixation, remaining extraorally under the anesthetist's view. DISCUSSION Only 2 patients (9.5%) reported complications related to submental intubation: in particular a patient (4.8%) reported oral floor infection, and in another patient (4.8%) an unesthetic skin scar was observed. No patients reported intraoperative complications related to the procedure. CONCLUSION The technique of pilot balloon protection that we have proposed seems to be effective in reducing the intraoperative complications related to the passage of the pilot balloon, such as rupture, damage or early extubation.
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Affiliation(s)
- Stefania Troise
- Maxillofacial Surgery Unit, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Via Sergio Pansini 5, 80131, Naples, Italy
| | - Umberto Committeri
- Maxillofacial Surgery Unit, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Via Sergio Pansini 5, 80131, Naples, Italy
| | - Simona Barone
- Maxillofacial Surgery Unit, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Via Sergio Pansini 5, 80131, Naples, Italy.
| | - Daniela Palumbo
- Department of Surgical, Anesthesiological Intensive Care and Emergency Sciences, Federico II University of Naples, Naples, Italy
| | - David D'Auria
- Department of Surgical, Anesthesiological Intensive Care and Emergency Sciences, Federico II University of Naples, Naples, Italy
| | - Antonio Arena
- Maxillofacial Surgery Unit, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Via Sergio Pansini 5, 80131, Naples, Italy
| | - Antonio Romano
- Maxillofacial Surgery Unit, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Via Sergio Pansini 5, 80131, Naples, Italy
| | - Giovanni Salzano
- Maxillofacial Surgery Unit, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Via Sergio Pansini 5, 80131, Naples, Italy
| | - Vincenzo Abbate
- Maxillofacial Surgery Unit, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Via Sergio Pansini 5, 80131, Naples, Italy
| | - Luca Raccampo
- Maxillofacial Surgery Unit, Academic Hospital of Udine, Department of Medicine, University of Udine, 33100, Udine, Italy
| | - Salvatore Sembronio
- Maxillofacial Surgery Unit, Academic Hospital of Udine, Department of Medicine, University of Udine, 33100, Udine, Italy
| | - Luigi Angelo Vaira
- Maxillofacial Surgery Operative Unit, Department of Medical, Surgical and Experimental Sciences, University of Sassari, 07100, Sassari, Italy
| | - Giovanni Dell'Aversana Orabona
- Maxillofacial Surgery Unit, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Via Sergio Pansini 5, 80131, Naples, Italy
| | - Luigi Califano
- Maxillofacial Surgery Unit, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Via Sergio Pansini 5, 80131, Naples, Italy
| | - Pasquale Piombino
- Maxillofacial Surgery Unit, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Via Sergio Pansini 5, 80131, Naples, Italy
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Ostrowski P, Bonczar M, Wilk J, Michalczak M, Czaja J, Niziolek M, Sienkiewicz J, Szczepanek E, Chmielewski P, Iskra T, Gregorczyk-Maga I, Walocha J, Koziej M. The complete anatomy of the lingual nerve: A meta-analysis with implications for oral and maxillofacial surgery. Clin Anat 2023; 36:905-914. [PMID: 36864652 DOI: 10.1002/ca.24033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 02/15/2023] [Accepted: 02/22/2023] [Indexed: 03/04/2023]
Abstract
Lingual nerve (LN) injury during surgical procedures in the third molar region warrants a detailed study of its common pathway and important variations. Therefore, the objective of this study was to analyze and compile the multiple anatomical variations of the LN for use in oral and maxillofacial surgery. It is anticipated that the results of the present meta-analysis may help to minimize the possible complications when performing procedures associated with this anatomical entity. Major online databases such as PubMed, Web of Science, Scopus, Embase were used to gather all relevant studies regarding the LN anatomy. The results were established based on a total of 1665 LNs. The pooled prevalence of the LN being located below the lingual/ alveolar crest was found to be 77.87% (95% CI: 0.00%-100.00%). The LN was located above the lingual/ alveolar crest in 8.21% (95% CI: 4.63%-12.89%) of examined nerves. The most common shape of the LN was established to be round with a prevalence of 40.96% (95% CI: 23.96%-59.06%), followed by oval at 37.98% (95% CI: 23.98%-53.02%) and flat at 25.16% (95% CI: 12.85%-39.77%). In conclusion, we believe that this is the most accurate and up-to-date study regarding the anatomy of the LN. The LN was found to be located below the lingual/alveolar crest in 77.87% of the cases. Furthermore, the LN was found to enter the tongue under the submandibular duct in 68.39% of the cases. Knowledge about the anatomy of the LN is crucial for numerous oral and maxillofacial procedures such as during the extraction of the third molar.
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Affiliation(s)
- Patryk Ostrowski
- Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland
- Youthoria, Youth Research Organization, Kraków, Poland
| | - Michał Bonczar
- Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland
- Youthoria, Youth Research Organization, Kraków, Poland
| | - Jakub Wilk
- Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland
| | - Mateusz Michalczak
- Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland
| | - Julia Czaja
- Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland
| | - Martha Niziolek
- Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland
| | - Justyna Sienkiewicz
- Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland
| | - Elżbieta Szczepanek
- Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland
| | | | - Tomasz Iskra
- Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland
| | | | - Jerzy Walocha
- Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland
- Youthoria, Youth Research Organization, Kraków, Poland
| | - Mateusz Koziej
- Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland
- Youthoria, Youth Research Organization, Kraków, Poland
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de Souza AAB, Araújo SCS, Martins GH, de Jesus AO, Amaral MBF, Silveira RL. New Device for Submental Endotracheal Intubation: A Prospective Cohort Study. J Oral Maxillofac Surg 2022; 80:1927-1942. [PMID: 36137556 DOI: 10.1016/j.joms.2022.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 08/18/2022] [Accepted: 08/18/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE Silveira et al (2020) described a new device that aims to facilitate submental intubation. This study aimed to verify the clinical complications from using this new device for submental endotracheal compared to the conventional technique. MATERIAL AND METHODS Patients who underwent submental intubation with the orotracheal tube transposition device were compared to those who underwent the conventional technique in a prospective cohort study. The primary predictor variable was intubation technique: conventional versus device-assisted. The primary outcome was total complications (all complications trans and postoperative, were recorded). Secondary variables were 1) age, 2) sex, 3) etiology, 4) race/ethnicity, 5) fracture types, and 6) intubation procedure time. The data were analyzed using descriptive and inferential statistics. Differences were considered statistically significant at P < .05. RESULTS Forty-two cases are described, including 24 cases with the device and 18 cases using the conventional technique. The mean age was 30.5 ± 11.228 years. The majority of patients were of male sex (88%), non-white (64%), and victims of motorcycle accidents (33%). The mean time to perform submental intubation was 9.9 minutes (±2.1293). Nine complications were recorded, including 2 intraoperative (2 tube dislocations) and 7 postoperative (5 unesthetic scars, one localized hematoma, and one skin infection). The technique used did not affect the time to submental intubation (P = .610). There was no association between technique and occurrence of intraoperative (P = .679; RR = 0.75; confidence interval [CI], 0.05-11.2), postoperative (P = .656; RR = 1.000; CI, 0.255-3.922), or total complications (P = .602; RR = 0.938; CI, 0.293-3.003). CONCLUSION The new device proposed seems to be a good option with similar complication rates as compared to conventional submental intubation.
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Affiliation(s)
| | | | - Gustavo Henrique Martins
- Resident, Resident of Oral and Maxillofacial Surgery, Hospital João XXIII/FHEMIG, Belo Horizonte, MG, Brazil
| | | | | | - Roger Lanes Silveira
- Residency Program Director of Oral and Maxillofacial Surgery, Hospital João XXIII/FHEMIG, Belo Horizonte, MG, Brazil; Otorhinolaryngology/Head and Neck Surgery Service, Santa Casa, Belo Horizonte, MG, Brazil
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Pitak-Arnnop P, Tangmanee C, Subbalekha K, Sirintawat N, Urwannachotima N, Auychai P, Messer-Peti R, Meningaud JP, Neff A. Factors associated with complications of submental intubation in 339 patients with facial fractures: A German retrospective cohort study. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2022; 124:101332. [PMID: 36400390 DOI: 10.1016/j.jormas.2022.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 10/27/2022] [Accepted: 11/14/2022] [Indexed: 11/17/2022]
Abstract
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.
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Wang XR, Zhang Q, Ding WS, Zhang W, Zhou M, Wang HB. Comparison of clinical outcomes of tracheotomy in patients with acute cervical spinal cord injury at different timing. Clin Neurol Neurosurg 2021; 210:106947. [PMID: 34583275 DOI: 10.1016/j.clineuro.2021.106947] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 09/08/2021] [Accepted: 09/12/2021] [Indexed: 11/16/2022]
Abstract
Respiratory failure is the leading cause of early death after acute CSCI. Tracheotomy is an effective approach to reduce mortality and improve the clinical outcomes. However, the optimal timing for tracheotomy remains controversial. Hence, the study aimed to compare the clinical outcomes of tracheotomy in patients with acute cervical spinal cord injury (CSCI) at different timing. A retrospectively review was performed of acute CSCI patients who underwent tracheotomy in the intensive care unit of Haian Hospital between January 2014 and June 2019. 124 CSCI patients were included and stratified into three groups based on the timing of tracheotomy: early group (≤4 days from initial intubation), medium group (4-10 days from initial intubation), and late group (≥10 days from initial intubation). The clinical outcomes and functional outcomes were analyzed. No significant intergroup differences in baseline characteristics were observed. The late group needed significantly longer duration of mechanical ventilation, longer ICU stay, and suffered higher ICU mortality, higher pneumonia after tracheotomy than the early and medium groups. More patients in the early and medium groups successfully weaned from mechanical ventilation. The early and medium groups achieved better improvement of JOA and NDI scores than the late group at one year after surgery and at the final follow-up. Early to medium term tracheotomy may lead to better clinical and functional outcomes in patients with acute CSCI who require prolonged mechanical ventilation.
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Affiliation(s)
- Xiao-Ran Wang
- Department of Intensive Care Unit, Affiliated Haian Hospital of Nantong University, Nantong 226001, China
| | - Qiang Zhang
- Department of Intensive Care Unit, Affiliated Haian Hospital of Nantong University, Nantong 226001, China
| | - Wen-Sen Ding
- Department of Intensive Care Unit, Affiliated Haian Hospital of Nantong University, Nantong 226001, China
| | - Wei Zhang
- Department of Intensive Care Unit, Affiliated Haian Hospital of Nantong University, Nantong 226001, China
| | - Min Zhou
- Department of Intensive Care Unit, Affiliated Haian Hospital of Nantong University, Nantong 226001, China
| | - Hai-Bo Wang
- Department of Intensive Care Unit, Affiliated Haian Hospital of Nantong University, Nantong 226001, China.
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Jung I, Yoo BH, Ju JY, Choi S, Yon JH, Kim KM, Lim YH, Lee WY. Novel alternative for submental intubation - A case report. Anesth Pain Med (Seoul) 2020; 15:247-250. [PMID: 33329821 PMCID: PMC7713814 DOI: 10.17085/apm.2020.15.2.247] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 09/24/2019] [Accepted: 09/25/2019] [Indexed: 11/17/2022] Open
Abstract
Background Submental intubation is commonly used during general anesthesia for maxillofacial surgeries as it provides a safe unrestricted surgical access compared to tracheostomy. During submental intubation, soft tissues and blood clots can become lodged in the endotracheal tube. To overcome this problem, we used a laparoscopic trocar. Case A 52-year-old male with maxillofacial injury was scheduled to undergo an open reduction and internal fixation. We performed submental intubation using laparoscopic trocar, which created sufficient space for the insertion of the endotracheal tube. Unlike conventional methods, our method did not require any blunt dissection and caused significantly less soft tissue damage and required significantly less time. Conclusions Submental intubation with laparoscopic trocar is a one-step method and is quick and easy-to-perform technique with less complications.
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Affiliation(s)
- Inyoung Jung
- Department of Anesthesiology and Pain Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Byung Hoon Yoo
- Department of Anesthesiology and Pain Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Ji Youn Ju
- Department of Anesthesiology and Pain Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Sijin Choi
- Department of Anesthesiology and Pain Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Jun Heum Yon
- Department of Anesthesiology and Pain Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Kye-Min Kim
- Department of Anesthesiology and Pain Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Yun-Hee Lim
- Department of Anesthesiology and Pain Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Woo Yong Lee
- Department of Anesthesiology and Pain Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
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Abstract
The submental intubation is a well-described technique as an alternative for the tracheostomy in the airway management in patients with contraindications for the nasotracheal and cannot remain in the orotracheal position due to the need to maintain the intermaxillary fixation. Residents and young oral and maxillofacial surgeons could have experienced some difficulty performing the technique first described by Altemir (1986). This report aims to describe a new device designed to facilitate and simplify the technique helping surgeons on the submental endotracheal intubation.
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Submental intubation in oral and maxillofacial surgery: a systematic review 1986–2018. Br J Oral Maxillofac Surg 2020; 58:43-50. [DOI: 10.1016/j.bjoms.2019.10.314] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 10/25/2019] [Indexed: 01/04/2023]
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Clinical Anatomy of Submental Intubation: A Review of the Indications, Technique, and a Modified Approach. Ann Plast Surg 2019; 84:232-237. [PMID: 31335466 DOI: 10.1097/sap.0000000000001948] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Since its original description in 1986 by Hernandez, submental intubation has been used in a wide variety of craniomaxillofacial cases as a way to satisfy both surgeon and anesthesiologist to provide access to necessary surgical sites and airway protection. Many modifications to the original technique have been described. There has been a paucity of plastic surgery literature over the last 10 years that have reviewed the anatomy, technique, and complications. In this article, the authors review the pertinent anatomy related to this method of intubation. A cadaver was used to enhance visualization of important structures and to show the modification used by our group. Submental intubation provides a useful alternative to tracheostomy in several craniomaxillofacial procedures. Our approach uses a reinforced endotracheal tube to prevent kinking and provide additional intraoperative protection of the airway. Submental intubation may be indicated in select patients undergoing craniomaxillofacial surgery. Therefore, it is pertinent to be aware of the important anatomy and the complications of this technique to appropriately counsel patients. Our modification provides safe airway control.
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Submental Intubation: an Underutilized Technique for Airway Management in Patients With Panfacial Trauma. J Craniofac Surg 2018; 29:1349-1351. [PMID: 29561488 DOI: 10.1097/scs.0000000000004496] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To evaluate submental intubation compared with secure airways of patients who have sustained significant maxillofacial trauma. PATIENTS AND METHODS Patient series of 3 patients who underwent submental intubation prior to open reduction internal fixation of fractures associated with the mid and lower face. All of these patients were initially orally intubated, and then converted to submental intubation prior to the reparative procedure. Detailed description of the procedure is discussed in each patient. RESULTS All the patients received appropriate reduction of facial fractures following submental intubation with no intraoperative complications. Two of the 3 patients were extubated immediately postoperatively and 1 was extubated on the second postoperative day. None of the patients had any complications associated with submental intubation. CONCLUSIONS Submental intubation is a safe and expedient technique to divert the airway in patients who require operative repair of panfacial injuries. This procedure is preferable over tracheostomy in selected patients of maxillofacial trauma without indication for prolonged ventilation support.
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Improving Postoperative Nasal Airway Patency in Le Fort-Based, Maxillofacial Trauma Patients Via a Modified Nasal Packing Technique. J Craniofac Surg 2018; 29:e475-e477. [PMID: 29561482 DOI: 10.1097/scs.0000000000004491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Combined mid-face and nasal apparatus trauma injuries pose a significant challenge to airway patency (AW), in the immediate postoperative setting following fracture reduction. As such, the authors describe a modified technique with the goal of maintaining a patent nasal AW, while at the same time, minimizing nasopharyngeal bleeding and nasal AW edema-which can complicate patients requiring intermaxillary fixation (IMF) in the setting of pan-facial trauma. METHODS A modified technique was devised to assist the reconstruction surgeon in avoiding the risks associated with tracheostomy placement. In an effort to avoid surgical AW complications and improve nasal AW patency in the setting of concurrent IMF and nasal trauma, the authors developed a 2-stage technique drawing upon knowledge from the literature and the authors' own experiences. TECHNIQUE Following safe extubation, the authors insert open lumen nasal splints in both the nostrils, and suture them together to the nasal septum. If additional inner nasal support is required, polyvinyl alcohol nonabsorbable nasal packing dressing is covered with antibiotic ointment, and then placed within the nasal cavity lateral to the open lumen splints-as a way to further bolster the internal valve and mid-vault anatomy. DISCUSSION Given the fact that traditional nasal packing with merocele/gauze dressing in concomitant to IMF reduced patients ability to ventilate, the authors felt that a modified technique should be applied. The authors' preferred materials in such patients are open lumen splint, which provides nasal AW patency along with some septum support accompanied by merocele dressing. The authors feel that by applying this technique they achieve dual objectives by supporting the traumatized nose and maintaining nasal AW patency.
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Oshima N, Shiraishi T, Kawauchi T, Oba J, Sato D, Fujiki M, Ozaki M, Takushima A, Harii K. A Simple and Reliable Submental Intubation Technique for Maxillofacial Fractures. J Craniofac Surg 2018; 29:1952-1955. [PMID: 30113420 PMCID: PMC6200376 DOI: 10.1097/scs.0000000000004628] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 04/01/2018] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
- Naoya Oshima
- Department of Plastic Surgery, Kyorin University School of Medicine, Shinkawa, Mitaka, Tokyo, Japan
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Evans SW, McCahon RA. Management of the airway in maxillofacial surgery: part 1. Br J Oral Maxillofac Surg 2018; 56:463-468. [PMID: 29907469 DOI: 10.1016/j.bjoms.2018.05.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 05/25/2018] [Indexed: 12/17/2022]
Abstract
In part 1 of this review of management of the airway in maxillofacial surgery we discuss preoperative assessment of the airway, and the practical means to deal with difficulties. We review the evidence for videolaryngoscopy and flexible indirect laryngoscopy, together with surgical access to the airway including tracheostomy, cricothyroidotomy, and submental intubation.
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Affiliation(s)
- S W Evans
- Nottingham University Hospitals NHS Trust, Queen's Medical Centre campus, Derby Road, Nottingham, NG7 2UH
| | - R A McCahon
- Nottingham University Hospitals NHS Trust, Queen's Medical Centre campus, Derby Road, Nottingham, NG7 2UH.
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Bhola N, Jadhav A, Kala A, Deshmukh R, Bhutekar U, Prasad GSV. Anterior Submandibular Approach for Transmylohyoid Endotracheal Intubation: A Reappraisal with Prospective Study in 206 Cases of Craniomaxillofacial Fractures. Craniomaxillofac Trauma Reconstr 2017; 10:255-262. [PMID: 29109835 DOI: 10.1055/s-0037-1607063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 07/15/2017] [Indexed: 10/18/2022] Open
Abstract
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.
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Affiliation(s)
- Nitin Bhola
- Department of Oral and Maxillofacial Surgery, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India
| | - Anendd Jadhav
- Department of Oral and Maxillofacial Surgery, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India
| | - Atul Kala
- Department of Oral and Maxillofacial Surgery, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India
| | - Rahul Deshmukh
- Department of Oral and Maxillofacial Surgery, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India
| | - Umesh Bhutekar
- Department of Oral and Maxillofacial Surgery, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India
| | - G S V Prasad
- Department of Oral and Maxillofacial Surgery, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India
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15
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Kita R, Kikuta T, Takahashi M, Ootani T, Takaoka M, Matsuda M, Tsurushima H, Yoshioka I. Efficacy and complications of submental tracheal intubation compared with tracheostomy in maxillofacial trauma patients. J Oral Sci 2017; 58:23-8. [PMID: 27021536 DOI: 10.2334/josnusd.58.23] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
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).
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Affiliation(s)
- Ryosuke Kita
- Department of Oral Medicine, Kyushu Dental University
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16
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Sysolyatin PG, Elizar'eva NL, Shmakov AN, Kolosov AN, Kohno VN, Loktin EM, Tsayukov YV. [The experience of submental intubation for severe maxillofacial injuries]. STOMATOLOGII︠A︡ 2017; 95:29-32. [PMID: 28139588 DOI: 10.17116/stomat201695629-32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Oral and nasal routes for intubation are often not feasible in maxillofacial fractures. The paper presents our experience of midline and paramedial approaches for submental intubation in the airway management of facial trauma patients. The prospective study included 47 patients with maxillofacial trauma in whom submental orotracheal intubation was performed in 2005-2014. When using midline approach the tube does not always accurately fit into the mandibular lingual groove creating an inconvenience for the surgeon. By paramesial approach the working conditions for the surgeon were the most comfortable. The average duration of the procedure was 5-6 minutes. At the end of the surgery the tube was reversed, the submental wound was stitched, patients were extubated (10 of them were extubated through the submental approach). Eight patients required short-term post-operative mechanical ventilation. In all patients the submental intubation allowed simultaneous reduction and fixation of fractures and intraoperative control of the dental occlusion without interference from the tube during the operation. There were no significant operative or postoperative complications. Submental intubation is a simple, secure and effective procedure for operative airway control in maxillofacial traumas. It is an attractive alternative to tracheotomy in the surgical management of selected cases of maxillofacial trauma.
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Affiliation(s)
- P G Sysolyatin
- Novosibirsk state medical university, Novosibirsk, Russia, Novosibirsk State Regional Hospital, Novosibirsk, Russia
| | - N L Elizar'eva
- Novosibirsk state medical university, Novosibirsk, Russia, Novosibirsk State Regional Hospital, Novosibirsk, Russia
| | - A N Shmakov
- Novosibirsk state medical university, Novosibirsk, Russia, Novosibirsk State Regional Hospital, Novosibirsk, Russia
| | - A N Kolosov
- Novosibirsk state medical university, Novosibirsk, Russia, Novosibirsk State Regional Hospital, Novosibirsk, Russia
| | - V N Kohno
- Novosibirsk state medical university, Novosibirsk, Russia, Novosibirsk State Regional Hospital, Novosibirsk, Russia
| | - E M Loktin
- Novosibirsk state medical university, Novosibirsk, Russia, Novosibirsk State Regional Hospital, Novosibirsk, Russia
| | - Yu V Tsayukov
- Novosibirsk state medical university, Novosibirsk, Russia, Novosibirsk State Regional Hospital, Novosibirsk, Russia
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17
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Ali S, Athar M, Ahmed SM, Siddiqi OA, Badar A. A Randomized Control Trial of Awake Oral to Submental Conversion versus Asleep Technique in Maxillofacial Trauma. Ann Maxillofac Surg 2017; 7:202-206. [PMID: 29264286 PMCID: PMC5717895 DOI: 10.4103/ams.ams_10_17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Aim This study was designed to evaluate the efficacy of awake oral to submental conversion over asleep technique. Materials and Methods This randomized clinical study was conducted in maxillofacial department of a tertiary care hospital in patients who had panfacial or mandibular fractures requiring elective surgical correction. The patients were randomly divided into two groups of 12 patients each, asleep fiberoptic-assisted submental intubation (SMI) (Group G; n = 12) and awake fiberoptic-assisted SMI (Group A; n = 12). The primary predictor was mean conversion time of oral to SMI while other predictors were overall success rate, ease of conversion, and complications. Data are presented as mean (±standard deviation) and frequencies (%) as appropriate. Statistical analysis done using unpaired t-test or Chi-square test was performed and P < 0.05 was considered statistically significant. Results Twenty-four patients (19:5;Male:Female) aged 18-55 years (Group G = 35.96; Group A = 32.43 years) were included in the study. SMI was successful in all except two patients in group G. Overall success rate was similar in both groups. Time to convert orotracheal intubation to SMI was significantly less in group A (Group G = 9.55 ± 1.42, Group A = 5.67 ± 1.73; P < 0.001). Ease of SMI was found Grade I in 30% and 83% of the patients of group G and A, respectively. No serious complications were observed except 2 cases of bleeding, and 1 case of tube damage. Conclusion Awake oral to submental conversion requires lesser time in comparison to asleep technique besides improving the ease (Δ = 53%) of the procedure.
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Affiliation(s)
- Shahna Ali
- Department of Anaesthesiology and Critical Care, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
| | - Manazir Athar
- Department of Anaesthesiology and Critical Care, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
| | - Syed Moied Ahmed
- Department of Anaesthesiology and Critical Care, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
| | - Obaid Ahmad Siddiqi
- Department of Anaesthesiology and Critical Care, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
| | - Amrin Badar
- Department of Anaesthesiology and Critical Care, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
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Hassanein AG, Abdel Mabood AMA. Can Submandibular Tracheal Intubation Be an Alternative to Tracheotomy During Surgery for Major Maxillofacial Fractures? J Oral Maxillofac Surg 2016; 75:508.e1-508.e7. [PMID: 27886977 DOI: 10.1016/j.joms.2016.10.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 10/08/2016] [Accepted: 10/11/2016] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Ahmed Gaber Hassanein
- Lecturer of Maxillofacial and Plastic Surgery, Maxillofacial Head and Neck Surgery Unit, General Surgery Department, Faculty of Medicine, Sohag University, Sohag, Egypt.
| | - Ahmed M A Abdel Mabood
- Lecturer of Anesthesia, Anesthesia Department, Faculty of Medicine, Sohag University, Sohag, Egypt
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Al-Amery SM, Nambiar P, Naidu M, Ngeow WC. Variation in Lingual Nerve Course: A Human Cadaveric Study. PLoS One 2016; 11:e0162773. [PMID: 27662622 PMCID: PMC5035068 DOI: 10.1371/journal.pone.0162773] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 08/29/2016] [Indexed: 11/18/2022] Open
Abstract
The lingual nerve is a terminal branch of the mandibular nerve. It is varied in its course and in its relationship to the mandibular alveolar crest, submandibular duct and also the related muscles in the floor of the mouth. This study aims to understand the course of the lingual nerve from the molar area until its insertion into the tongue muscle. This cadaveric research involved the study of 14 hemi-mandibles and consisted of two parts: (i) obtaining morphometrical measurements of the lingual nerve to three landmarks on the alveolar ridge, and (b) understanding non-metrical or morphological appearance of its terminal branches inserting in the ventral surface of the tongue. The mean distance between the fourteen lingual nerves and the alveolar ridge was 12.36 mm, and they were located 12.03 mm from the lower border of the mandible. These distances were varied when near the first molar (M1), second molar (M2) and third molar (M3). The lingual nerve coursed on the floor of the mouth for approximately 25.43 mm before it deviated toward the tongue anywhere between the mesial of M1 and distal of M2. Thirteen lingual nerves were found to loop around the submandibular duct for an average distance of 6.92 mm (95% CI: 5.24 to 8.60 mm). Their looping occurred anywhere between the M2 and M3. In 76.9% of the cases the loop started around the M3 region and the majority (69.2%) of these looping ended at between the first and second molars and at the lingual developmental groove of the second molar. It gave out as many as 4 branches at its terminal end at the ventral surface of the tongue, with the presence of 2 branches being the most common pattern. An awareness of the variations of the lingual nerve is important to prevent any untoward complications or nerve injury and it is hoped that these findings will be useful for planning of surgical procedures related to the alveolar crest, submandibular gland/ duct and surrounding areas.
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Affiliation(s)
- Samah M Al-Amery
- Dept. of Oro-Maxillofacial Surgical and Medical Sciences, Faculty of Dentistry, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Phrabhakaran Nambiar
- Dept. of Oro-Maxillofacial Surgical and Medical Sciences, Faculty of Dentistry, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Murali Naidu
- Dept. of Anatomy, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Wei Cheong Ngeow
- Dept. of Oro-Maxillofacial Surgical and Medical Sciences, Faculty of Dentistry, University of Malaya, 50603, Kuala Lumpur, Malaysia
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Airway Management of the Patient with Maxillofacial Trauma: Review of the Literature and Suggested Clinical Approach. BIOMED RESEARCH INTERNATIONAL 2015; 2015:724032. [PMID: 26161411 PMCID: PMC4486512 DOI: 10.1155/2015/724032] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Accepted: 02/10/2015] [Indexed: 11/17/2022]
Abstract
According to the Advanced Trauma Life Support recommendations for managing patients with life-threatening injuries, securing the airway is the first task of a primary caregiver. Airway management of patients with maxillofacial trauma is complex and crucial because it can dictate a patient's survival. Securing the airway of patients with maxillofacial trauma is often extremely difficult because the trauma involves the patient's airway and their breathing is compromised. In these patients, mask ventilation and endotracheal intubation are anticipated to be difficult. Additionally, some of these patients may not yet have been cleared of a cervical spine injury, and all are regarded as having a full stomach and having an increased risk of regurgitation and pulmonary aspiration. The requirements of the intended maxillofacial operation may often preclude the use of an oral intubation tube, and alternative methods for securing the airway should be considered before the start of the surgery. In order to improve the clinical outcome of patients with maxillofacial trauma, cooperation between maxillofacial surgeons, anesthesiologists, and trauma specialists is needed. In this review, we discuss the complexity and difficulties of securing the airway of patients with maxillofacial trauma and present our approach for airway management of such patients.
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21
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Soukup JW, Snyder CJ. Transmylohyoid Orotracheal Intubation in Surgical Management of Canine Maxillofacial Fractures: An Alternative to Pharyngotomy Endotracheal Intubation. Vet Surg 2014; 44:432-6. [DOI: 10.1111/j.1532-950x.2014.12138.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Accepted: 11/01/2013] [Indexed: 12/01/2022]
Affiliation(s)
- Jason W. Soukup
- Department of Surgical Sciences; School of Veterinary Medicine; University of Wisconsin-Madison; Madison Wisconsin
| | - Christopher J. Snyder
- Department of Surgical Sciences; School of Veterinary Medicine; University of Wisconsin-Madison; Madison Wisconsin
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