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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Surman K, Duffy N, Anwar Z, Basyuni S, Santhanam V. Submental intubation in craniomaxillofacial surgery. Anaesth Crit Care Pain Med 2020; 40:100796. [PMID: 33373721 DOI: 10.1016/j.accpm.2020.100796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/28/2020] [Accepted: 10/04/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Katy Surman
- School of Clinical Medicine, Cambridge University, Cambridge, United Kingdom
| | - Nicola Duffy
- School of Clinical Medicine, Cambridge University, Cambridge, United Kingdom
| | - Zuhair Anwar
- Department of Maxillofacial Surgery, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Shadi Basyuni
- Department of Maxillofacial Surgery, Addenbrooke's Hospital, Cambridge, United Kingdom.
| | - Vijay Santhanam
- Department of Maxillofacial Surgery, Addenbrooke's Hospital, Cambridge, United Kingdom
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Emara TA, El-Anwar MW, Omara TA, Anany A, Elawa IA, Rabea MM. Submental intubation versus tracheostomy in maxillofacial fractures. Oral Maxillofac Surg 2019; 23:337-341. [PMID: 31093795 DOI: 10.1007/s10006-019-00771-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 04/30/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To compare submental intubation with tracheostomy in patients with maxillofacial fractures who were operated under general anesthesia and nasotracheal intubation was contraindicated. PATIENTS AND METHODS This prospective comparative study was conducted on 32 patients undergoing maxillofacial operations. All patients had a panfacial trauma (including naso-ethmoid orbital fracture combined with mandibular fracture). Patients who had unstable cervical vertebra, laryngeal trauma, urgent tracheostomy, and patients with expected prolonged postoperative ventilation were excluded from the study. Patients were randomly assigned to elective tracheostomy and submental intubation groups. The patients were evaluated according to the time required to do elective tracheostomy or submental intubation, the operation comorbidity and complications, and the postoperative scar. RESULTS The average time required to do submental intubation was 8.35 min versus 30.75 min required to do elective tracheostomy with significant difference (p < 0.0001). No complication was reported with submental intubation while in elective tracheostomy group, surgical emphysema was registered in two patients. The submental scar was acceptable in all patients while the tracheostomy scar needs scar revision in four cases (p = 0.0325). CONCLUSION Submental endotracheal intubation appeared to be a simple, safe, and significantly faster reliable alternative to tracheostomy during surgical reconstruction of selected cases of maxillofacial fractures without indication for prolonged postoperative ventilation support with significantly lower morbidity.
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Affiliation(s)
- Tarek Abdelzaher Emara
- Otorhinolaryngology-Head and Neck Surgery Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Mohammad Waheed El-Anwar
- Otorhinolaryngology-Head and Neck Surgery Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt.
| | | | - Ahmed Anany
- Otorhinolaryngology-Head and Neck Surgery Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | | | - Mohamed Mohamed Rabea
- Otorhinolaryngology-Head and Neck Surgery Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
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Kumar RR, Vyloppilli S, Sayd S, Thangavelu A, Joseph B, Ahsan A. Submental intubation: alternative short-term airway management in maxillofacial trauma. J Korean Assoc Oral Maxillofac Surg 2016; 42:151-6. [PMID: 27429937 PMCID: PMC4940200 DOI: 10.5125/jkaoms.2016.42.3.151] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 02/14/2016] [Accepted: 03/06/2016] [Indexed: 11/15/2022] Open
Abstract
Objectives To assess submental route intubation as an alternative technique to a tracheostomy in the management of the airway in cranio-maxillofacial trauma, along with an assessment of its morbidity and complications. Materials and Methods Submental intubation was performed in 17 patients who had maxillofacial panfacial trauma and management was done under general anesthesia during a period of one year from 2013 to 2014 at Departments of Oral and Maxillofacial Surgery and Dentistry, the Malankara Orthodox Syrian Church Medical College, Kochi, India. Results In all 17 cases, the technique of submental intubation was found to be simple and reliable. Hypertrophic scars were noted in three cases, orocutaneous fistula and mucocele in one case each. All these complications were managed comfortably without significant morbidity to the patient. Conclusion Submental intubation is a good technique that can be used regularly in the management of the airway in cranio-maxillofacial trauma, but with some manageable complications.
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Affiliation(s)
- Ravi Raja Kumar
- Department of Oral and Maxillofacial Surgery, St. Joseph Dental College, Eluru, India
| | - Suresh Vyloppilli
- Department of Oral and Maxillofacial Surgery, Malankara Orthodox Syrian Church Medical College, Kochi, India
| | - Shermil Sayd
- Department of Oral and Maxillofacial Surgery, KMCT Dental College and Hospitals, Kozhikode, India
| | - Annamala Thangavelu
- Department of Oral and Maxillofacial Surgery, Rajah Muthiah Dental College & Hospital, Tamil Nadu, India
| | - Benny Joseph
- Department of Oral and Maxillofacial Surgery, KMCT Dental College and Hospitals, Kozhikode, India
| | - Auswaf Ahsan
- Department of Oral Medicine and Radiology, KMCT Dental College and Hospitals, Kozhikode, India
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Ujam A, Perry M. Minimally traumatic submental intubation: a novel dilational technique. Eur J Trauma Emerg Surg 2017; 43:359-62. [PMID: 27138007 DOI: 10.1007/s00068-016-0675-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Accepted: 04/21/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE Submental intubation is widely accepted as a safe and effective alternative to nasal intubation or tracheostomy in head and neck surgery patients. Forceful or careless technique can cause significant bleeding and trauma to the soft tissues at this point, increasing the likelihood of troublesome sublingual haematoma. METHODS We describe the use of a percutaneous tracheostomy horn (Cook Medical Blue Rhino®) to allow minimally traumatic submental intubation without the need for serial dilations. A patient with severe midfacial injuries requiring surgery was intubated via a standard oral technique. Following this, submental access was achieved using a novel dilational technique with a tracheostomy dilator. This resulted in a very secure and safe submental intubation and unrestricted access to the entire surgical field. RESULTS The single instrument, one-pass dilation technique to achieve submental intubation was found to be easy, quick, and avoided excessive trauma to the floor of mouth. CONCLUSION Patients will sometimes require a protected airway that allows surgeons unrestricted and simultaneous access to the dental occlusion, oral cavity, midface, and nose. In our case, this simple, easy, and quick adaptation of an established technique using a tracheostomy dilator is an excellent alternative to the traditional blunt dissection used to achieve submental intubation.
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Kumar KAJ, Kumar BP, Mohan AP, Masram AK, Tyro D, Gandla D. Assessment of the Efficacy of Submental Intubation in the Management of Midfacial and Panfacial Trauma Patients. J Maxillofac Oral Surg 2015. [PMID: 26225061 DOI: 10.1007/s12663-014-0684-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
- K A Jeevan Kumar
- Department of Oral and Maxillofacial Surgery, Kamineni Institute of Dental Sciences, Narketpally, Nalgonda, Andhra Pradesh India
| | - B Pavan Kumar
- Department of Oral and Maxillofacial Surgery, Kamineni Institute of Dental Sciences, Narketpally, Nalgonda, Andhra Pradesh India
| | - A P Mohan
- Department of Oral and Maxillofacial Surgery, Kamineni Institute of Dental Sciences, Narketpally, Nalgonda, Andhra Pradesh India
| | - Aruna Kishore Masram
- Department of Oral and Maxillofacial Surgery, Kamineni Institute of Dental Sciences, Narketpally, Nalgonda, Andhra Pradesh India
| | - David Tyro
- Department of Oral and Maxillofacial Surgery, Kamineni Institute of Dental Sciences, Narketpally, Nalgonda, Andhra Pradesh India
| | - Divya Gandla
- Department of Oral and Maxillofacial Surgery, Kamineni Institute of Dental Sciences, Narketpally, Nalgonda, Andhra Pradesh India
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Ricour C, Ferri J, Nunes F, Wiel E, Raoul G. [Patient treated with sub-mental intubation for maxillofacial trauma]. ACTA ACUST UNITED AC 2014; 33:593-5. [PMID: 25450733 DOI: 10.1016/j.annfar.2014.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Accepted: 08/25/2014] [Indexed: 11/28/2022]
Abstract
Maxillo-facial traumas are frequent and most often occur in young patients. Naso-tracheal or orotracheal intubation may be contraindicated in case of combined occlusal fracture and nasal or ethmoido-nasal fracture. This study was carried out a clinical case of a patient treated at the Lille University Hospital for a maxillofacial trauma associating fracture of nose and maxilla. The purpose was to assess the reliability of submental intubation as an alternative to tracheotomy. Submental intubation is a reliable single and safe technique allowing an one-stage surgical treatment in case of complex association of fractures without using tracheotomy. Its use should be implemented on a larger scale.
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Affiliation(s)
- C Ricour
- Service chirurgie maxillo-faciale, hôpital Roger-Salengro, CHRU de Lille, avenue du Pr Émile-Laine, 59037 Lille cedex, France.
| | - J Ferri
- Service chirurgie maxillo-faciale, hôpital Roger-Salengro, CHRU de Lille, avenue du Pr Émile-Laine, 59037 Lille cedex, France
| | - F Nunes
- Service d'anesthésie-réanimation, hôpital Huriez, CHRU de Lille, 59037 Lille, France
| | - E Wiel
- EA 2694, pôle de l'urgence, université Lille Nord de France, CHRU de Lille, 59037 Lille, France
| | - G Raoul
- Service chirurgie maxillo-faciale, hôpital Roger-Salengro, CHRU de Lille, avenue du Pr Émile-Laine, 59037 Lille cedex, France
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Vidya B, Cariappa KM, Kamath AT. Current perspectives in intra operative airway management in maxillofacial trauma. J Maxillofac Oral Surg 2011; 11:138-43. [PMID: 23730059 DOI: 10.1007/s12663-011-0316-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Accepted: 10/18/2011] [Indexed: 10/14/2022] Open
Abstract
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.
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Affiliation(s)
- B Vidya
- Department of Oral and Maxillofacial Surgery, D J College of Dental Sciences and Research, Modinagar, Ghaziabad, UP India
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Kar C, Mukherjee S. Submental intubation: an alternative and cost-effective technique for complex maxillofacial surgeries. J Maxillofac Oral Surg 2010; 9:266-9. [PMID: 22190802 DOI: 10.1007/s12663-010-0084-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2009] [Accepted: 04/13/2010] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Management of airway is a significant issue especially in cases of complex maxillofacial trauma like panfacial fractures or concomitant nasoethmoidal injuries, where the nasotracheal intubation is contraindicated or possess a significant problem. In these cases the only other alternative is tracheostomy. Submental intubation is an alternative to tracheostomy and it can be easily performed with little or lesser post-operative complications. This method involves lesser expenses as it does away with longer post-operative stay in the hospital as required by tracheostomy patients. TECHNIQUE The patient is orally intubated with a reinforced armoured tube with a detachable plastic gas connector. An incision is made in the submental area of the patient and a tunnel is prepared from this region to the floor of the mouth through which the proximal end of the tube is diverted. Thus the occlusion of the patient can be checked intraoperatively. After completion of the surgery the proximal end in reintroduced onto the oral cavity and the patient is extubated orally. DISCUSSION Originally proposed by Altemir in 1986, this method cannot be used in all cases as it is not without limitations. In spite of these, submental intubation can be a useful alternative to tracheostomy, especially in regions where cost cutting is a major factor in health infrastructure. CONCLUSION Maxillofacial surgeons addressing major facial trauma surgery may have this procedure in mind before opting for tracheostomy. It avoids a lot of complications associated with tracheostomy.
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Navaneetham A, Vinod Thangaswamy S, Rao N. Submental intubation: our experience. J Maxillofac Oral Surg 2010; 9:64-7. [PMID: 23139571 DOI: 10.1007/s12663-010-0018-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2009] [Accepted: 01/05/2010] [Indexed: 10/19/2022] Open
Abstract
INTRODUCTION Airway management for patients who suffered midfacial fractures is complicated. In maxillofacial injuries, a choice has often to be made between different ways of intubation when surgical access to both the nasal and oral cavities is necessary. Submental intubation technique is an alternative to nasoendotracheal intubation and tracheostomy in the management of patients with severe midfacial fractures. This procedure is simple to do and has a low morbidity. MATERIAL Submental intubation-paramedian technique has been used in 15 cases from May 2005-April 2007 in Hosmat Hospital, Bangalore. All patients had fractures disturbing the dental occlusion plus either an associated fracture of the skull base or a displaced nasal fracture. RESULTS Average duration of procedure was 7 minutes. Average duration of tube in vitro after surgery was 20 hours. There were 2 postoperative complications of tube obstruction which were successfully managed. CONCLUSION Submental intubation demands certain technical skills but it is simple, rapid and may avoid tracheostomy in selected patients.
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Franco J, Coppage J, Fallucco M, Ferguson JS. Submental intubation: An alternative to tracheostomy when nasoendotracheal intubation is unsuccessful - A case report. Can J Plast Surg 2009; 17:e37-e38. [PMID: 21119832 PMCID: PMC2827288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Submental intubation (SI) has been proposed as an alternative to nasoendotracheal intubation when oral endotracheal intubation is contraindicated. In patients who require intubation for maxillofacial reconstruction, this is an alternative to a traditional tracheostomy. The present case report presents an 18-year-old woman who suffered a comminuted mandibular fracture. Two days after her accident, she was taken to the operating room for open reduction with internal fixation of her mandible; however, the anesthesia staff was unable to nasally intubate the patient. A SI was performed. The procedure was completed without complications and the surgery accomplished with the SI. The patient was able to avoid a tracheostomy for an isolated operation. SI avoids the dangers of nasoendotracheal intubation in patients with midfacial fractures and avoids complications related to tracheostomy. Thus, SI may serve as an alternative to tracheostomy in patients without other medical conditions and indications for long-term intubation.
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Affiliation(s)
- Johnny Franco
- Correspondence: Dr Johnny Franco, 1010 Charles Street, Apartment 308, Saint Louis, Missouri 68715, USA. Telephone 575-496-3774, e-mail
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