Posters
Presentation Type
Poster
Discipline Track
Clinical Science
Abstract Type
Case Report
Abstract
Introduction/Background: Submental intubation is a valuable alternative airway management technique employed in oral maxillofacial surgery when intraoral or nasal intubation is contraindicated or poses a potential risk (Schütz, 2008). This case report presents a clinical scenario in which a patient underwent oral maxillofacial surgery necessitating submental intubation. Additionally, we review the indications, technique, and potential complications associated with this specialized intubation approach.
Oral maxillofacial surgeries frequently involve complex fractures, extensive soft tissue injuries, or anatomical variations that preclude traditional intraoral or nasal intubation. Submental intubation provides a safe and effective option in such cases, avoiding the need for tracheostomy or alternative invasive procedures (Caron, 2000).
During submental intubation, a modified oral endotracheal tube is passed through an incision made in the submental region, and then threaded into the oropharynx, allowing for secure airway access while preserving the integrity of the oral cavity and nasal passages. This technique offers several advantages, including improved surgical field visualization, reduced risk of oral trauma, better postoperative pain management, and enhanced patient comfort during the recovery phase (Valsa, 2012).
However, submental intubation is not without potential complications. These include surgical site infection, subcutaneous emphysema, hematoma formation, damage to the sublingual and lingual arteries, recurrent laryngeal nerve palsy, and difficulty with tube manipulation. Familiarity with the anatomical landmarks and meticulous technique is essential to minimize these risks and optimize patient outcomes (Das, 2012).
This case report highlights a patient who underwent oral maxillofacial surgery and required submental intubation due to complex facial fractures. By presenting this case and reviewing the literature, we aim to enhance understanding of the indications, technique, and potential complications associated with submental intubation in oral maxillofacial surgery.
Case Description: The patient is a 45-year-old female with a past medical history of diabetes mellitus (DM), hypertension (HTN), and hyperlipidemia (HLD), transferred to a level 1 trauma center following a motor vehicle collision (MVC). The patient, a restrained driver, collided with a school bus, resulting in her vehicle going underneath the bus. She arrived at the emergency department intubated and sedated, with a Glasgow Coma Scale (GCS) score of 3T, indicating severe neurological impairment.
Upon physical examination, the patient presented with a deformity of the face, specifically a depressed nasal bridge. Trauma CT scans were performed, revealing multiple significant injuries. These included comminuted fractures of the nasal bones and a bony nasal septal fracture. Additionally, a left orbital blowout fracture, bilateral inguinal sinusitis, and fractures of the bilateral orbital and maxillary sinus walls were observed. The left inferior rectus muscle was entrapped in the left orbital blowout fracture, resulting in the presence of intraorbital air bubbles and subcutaneous emphysema. Furthermore, bilateral lung contusions were detected on the CT scan.
Due to the severity of her life-threatening injuries, the patient was admitted to the Surgical Intensive Care Unit (SICU) for further surgical management. Interval surgery was performed, specifically addressing the left orbital floor and maxillary sinus fracture, which demonstrated decreased displacement and angulation compared to the initial assessment. The complexity of this surgery as well as the extent of her lesions prompted the Anesthesiology team to perform a submental intubation to properly secure the patient’s airway.
As a result of the treatment, the patient’s respiratory status significantly improved, leading to the discontinuation of DuoNeb and positive expiratory pressure (PEP) therapy, which had been initiated to address acute hypoxemic respiratory failure and respiratory alkalosis associated with the bilateral pulmonary contusion.
Discussion: Submental intubation is an effective way to ensure the restoration of a functional airway in the setting of simple to complex OMF trauma fractures. This intubation method secures a patient’s airway while providing uninterrupted access to the operative field. OMF trauma fractures may compromise adequate mask ventilation due to facial edema, facial asymmetry, nasal septum deviation, or oral occlusion by blood and secretions. Thus, in the setting of trauma, the airway must be secured using a method that is quick and allows for adequate ventilation.
When compared to nasotracheal or orotracheal intubation, submental intubation is associated with minimal complications. Complications such as nasal bleeding, tracheal stenosis, neck vessel injuries, or skull base fractures are rarely seen in submental intubations (Agrawal, 2010). OMF trauma fractures may result in alteration of normal airway anatomy thus adding to the difficulty of inserting a nasotracheal tube despite the assistance of Fiberoptic bronchoscopy or Video laryngoscopy. The patient presented with nasal, orbital, and bilateral maxillary fractures making submental intubation the more effective method compared to nasotracheal intubation.
Performing a tracheostomy would also be a viable alternative in this case, however this method is associated with increased complications, including: hemorrhage, pneumomediastinum, subcutaneous emphysema, pneumothorax, tracheal erosions, dysphagia, stoma infection, voice changes, and excessive scarring.
According to the International Journal of Oral and Maxillofacial Surgery, if maxillo-craniofacial surgery is indicated and less than 7 days are required for ventilatory support, a patient with jaw fractures, naso-orbital ethmoid fractures, or contraindications to nasotracheal intubation should be initially intubated through the submental route (Figure 1, Jundt et al. 2012). Previous studies have shown that the average time required for completion of submental intubations may range from 5.6-9 minutes (Valsa et al, 2012). According to Valsa et al, the average time it takes to disconnect the endotracheal tube from the ventilation circuit while performing a submental intubation is approximately 1.5±0.35 min. A shorter disconnection time from the ventilatory circuit, decreases the chances of hypoxic injury to the patient during intubation.
The patient tolerated this method of intubation well as a secure airway was established and sufficient space for the operation was provided. After surgery, the patient was transferred to the ICU and discharged home a few days later.
Academic/Professional Position
Medical Student
Academic/Professional Position (Other)
MS4
Recommended Citation
Inofomoh, Jennifer; Lavering, Mark; Wong Alvarado, Ed; and Aleman, Diego, "Submental Intubation in Oral Maxillofacial Surgery: A Case Report and Review of Indications and Complications" (2024). Research Symposium. 19.
https://scholarworks.utrgv.edu/somrs/2023/posters/19
Included in
Submental Intubation in Oral Maxillofacial Surgery: A Case Report and Review of Indications and Complications
Introduction/Background: Submental intubation is a valuable alternative airway management technique employed in oral maxillofacial surgery when intraoral or nasal intubation is contraindicated or poses a potential risk (Schütz, 2008). This case report presents a clinical scenario in which a patient underwent oral maxillofacial surgery necessitating submental intubation. Additionally, we review the indications, technique, and potential complications associated with this specialized intubation approach.
Oral maxillofacial surgeries frequently involve complex fractures, extensive soft tissue injuries, or anatomical variations that preclude traditional intraoral or nasal intubation. Submental intubation provides a safe and effective option in such cases, avoiding the need for tracheostomy or alternative invasive procedures (Caron, 2000).
During submental intubation, a modified oral endotracheal tube is passed through an incision made in the submental region, and then threaded into the oropharynx, allowing for secure airway access while preserving the integrity of the oral cavity and nasal passages. This technique offers several advantages, including improved surgical field visualization, reduced risk of oral trauma, better postoperative pain management, and enhanced patient comfort during the recovery phase (Valsa, 2012).
However, submental intubation is not without potential complications. These include surgical site infection, subcutaneous emphysema, hematoma formation, damage to the sublingual and lingual arteries, recurrent laryngeal nerve palsy, and difficulty with tube manipulation. Familiarity with the anatomical landmarks and meticulous technique is essential to minimize these risks and optimize patient outcomes (Das, 2012).
This case report highlights a patient who underwent oral maxillofacial surgery and required submental intubation due to complex facial fractures. By presenting this case and reviewing the literature, we aim to enhance understanding of the indications, technique, and potential complications associated with submental intubation in oral maxillofacial surgery.
Case Description: The patient is a 45-year-old female with a past medical history of diabetes mellitus (DM), hypertension (HTN), and hyperlipidemia (HLD), transferred to a level 1 trauma center following a motor vehicle collision (MVC). The patient, a restrained driver, collided with a school bus, resulting in her vehicle going underneath the bus. She arrived at the emergency department intubated and sedated, with a Glasgow Coma Scale (GCS) score of 3T, indicating severe neurological impairment.
Upon physical examination, the patient presented with a deformity of the face, specifically a depressed nasal bridge. Trauma CT scans were performed, revealing multiple significant injuries. These included comminuted fractures of the nasal bones and a bony nasal septal fracture. Additionally, a left orbital blowout fracture, bilateral inguinal sinusitis, and fractures of the bilateral orbital and maxillary sinus walls were observed. The left inferior rectus muscle was entrapped in the left orbital blowout fracture, resulting in the presence of intraorbital air bubbles and subcutaneous emphysema. Furthermore, bilateral lung contusions were detected on the CT scan.
Due to the severity of her life-threatening injuries, the patient was admitted to the Surgical Intensive Care Unit (SICU) for further surgical management. Interval surgery was performed, specifically addressing the left orbital floor and maxillary sinus fracture, which demonstrated decreased displacement and angulation compared to the initial assessment. The complexity of this surgery as well as the extent of her lesions prompted the Anesthesiology team to perform a submental intubation to properly secure the patient’s airway.
As a result of the treatment, the patient’s respiratory status significantly improved, leading to the discontinuation of DuoNeb and positive expiratory pressure (PEP) therapy, which had been initiated to address acute hypoxemic respiratory failure and respiratory alkalosis associated with the bilateral pulmonary contusion.
Discussion: Submental intubation is an effective way to ensure the restoration of a functional airway in the setting of simple to complex OMF trauma fractures. This intubation method secures a patient’s airway while providing uninterrupted access to the operative field. OMF trauma fractures may compromise adequate mask ventilation due to facial edema, facial asymmetry, nasal septum deviation, or oral occlusion by blood and secretions. Thus, in the setting of trauma, the airway must be secured using a method that is quick and allows for adequate ventilation.
When compared to nasotracheal or orotracheal intubation, submental intubation is associated with minimal complications. Complications such as nasal bleeding, tracheal stenosis, neck vessel injuries, or skull base fractures are rarely seen in submental intubations (Agrawal, 2010). OMF trauma fractures may result in alteration of normal airway anatomy thus adding to the difficulty of inserting a nasotracheal tube despite the assistance of Fiberoptic bronchoscopy or Video laryngoscopy. The patient presented with nasal, orbital, and bilateral maxillary fractures making submental intubation the more effective method compared to nasotracheal intubation.
Performing a tracheostomy would also be a viable alternative in this case, however this method is associated with increased complications, including: hemorrhage, pneumomediastinum, subcutaneous emphysema, pneumothorax, tracheal erosions, dysphagia, stoma infection, voice changes, and excessive scarring.
According to the International Journal of Oral and Maxillofacial Surgery, if maxillo-craniofacial surgery is indicated and less than 7 days are required for ventilatory support, a patient with jaw fractures, naso-orbital ethmoid fractures, or contraindications to nasotracheal intubation should be initially intubated through the submental route (Figure 1, Jundt et al. 2012). Previous studies have shown that the average time required for completion of submental intubations may range from 5.6-9 minutes (Valsa et al, 2012). According to Valsa et al, the average time it takes to disconnect the endotracheal tube from the ventilation circuit while performing a submental intubation is approximately 1.5±0.35 min. A shorter disconnection time from the ventilatory circuit, decreases the chances of hypoxic injury to the patient during intubation.
The patient tolerated this method of intubation well as a secure airway was established and sufficient space for the operation was provided. After surgery, the patient was transferred to the ICU and discharged home a few days later.