TRANSMYLOHYOID SUBMENTAL INTUBATION IN ORAL AND MAXILLOFACIAL

SURGERIES

Dr Venkata Ramana Murthy, MDS

Assistant professor, Maxillofacial Surgery
NRI Institute of Medical Sciences
Sangivalasa, Bheemunipatnam, Visakhapatnam-531162, A.P. ,India
maxfacmurti@gmail.com
Dr K C Sekhar, M.D., Assistant Professor
NRI Institute of Medical Sciences
Sangivalasa, Bheemunipatnam, Visakhapatnam-531162, A.P. India
globeshaker@gmail.com

Keywords: Airway management, panfacial fractures, submental intubation

ABSTRACT
This study evaluated the efficacy of the submental route for endotracheal intubation during specialized
oral and maxillofacial surgeries. The time taken for airway access, surgical field advantages,quantity of
blood loss, incidence of complications (salivary fistulae, damage to lingual and marginal mandibular
branch of VII nerve, wound infection rate) and cosmetic advantage was significantly less when
compared to conventional tracheostomy.
INTRODUCTION
Panfacial or maxillofacial injuries may lead to derangement of the architecture and disruption of
different components (soft tissue, bony, and cartilages of cranium, midface and the mandible), often with
little external evidence of the deformity. These fractures are nowadays treated by open reduction and
rigid internal fixation with mini and microplate osteosynthesis. Management of the airway is always a
primary concern during such complex procedures, as the surgeon desires a field without an obtrusive
endotracheal tube while the anesthesiologist has priorities to ensure integrity of the airway and efficient
ventilation.
Delivery of anesthesia for maxillofacial surgeries is a challenge because the anesthesiologist has to share
the upper airway field with the surgeon. Nasotracheal intubation is not recommended in presence of
panfacial fracture, cervical spine injury, skull base fracture with or without cerebrospinal fluid
rhinorrhea, systemic coagulation disorders, distorted nasal anatomy and when nasal packing is indicated.
Nasotracheal intubation may be impossible as deformity or fracture of nasal bones, cribriform plate of
ethmoid or nasoorbital ethmoid complex are often associated. Nasotracheal intubation in such a

situation can be complicated by mucosal dissection, injury to adenoids, meningitis, sepsis, sinusitis,
epistaxis, dislodgement of bony fragments, and obstruction of the tube by the distorted airway anatomy,
or rarely intracranial intubation. Though fiberoptic-guided nasotracheal intubation, can be tried in
selected patients, efficacy of topical anesthesia over traumatized and inflamed mucosa is uncertain.
Moreover, even a small bleed in presence of altered anatomy may lead to complete loss of vision
through a fiberscope and may lead to an emergent situation In patients requiring simultaneous nasal or
nasoorbital ethmoid reconstruction after the rigid fixation of mandible and/or maxilla, intraoperative
switching over of the endotracheal tube (ETT) from nasal to oral route is required which may
compromise the surgical field sterility and may increase the possibility of pulmonary aspiration Also,
temporary intraoperative occlusion of teeth (intramaxillary and maxillomandibular fixation) is needed to
check the alignment of the fracture fragments, making orotracheal intubation unsuitable.
Hence, implementing a safe and acceptable alternative to tracheostomy for short-term airway
management is a desirable objective for the optimal management of complex craniofacial injuries.
Attempts have been made to tide over the problem with retromolar intubation (1) or nasal tube switch
technique. The former is traumatic, obtrusive, and time consuming and with large individual variations
in the retromolar space in adults especially when the third molars are impacted or completely erupted.
The latter has the danger of hypoxemia, aspiration and severe posterior nasal bleeding. The problems are
compounded in the presence of an unstable cervical spine and both these techniques can impose
excessive stresses on implants and cause loosening of inserted plates and screws.
Preoperative submental intubation (SMI) in craniofacial injuries was first proposed by a Spanish
faciomaxillary surgeon, Francisco Hernandez Altemir in 1986. (2) It consists of passing the endotracheal
tube through the anterior floor of mouth. This technique permits good dental occlusion and better
assessment of facial symmetry for superior aesthetic results, and also greater safety in cases associated
with skull base fractures. SMI combines the advantages of nasotracheal intubation, which permits good
dental occlusion, and that of orotracheal intubation,which allows access to frontonasal fractures without
the risk of iatrogenic meningitis or trauma of the anterior skull base. The technique also surmounts the
problems associated with tracheostomy.
There is a trend of rising attention on this useful, but underutilized mode of airway access over the last
25 years

MATERIAL & METHODS

This prospective clinical study was conducted from October 2008 to March 2013 after obtaining
clearance from the institutional ethical committee. Five male patients of mean age 26.6 years (range, 2338 years) with LeFortII type nasoethmoidal fractures and another five females of mean age 22.5 years
(range 19 - 26 years)posted for elective orthognathic surgery were included in the study. (Table 1)

Inclusion criteria were patient aged 18 to 50 years, those with mid facial and nasoethmoidal fractures,
and those posted for elective orthognathic surgery.
Exclusion criteria: Multi-trauma patients presenting with severe neurological damage, major thoracic or
multi organ trauma, those patients with severe systemic disease, those who might need long term post
operative ventilation and repeated surgeries, and those with known keloid tendencies.
Materials required for submental intubation procedure were assorted sizes of flexometallic endotracheal
tubes (ETT), incision and suturing tray, a Magill intubating forceps, Spencer Wells artery forceps and
suture materials.
The parameters studied were time taken for procedure, surgical access, quantum of bleeding and
incidence of complications like damage to the marginal mandibular branch of the facial and also the
lingual nerves, salivary fistulae, wound infection rate, post operative scarring and aesthetics.
All patients included in the study underwent thorough pre operative evaluation that included detailed
history, clinical examination, imaging and pre anesthetic assessment. Informed consent was secured
from all the patients.
The night before surgery 10 mg Tab Diazepam was administered to all the patients orally. On the
morning of surgery, the patients were kept in nil oral state and administered prophylactic antibiotic Inj
amoxicillin 1.0 gm with clavulanic acid intravenously 1 h prior to surgery. Patients were premedicated in
the operation theatre with Inj glycopyrrolate 0.2 mg and Inj tramadol 50 mg intravenously and general
anesthesia was induced with sleep dose of 0.1% propofol , nitrous oxide:oxygen 4:4 litre/min flow by
face mask followed by succinylcholine 2 mg/kg. Sellicks manouvre was applied and trachea intubated
with a cuffed 7.5 ID flexometallic ETT with stylet. Position of tune was confirmed by auscultation,
oximetry and capnography and fixed. Anesthesia was maintained with nitrous oxide:oxygen 4:4
litres/min flow using a Bain circuit, 1-2% isoflurane and Inj rocuronium 0.1 mg/kg.
The area around proposed site of incision was prepped with 10% povidone iodine solution and a
temporary draping of the mouth and chin was carried out.
Median incision: A 2-cm skin incision made in the median region of the submental area, directly
adjacent to the lower border of the mandible. The muscular layers (platysma and mylohyoid muscles)
were traversed by blunt dissection using a Kelly forceps that was always kept in contact with the lingual
cortex of the mandible. The mucosal layer on the floor of the mouth was incised over the distal end of
the forceps, at a point in front of the sublingual caruncle, and the tip of the forceps opened to create a
tunnel. (Figures 1 and 2) During the dissection, the internal planes of the track was kept about the same
size as the skin incision.
Paramedian approach: After local infiltration of skin and soft tissue of the proposed site with 2%
lignocaine with adrenaline, a 2 cm skin incision was made in the right submental region parallel to the
inferior border of the corresponding mandible and a finger breadth medial to it. A curved hemostat was
pushed through the subcutaneous tissue, platysma, myolohyoid muscle until it traversed the mucosa and

entered the oral cavity at the junction of the lingual alveolar mucosa and the free mucosa of the floor of
the mouth. The intraoral incision was extended parallel to the gingival margin.
The size of the incisions permitted easy passage of an 7.5 mm internal diameter endotracheal
tube(ETT). A right-sided incision was prefered as it permitted better visualization of the intraoral part of
the ETT while performing left handed laryngoscopy. However, selection of the side was dictated by the
site of injury and presence of mandibular fracture.
The patient was then ventilated with 100% oxygen and 2% isoflurane for 5 min, before drawing the tip
of the pilot balloon port through the submental incision by grasping with an artery forceps, immediately
followed by delivery of the ETT in a similar fashion while an assistant gripped intraoral part of the
flexometallic ETT with a Magill's forceps to prevent its dislodgement. The ETT connector was
reattached and connected to the breathing circuit. The position of the ETT was then confirmed by direct
laryngoscopy, chest auscultation, and capnography and the tube secured to the skin at the submental
level with 30 silk suture, in a similar fashion as a drainage tube. Transparent Tegaderm adhesive
dressing was used to secure the ETT to the skin as an additional precaution. The total duration of
submental intubation procedure ranged from 5 to 8 minutes (mean 5.9 minutes).
At the conclusion of the surgery, anesthesia reversed with 100% oxygen and a mixture of glycopyrrolate
and neostigmine and, on return of consciousness and active laryngeal and pharyngeal reflexes, the
patient was extubated.

RESULTS
None of the subjects in the present study required postoperative ventilation. All 10 subjects were
extubated in the operating room itself. The decision to extubate in the operation theatre was taken in
consultation with the surgeon and the attending anaesthesiologist based on the clinical condition of the
patient at the time of the surgical procedure, as well as intraoperative events.
There were no incidence of motor or sensory deficit and the mucosa of the floor of the mouth healed by
primary intention in all cases, without significant bleeding or infection. The submental scar was discrete
and well accepted by the subjects without any evidence of hypertrophic scarring or keloid formation. No
episodes of airway compromise or arterial desaturation occurred during the procedure. There were also
no cases with potential complications like orocutaneous fistula, trauma to the submandibular and
sublingual glands or canals or damage to the lingual nerve.
The present study reports good results with the use of submental endotracheal intubation for surgical
treatment of 5 patients with panfacial fractures and 5 for orthognathic surgery. In all cases, the planned
surgery was completed without interference from the artificial airway and, most importantly, without
compromising the airway.

DISCUSSION
The submental area is situated just below the chin, and demarcated by the anterior bellies of digastric
muscles of both sides, chin at the apex, body of the hyoid bone at the base with the mylohyoid muscles
forming the floor. It contains a few anatomical structures like lymph nodes and blood vessels. (3)
About 21.8% of all the maxillofacial injuries need open reduction and internal fixation. Panfacial
trauma cases present an unique set of problems and challenges to the anesthesiologist and maxillofacial
surgeon. Airway management in such emergencies is critical to the patients survival, and all modalities
of securing the lower airway have their own inherent advantages and disadvantages, not only for the
patient but also for the surgeon. Though infrequently resorted to, the submental route of tracheal
intubation offers an excellent alternative when both oral and nasal routes are unsuitable. A thorough pre
operative evaluation using imaging studies, surgical requirements and experience of the anesthesiologist
must be considered before choosing the most appropriate technique in each case.
SMI is particularly useful in surgeries where both nasal and oral passages are used by the surgeons e.g.,
repair of postcancrum oris defects, oronasal fistula, selected cleft lip, and palate surgeries, repair of
congenital malformations, skull base surgery, multiple or complex facial osteotomies, transfacial
oncologic procedures of the cranial base, and pediculated craniofacial surgeries. SMI permits elective
ventilation for maximum ten days and the resulting scar is cosmetically superior to that of a
tracheostomy. (4)
Nasal intubation distorts the nasolabial folds, making it difficult to assess the midline. Cant and incisor
display cannot be accurately made out during concomitant orthognathic procedures, elective Le Fort
osteotomies and rhinoplasty. (5, 6) Tube cuff can also be ruptured while placing bone screws while
securing an obturator to the hard palate. This will affect the ventilation and risk aspiration. Fibre optic
placement under direct visual control of a naso-endotracheal tube has vastly improved the success of this
procedure. (7)
Elective short-term tracheostomy is the conventional and time-tested method for airway access in
complex maxillofacial fractures. The procedure is difficult in obese patients, children, and patients with
thyroid swelling. There is a 6-8% incidence of immediate complications like hemorrhage, surgical
emphysema, pneumothorax, pneumomediastinum, and recurrent laryngeal nerve palsy; a 11 to 60% of
tracheostomy patients develop complications within 30 days of the procedure like stomal and
respiratory tract infections, blockage of the tube, dysphagia, difficulty with decannulation, tracheal
stenosis, tracheoesophageal fistula, and suboptimal visible scar. These are considerably more and
sometimes life threatening in those patients who have received preoperative radiotherapy. Compared to
tracheostomy, (8,9,10) SMI is associated with lesser postoperative complications and requires minimal
postoperative care resulting in shorter duration of hospitalization. This procedure can be carried out even

in a set up with limited resources. (11) Hence, tracheostomy for airway management is not ideal and
was avoided in this study .
SMI is considered a safe and simple alternative to secure the airway for complex craniomaxillofacial
trauma, midface and panfacial trauma with or without associated skull base fractures. It is also useful in
cases of lesions of the nasal pyramid associated with mandibular fractures or defec ts for procedures like
rhytidectomy, lip correction and rhinosplasty. SMI is safe and quick to execute, does not require
specialized equipments and associated with minimal complications. (12,13)
SMI consists of diverting the proximal end of an orotracheal tube through the floor of the mouth and
submental region. This allows free intraoperative access to the nasal pyramid without endangering
patients with skull base trauma, and at the same time avoids transtracheal dissection. The procedure
offers an excellent view of the surgical field and is associated with shorter stay in ICU and less sedation
requirements, minimal morbidity and complications. SMI allows the surgical team to work on the whole
face and permits optimal intra operative control of the status of dental occlusion, enabling the surgeons
to deliver a better quality patient care if used in appropriate cases. (14,15,16,17,18) The median
approach has two advantages as this area has only a few anatomic structures with minimum risk of nerve
or vascular damage and also, the scar is less visible behind the mental symphisis.
Complications
Accidental extubation predisposes to aspiration, especially in children. Bleeding from the incision site
usually responds to pressure. Compression and deviation of the tube can result in increased airway
pressure during surgical maneuver. If there is difficulty in passing the tube through submental incision
and reestablishing connection is delayed, transient desaturation can occur. Instances of superficial
infection, abscess, sepsis, damage to the lingual nerve, hypertrophic scar, and mucocele have been
reported. Trauma to submandibular and sublingual gland and ducts and salivary fistula have been
described. The postoperative period may be complicated by airway edema, obstruction, hematoma, that
may necessitate reexploration. Accidental detachment of the pilot balloon while converting the
submental intubation to an orotracheal one is a possibility.
Contraindications to SMI are patients' refusal, bleeding diathesis, laryngotracheal disruption, infection at
the proposed site, gunshot injuries in the maxillofacial region, long-term airway maintenance, tumor
ablation in maxillofacial region, and history of keloid formation, associated severe neurological damage
or major thoracic trauma, and patients who may to need repeated surgeries.

Figure 1: Lateral view of Submental

Figure 2: Submental intubation

Converting oral to Submental intubation

Table 1
Demographic Data and Clinical Details
Age Sex Diagnosis
23
29
19
28
38

M
M
M
M
M

LeFort II NOE*
LeFort II NOE*
LeFort II NOE*
LeFort II NOE*
LeFort II NOE*

SMI
Incision
Paramedian
Paramedian
Paramedian
Paramedian
Paramedian

19
22
22
26
22

F
F
F
F
F

Class 1 Bimaxillary protrusion

Vertical Maxillary Excess
Vertical Maxillary Excess
Class 1 Bimaxillary protrusion
Class 1 Bimaxillary protrusion

Median
Paramedian
Paramedian
Paramedian
Paramedian

*NOE=Naso-orbit-ethmoidal.
@SMI- Submental intubation

Complications Complications
Time taken
Intraoperative Postoperative
for SMI@
Nil
Nil
6 min
Nil
Mild wound infection 7 min
Nil
Nil
5 min
Nil
Mild wound infection 8 min
Pilot balloon
Nil
6 min
rupture
Nil
Nil
5 min
Nil
Nil
7 min
Nil
Nil
5 min
Nil
Nil
6 min
Nil
Nil
6 min

Scar
Good
Good
Good
Good
Good
Good
Good
Good
Good
Good

Conclusions
Some precautions must be considered to make submental endotracheal intubation a successful technique
with minimal morbidity. At every step, good communication between the surgeon and the
anaesthesiologist is mandatory. Initial management of the airway of patients with facial trauma can be
challenging. Submental intubation is always a second step after the airway has been secured. During the
submental intubation procedure, the endotracheal tube must be firmly secured intraorally to prevent
accidental extubation. To avoid injuries to the salivary glands and ducts, blunt dissection with the
haemostat clamp must run in close approximation to the medial border of the mandible. It demands a
certain surgical skill without specialized equipments and is safe and quick to execute and presents a low
incidence of operative and postoperative complications and eliminates the risks and side effects of
tracheotomy. (19)
Submental orotracheal intubation is particularly indicated for airway management of craniomaxillofacial
traumas and during transfacial approaches to the cranial base. It avoids the complications associated
with tracheostomy. It also permits considerable downward retraction of the maxilla after a Le Fort I
osteotomy and is associated with good clival exposure. Furthermore, it does not interfere with
maxillomandibular fixation at the end of the surgery.

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