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CASE REPORT
Year : 2011  |  Volume : 14  |  Issue : 1  |  Page : 98-101

Submental / Transmylohyoid intubation in maxillofacial surgery: Report of two cases


1 Department of Oral and Maxillofacial Surgery, Faculty of Dental Sciences, College of Medicine, University of Lagos, Nigeria
2 Department of Anaesthesia, Faculty of Clinical Sciences, College of Medicine, University of Lagos, Nigeria

Date of Acceptance16-Feb-2011
Date of Web Publication11-Apr-2011

Correspondence Address:
W L Adeyemo
Department of Oral and Maxillofacial Surgery, Faculty of Dental Sciences, College of Medicine, University of Lagos, Nigeria, P. M. B. 12003, Lagos
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1119-3077.79266

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   Abstract 

The submental / transmylohyoid intubation technique, as an alternative technique of airway management in oral and maxillofacial surgery, and its modifications, have been widely reported in the literature since it was first described by Altemir in 1986. However, the technique is not yet popular in Nigeria and Africa in general. A report of two cases in which this technique was used in orofacial reconstruction is presented here. The surgical / anesthetic outcome was satisfactory. No complication was seen in the two cases, and healing of the submental wound was uneventful. Submental intubation is a reliable technique of alternative airway management in oral and maxillofacial surgery. The submental / transmylohyoid technique should be considered by both the anesthetist and the maxillofacial surgeon in challenging cases, where an alternative airway technique is required for maxillofacial surgery.

Keywords: Intubation, submental, technique


How to cite this article:
Adeyemo W L, Ogunlewe M O, Desalu I, Akanmu O N, Ladeinde A L. Submental / Transmylohyoid intubation in maxillofacial surgery: Report of two cases. Niger J Clin Pract 2011;14:98-101

How to cite this URL:
Adeyemo W L, Ogunlewe M O, Desalu I, Akanmu O N, Ladeinde A L. Submental / Transmylohyoid intubation in maxillofacial surgery: Report of two cases. Niger J Clin Pract [serial online] 2011 [cited 2019 May 19];14:98-101. Available from: http://www.njcponline.com/text.asp?2011/14/1/98/79266


   Introduction Top


Oral and maxillofacial surgical procedures present a unique set of problems both for the surgeon and the anesthetist. [1],[2] Achieving dental occlusion is one of the fundamental aims of most oromaxillofacial procedures. Oral intubation precludes this surgical prerequisite of checking dental occlusion. In other instances, oral intubation is a nuisance in some procedures in oromaxillofacial surgery and skull base surgery. [1],[2],[3],[4] Nasotracheal intubation is contraindicated in nasal fractures, midfacial fractures and panfacial factures, and other pathologies involving the nose. [3],[4] Conventional tracheostomy, as an alternative method of airway management in maxillofacial surgery, has many inherent complications. [5],[7]

The technique of submental / transmylohyoid intubation as an alternative airway to orotracheal / nasotracheal intubations and tracheostomy was first described by Altemir in 1986. [8] The technique consisted of diverting the proximal end of an orotracheal tube through the floor of the mouth and submental region. [9] Since 1986, the technique has undergone various modifications and found new indications. [2],[3],[4]

The use of this intubation technique in oral and maxillofacial surgery has not been reported in Nigeria. A report of two cases in which this technique was used in orofacial reconstruction is presented.


   Case Reports Top


Case 1

A 22-year-old man was planned for surgical closure of an oronasal fistula [Figure 1]a with a tongue flap, under general anesthesia. Nasotracheal intubation was not possible due to a lack of patency of the nasal cavity, as a result of previous surgical reconstruction of a nasal defect [Figure 1]b. Orotracheal intubation was also avoided due to the fact that there would be a need to place a maxilla-mandibular fixation after the tongue flap placement, to prevent excessive mobility of the tongue during healing. The submental intubation technique rather than tracheostomy was opted for, after discussion with the anesthetist.

Submental technique

The airway was secured through orotracheal intubation [Figure 1]c. A 2 cm long skin incision was made midway between the angle of the mandible and the symphysis, just medial to the lower border of the mandible (paramedian incision). With blunt dissection, an orocutaneous connection (extra-periosteal) large enough to allow the passage of the endotracheal tube was created. A hemostat was introduced into the oral cavity through the skin incision; the endotracheal tube was disconnected from the anesthesia machine and the open end of the tube was covered with a nylon tube sac, which was held with the hemostat, and pulled through the wound extraorally while securing the tube, to prevent accidental extubation. The tube was then secured in place with sutures [Figure 1]d. The procedure was successfully carried out, and extubation (done immediately after surgery) through the submental route was uneventful. Healing of the submental wound was uneventful [Figure 1]e. No postoperative complication was seen.
Figure 1: (a)Oronasal fistula in a 22-year-old man
Figure 1b : Frontal view of patient in 1a with complete obliteration of the nostrils
Figure 1c : Securing of airway was done by orotracheal intubation
Figure 1d : Submental intubation (paramedian) in place before surgical repair
Figure 1e : Submental surgical wound before suture removal


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Case 2

A 10-year old boy presented with post cancrum oris defects affecting the left side of his upper lip, floor of the nose, and commissure [Figure 2]a. The associated defects included collapse of the right and left alae of the nose. The patient was planned for surgical reconstruction of the defects under general anesthesia. Nasotracheal intubation was not possible due to collapse of the alae of the nose, and orotracheal intubation was also jettisoned, due to the possibility of disruption of the surgical wound during recovery and extubation. The submental intubation technique rather than tracheostomy was opted for after discussion with the anesthetist. The procedure was successfully carried out using the submental intubation technique [Figure 2]b. The procedure was essentially the same as that of Case 1, except that a midline rather than paramedian incision was made [Figure 2]c. Extubation was done immediately after surgery. No postoperative complication associated with submental technique was recorded.
Figure 2: (a)A 10-year-old boy with orofacial defects due to can­crum oris
Figure 2b : Submental intubation (midline) in place
Figure 2c : Suturing of submental incision wound after successful extubation


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   Discussion Top


The technique of submental intubation was first described by Altemir in 1986. [1] Indications for submental intubation included midfacial and panfacial fractures, with skull base involvement, orthognathic surgery, facial aesthetic surgery, and rhinoplasty. [5],[6],[7] In the present case series, the reason for preference of the submental technique in the first case was that there would be a need to place a maxillomandibular fixation after the tongue flap placement, to prevent excessive mobility of the tongue during healing. This would not have been possible intraoperatively if the orotracheal intubation technique was used. Collapse of the alae of the nose (difficult nasal intubation), and the possibility of disruption of the surgical wound by the orotracheal tube during recovery and extubation, were the reasons for the choice of submental intubation in the second case.

The technique of submental intubation was found to be a suitable alternative in both cases. The alternative technique in these cases would have been tracheostomy. An advantage of submental intubation over tracheostomy was the fact that extubation was done immediately after the operation, avoiding the stress of care for the in-situ tracheostomy tube during the postoperative period. With this technique other possible complications of tracheostomy were avoided. The possible complications included: tracheal stenosis, internal emphysema, damage to the laryngeal nerves, tracheoesophageal fistula, and scarring. [5],[6],[7]

The submental route for endotracheal intubation represents a fast and low-morbidity alternative to tracheostomy. [10] The submental intubation procedure requires no more than five minutes to perform. [10] The technique is very easy, and the risk of damage to structures such as the sublingual and submaxillary glands, Wharton's duct, and the lingual nerve is very low. [11] In fact, these major complications have never been reported. [11] Attention to the technical details of the technique and careful blunt dissection close to the medial border of the mandible and a good knowledge of the anatomy can help avoid damage to the structures of the floor of the mouth. [11]

There are many modifications to the original technique described by Altemier regarding the placement of the skin incision. [8],[10],[12] The skin incision can be placed midway between the angle of the mandible and the symphysis and just medial to the lower border of the mandible or one-third of the way from the symphysis to the angle of the mandible (paramedian incision) or in the midline region behind the lower border of the mandible (midline incision). [4],[10],[12] In the present series, the incision was placed midway between the angle of the mandible and the symphysis in the first case, whereas, in the second case, the incision was placed in the midline region, behind the lower border of the mandible. Risks to the lingual nerve, submandibular duct, sublingual gland, and submental vessels were possible with the paramedian incision; therefore, the need to stay close to the lingual surface of the mandible, in order to avoid damaging these structures, has been suggested. [12] Excessive bleeding that may be encountered with the paramedian incision is usually avoided with the midline incision. [12] The relatively avascular plane between the two bellies of mylohyoid and the anterior bellies of the digastric has been suggested as another advantage of the midline technique. [13] The midline incision heals imperceptibly and is therefore suggested to be cosmetically superior. [14]

Although, this technique is termed and known as the submental intubation technique, some authors have suggested that the terminology transmylohyoid intubation seems more appropriate to use than submental intubation, as the passage of the tube is through the mylohyoid muscle. [15],[16] The term 'transmylohyoid' denotes that the incision can be made anywhere from the first mandibular molar on one side to the first mandibular molar on the other side. [15],[16]

Altemir in his original report suggested the creation of the subperiosteal passage for the tube in the lingual surface of the mandible. [8] However; others have suggested an extraperiosteal approach for the passage of the tube. [11] The extraperiosteal approach was employed in the two cases in this series.

It has been suggested that the tube be tightly secured after exterioration, to avoid accidental extubation. [13] In the present series, the tubes were firmly secured in place with a 1 / 0 silk suture. In addition, after normal orotracheal intubation, the tube had to be firmly secured intraorally to prevent accidental extubation during the submental procedure.

Submental intubation is contraindicated where more long-term control of the airway is required, for example, gun shot injuries. [12],[13],[14] Other possible contraindications are infection at the site of the incision and bleeding diathesis. [12],[13],[14]

No complication was recorded in the two cases presented. No episode of accidental extubation, leaking cuff, submental orotracheal fistulae or anomalous scars was seen in the two cases. Complications after submental intubation were rare. [10],[11],[12] These could include submental infection, orotracheal fistula, accidental extubation, and submental scarring. [11],[13] Sharma et al,[13] reported a complication rate of 10% in a series 20 patients who underwent submental intubation. These included wound infection and partial extubation. [13] Nyarady et al, [17] reported no complication in a series of 13 patients who underwent submental intubation for orthognathic surgery.


   Conclusions Top


Submental intubation is a reliable method of alternative airway management in oral and maxillofacial surgery. The technique demands a surgical skill, but it is simple, safe and quick to perform. The technique presents a low incidence of operative and postoperative complications and eliminates the risks and side effects of tracheostomy. This technique should be considered by both the anesthetist and the maxillofacial surgeon in challenging cases, where an alternative airway technique is required, in maxillofacial surgery.

 
   References Top

1.Nwoku AL, Al-Balawi SA, Al-Zahrani SA. A modified method of submental oroendotracheal intubation. Saudi Med J 2002;23:73-6.  Back to cited text no. 1
[PUBMED]    
2.Green JD, Moore UJ. A modification of sub-mental intubation. Br J Anaesthesia 1996;77:789-91.  Back to cited text no. 2
    
3.Bale DR, Clark M, Jefferson P, Stewart T. Improved submental intubation. Anaesthesia 2003;58:189.  Back to cited text no. 3
    
4.Maclnnis E, Baig M. A modified submental approach for oral endotracheal intubation. Int J Oral Maxillofac Surg 1999;28:344-6.  Back to cited text no. 4
    
5.Al-Samir M, Mitchell I, Drummond DS, Bjornson C. Tracheostomy in children: A populations-based experience over 17 years. Pediatr Pulmonol 2010;45:487-93.  Back to cited text no. 5
    
6.Chew JY, Cantrell RW. Tracheostomy, complications and their management. Arch Otolaryngol 1972;96:538-45.  Back to cited text no. 6
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7.Callahan V, O Connor AF. Adult and pediatric tracheostomy- technique, complications and alternatives. Curr Pract Surg 1994;6:219-22.  Back to cited text no. 7
    
8.Altemir FH. The submental route for endotracheal intubation. J Maxillofac Surg 1986;14:64-5.  Back to cited text no. 8
    
9.Caubi AF, Vasconcelos BC, Vasconcelos RJ, de Morais HH, Rocha NS. Submental intubation oral and maxillofacial surgery. Review of the literature and analysis of 13 cases. Med Oral Patol Oral Cir Buccal 2008;13:E197-200.  Back to cited text no. 9
    
10.Paetikau D, Strand M, Onc B. Submental orotracheal intubation for maxillofacial surgery. Anesthesiology 2000;92:912-4.  Back to cited text no. 10
    
11.Biglioli F, Mortini P, Goisis M, Bardazzi A, Boari N. Submental orotracheal intubation: An alternative to tracheostomy in transfacial cranial base surgery. Skull Base 2003;13:189-95.  Back to cited text no. 11
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12.Amin M, Dill-Rusell P, Manisali M, Lee R, Sintoi I. Facial fractures and submental intubation. Anaesthesia 2002;57:1195-212.  Back to cited text no. 12
    
13.Sharma RK, Tuli P, Cyriac C, Parashar A, Makkar S. Submental tracheal intubation in oromaxillofacial surgery. Indian J Plast Surg 2008;41:15-9.  Back to cited text no. 13
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14.Davis C. Submental intubation in complex craniomaxillofacial trauma. ANZ J Surg 2004;74:379-81.  Back to cited text no. 14
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15.Gadre KS, Kushte D.Transmylohyoid oroendotracheal intubation: A novel method. J Craniofac Surg 1992;3:39-40.  Back to cited text no. 15
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16.Gadre KS, Waknis PP. Transmylohyoid/submental intubation: Review, analysis and refinement. J Craniofac Surg 2010;21:516-9.  Back to cited text no. 16
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17.Nyarady Z, Sari F, Olasz S, Nyarady J. Submental endotracheal intubation in concurrent orthognathic surgery: A technical note. J Craniomaxillofac Surg 2006;34:362-5.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2]


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