Szantyr, Aleksandra

Szuta, Mariusz

Zapała, Jan

English

Jagiellonian Univeristy Repository

FOLIA MEDICA CRACOVIENSIAVol. LVI, 3, 2016: 79–85PL ISSN 0015-5616Airway management using submental intubation in head and neck surgeryAleksandra Szantyr1, Mariusz Szuta1, Jan Zapała11Department of Cranio-Maxillofacial, Oncological and Reconstructive Surgery,  Jagiellonian University Medical College, Ludwik Rydygier Memorial Specialized Hospital, Kraków, PolandCorresponding author: Aleksandra Szantyr, Department of Cranio-MaxillofacialOncological and Reconstructive SurgeryJagiellonian University Medical College, Kraków, Polandos. Złotej Jesieni 1, 31-826 Kraków, PolandPhone: +48 12 646 85 39, Fax: +48 12 646 88 36; E-mail: ola_sz@op.plAbstract: In 1995 the fi rst tracheosubmental intubation (TSI) in Poland was performed in the Clinic and De-partment of Cranio-Maxillofacial Surgery at Jagiellonian University Medical College in Kraków. Our 20 years of experience with using TSI in the fi eld of cranio-maxillofacial surgery, with 316 successfully performed intu-bations, resulted in one of the largest bodies of material analysed in the literature so far. Th e aim of this study was to evaluate the effi  cacy and complications of TSI in the fi eld of cranio-maxillofacial surgery in patients where orotracheal or nasotracheal intubation is contraindicated and tracheostomy can be avoided. To fulfi l this objective we present our own experience with the use of TSI in the fi eld of cranio-maxillofacial surgery. Th is retrospective study included 316 patients who were operated on with general anaesthesia via TSI in the Department of Cranio-Maxillofacial Surgery, Jagiellonian University Medical College, Kraków, from 1995 to 2014 (20 years). Indications for TSI were as follows: multifragmentaric fractures of the bones of mid- and lower face in 262 patients (82.9%), simultaneous osteotomies of the maxilla and mandible due to mandibular prognathism with maxillary compression in 62 patients (19.6%), extensive facial cancer infi ltrating both the nose and lips in 4 patients (1.2%) and posttraumatic deformities of the nose and jaws in 4 patients (1.2%). In all 316 patients TSI was successfully performed and proved to be the optimal method of airway management, providing a comfortable surgical approach with the operating fi eld free from an intubation tube. Complica-tions were observed in 12 patients (3.8%) and included wound infection in 7 patients (2.21%), transitory sali-vary fi stula in 3 patients (0.95%), and hypertrophic scarring in 2 patients (0.63%). TSI is considered to be a safe and simple technique of intubation, which makes it possible to to avoid tracheotomy complications when it is diffi  cult or impossible to perform orotracheal or nasotracheal intubation. TSI facilitates the simultaneous performance of complex procedures, including both mid-face and lower face correction, in a one-step proce-dure, providing complete intraoperative control of the occlusion as well as facial symmetry.80 Aleksandra Szantyr, Mariusz Szuta, et al.Key words: panfacial trauma, submental intubation, airway management, maxillofacial injuries, orthog-nathic surgery.IntroductionTh ere are certain clinical situations in the fi eld of head and neck surgery which make general anaesthesia via oro- or nasotracheal intubation signifi cantly inconvenient or even impossible to perform. In such cases, an elective short-term tracheotomy or tra-cheosubmental intubation (TSI) is indicated. Th e latter is considered to be less inva-sive and associated with a lower complication rate than a tracheotomy [1, 2].Th e submental route for endotracheal intubation was fi rst described by Francisco Hernandez Altemir in 1986 [3]. From the first introduction of TSI by Altemir, indications for this method of airway management on general anaesthesia have considerably increased.Currently, the use of TSI include:— in traumatology: patients with panfacial fractures who require reduction and osteosynthesis of the fractured bones of the midface, nose and/or mandible with simultaneous control of the occlusion— in aesthetic and reconstructive surgery: simultaneous performance of nose and lips correction or reconstruction, facelift , rhynoplasty— in orthognathic surgery: simultaneous osteotomies of the maxilla and mandible— selected oncological patients: tumours infi ltrating both nose and lips— cranial base oncological surgery, including transfacial approaches to the cranial base [4, 5].Possible complications of TSI include dislocation of endotracheal tube and unplanned extubation (especially in paediatric surgery), lingual nerve injury, Wharton’s duct or submandibular salivary gland injury, excessive bleeding, wound infection, salivary fi stula, keloid or hypertrophic scarring [5–7].Inflammatory and neoplastic infiltrations of the floor of the mouth and submandibular region and temporomandibular ankylosis are local contraindications to TSI. Th is method of intubation is also contraindicated in patients with coagulopathies and tendency to keloid or hypertrophic scar formation. Additionally, TSI is not performed when prolonged ventilation is expected (>72 hours) or in case of lack of patient consent for this procedure [1, 3, 5, 7, 8]. Airway management using submental intubation in head and neck surgery 81Aim of the studyTh e aim of this study was to evaluate the effi  cacy and complications of TSI in the fi eld of cranio-maxillofacial surgery in patients where orotracheal or nasotracheal intuba-tion is contraindicated and tracheostomy can be avoided. To fulfi l this objective we present our own experience with the use of TSI in the fi eld of cranio-maxillofacial surgery.Matherial and methodsMedical documentation of patients hospitalized in the Department of Cranio-Max-illofacial Surgery, Jagiellonian University Medical College, Kraków was analysed to select the study group. We included patients who were operated on with general anaesthesia via tracheosubmental intubation. From 1995 to 2014 (20 years) 316 pa-tients (100%) were operated on with general anaesthesia via TSI in the Department of Cranio-Maxillofacial Surgery, Jagiellonian University Medical College, Kraków: 249 men (78.8%) and 67 women (21.2%), aged from 6 to 72 years (32 years on aver-age). Th e analysed variables were as follows: age, sex, indication for TSI, intraopera-tive and postoperative complications, need of post-operative ventilation, duration of the post-operative ventilation.ResultsIndications for TSI were as follows: multifragmentaric fractures of the bones of mid- and lower face in 262 patients (82.9%), simultaneous osteotomies of the maxilla and mandible due to mandibular prognathism with maxillary compres-sion in 62 patients (19.6%), extensive facial cancer infi ltrating both the nose and lips in 4 patients (1.2%) and posttraumatic deformities of the nose and jaws in 4 patients (1.2%).Table 1. Indications for tracheosubmental intubation in 316 patients.Multifragmentaric fractures of the facial skeletonSimultaneous osteotomies of the maxilla and mandible (orthognathic surgery)Extensive facial cancer infi ltrating both the nose and lipsOther (posttraumatic deformities of the nose and jaws)Total number of patients262 (82.9%) 62 (19.6%) 14 (4.4%) 4 (1.2%) 316 (100%)82 Aleksandra Szantyr, Mariusz Szuta, et al.Operative procedureTracheosubmental intubation follows orotracheal intubation with a  reinforced airtight tube with the use of a  laryngoscope or a fi beroscope. Aft er skin decontamination with a  coloured antiseptic (e.g. 10% povidone-iodine solution), a  horizontal 1.5 cm line in the place of the planned skin incision is marked in the midline of the submandibular fold. Incision of the skin, performed with blade no. 15, is followed by blunt dissection of the tissues of the sumbandibular triangle including mylohyoid, geniohyoid, and gen-ioglossal muscles into the oral cavity, behind the lower incisors, posteriorly to the sub-lingual caruncle. Incision of the oral mucosa is made laterally from the frenulum of the tongue. First the cuff  and then the tube are inserted through the formed channel. Th e tube is then sutured to the skin with Nylon 3.0, which stabilizes the tube, with addi-tional fi xation by the muscles of the fl oor of the mouth. When the surgery is completed, the tube together with the cuff  is passed back into the oral cavity (unless longer intuba-tion is required, TSI may be prolonged safely for 72  hours). Extubation is conducted routinely. Th e skin wound is closed with Nylon 5.0 using layered closure technique. Th e oral mucosa is closed with Nylon 4.0. During the postoperative period perfect oral hy-giene must be kept (including the use of 0.12% chlorhexidine oral rinse every 6 hours) as well as daily submandibular skin wound cleansing and disinfection. Skin sutures are removed aft er 7 days, and intraoral sutures — 10 days aft er the  surgery.In all 316 patients TSI was successfully performed. It proved to be a very useful technique, providing a  comfortable surgical approach with the operating fi eld free from an intubation tube, complete intraoperative control off  the occlusion as well as facial symmetry. Th e scar in the submental area was hidden in the submental fold and aesthetically well accepted by all patients, apart from two patients with hypertrophic scarring. In fi ve patients with extensive facial trauma prolonged TSI enabled artifi cial and controlled ventilation (in 4 patients up to 48 hours and in one patient to up 72 hours) in the Intensive Care Unit without performing a tracheotomy. Complications were observed in 12 patients (3.8%) and included wound infection in 7 patients (2.21%), transitory salivary fi stula in 3 patients (0.95%), and hypertrophic scarring in 2 patients (0.63%) (Table 2).Table 2. Complications of tracheosubmental intubation in 316 patients.Complication Number of patients (%)Wound infection  7 (2.21%)Salivary fi stula  3 (0.95%)Hypertrophic scar  2 (0.63%)Total number of patients 12 (3.80%) Airway management using submental intubation in head and neck surgery 83DiscussionTh e choice of the best method of intubation to provide general anaesthesia for patients operated on in the fi eld of cranio-maxillofacial surgery is particularly challenging due to the fact that the operating fi eld for both the surgeon and the anesthesiologist overlap. Another reason that makes airway management diffi  cult, is that some clinical situations make orotracheal or nasotracheal intubation diffi  cult or impossible to perform [3, 9]. Orotracheal intubation doesn’t allow control of the occlusion (necessary in traumatology and orthognathic surgery), and impairs assessment of the symmetry of the face. Nasotracheal intubation tends to be diffi  cult or even impossible to perform in cases of nasal septum deviation or hypertrophy of nasal turbinates. Th is method of intubation may lead to transferring infection from the nose to the bronchial tree, retropharyngeal perforation, and additionally, in patients with maxillary fractures may lead to epidural infection [5, 10]. Other disadvantages of nasotracheal intubation include: poor tolerance of the tube when prolonged intubation is indicated, the risk of sores and subsequent secondary deformities of the nostril, and the possibility of damaging the tube during Le Fort I osteotomy of maxilla [3, 5]. Tracheotomy is associated with numerous general and local, early and late clinically important complications, it may also be diffi  cult to perform in children, obese patients, and patients with thyroid gland enlargement [11]. On the basis of the literature and our own experience, planned anaesthesia via tracheotomy should be considered as the last method to be chosen [3, 5, 6, 11]. Early local complications include bleeding, haemorrhage, subcutaneous or mediastinal emphysema, esophagotracheal fi stula, and laryngeal recurrent nerve palsy. Early general complications include cardiac arrest due to the stimulation of the vagus nerve, posthypercapnic shock as the result of a sudden decrease in carbon dioxide level, acute pulmonary edema without connection with circulatory disturbances, and aeroembolism [3, 5, 11]. A number of late complications have been recognized: laryngeal or tracheal stricture, haemorrhage from large blood vessels as the result of the decubitus of the vessel walls, extensive granulation and infl ammatory complications. Reported incidence of early complications of tracheotomy is 6–8%, and the incidence of late complications is 60% [12].According to the literature, the reported complication rate of TSI varies from 0.24% to 7.13% [13]. Table 3 depicts the incidence of complications relating to TSI representing 842 patients from 41 articles published between 1984 and 2011 [13].Since the fi rst introduction of TSI by Altemir in 1986, several modifi cations of the previous technique have been proposed in order to improve outcomes and to minimise the risk of complications [5, 9, 10]. In Altemir’s original technique the tube was inserted in the submandibular area which could harm important anatomical structures in the mentioned region (facial vein and artery, submandibular salivary gland, lingual nerve, sublingual nerve).84 Aleksandra Szantyr, Mariusz Szuta, et al.Table 3. Complications of tracheosubmental intubation in 842 patients — a  literature review (1984–2011) [13].Complication Number of patients (%)Wound infection 23 (2.7%)Damage of the tracheal tube 10 (1.1%)Salivary fi stula 10 (1.1%)Hypertrophic scar  3 (0.4%)Unplanned extubation  2 (0.3%)Lingual nerve paresis  1 (0.1%)Extensive bleeding  2 (0.3%)Mucocele  1 (0.1%)J.F. Hönig from Göttingen in 1993 modifi ed the TSI technique by relocating the insertion point of the endotracheal tube into the submental triangle [10]. On the basis of the review of the literature concerning TSI from the last 30 years, the majority of technique alterations involve passing the tube through the mylohyoid muscle. Gadre and Waknis proposed “transmylohyoid” as more adequate terminology, as in this technique the tube can be inserted through the mylohyoid muscle anywhere between the fi rst mandibular molars of either side anterior to the massetor muscle, instead of being limited to the submental triangle [14].Most authors agree that subperiosteal tube placement, originally proposed by Altemir, is not necessary. Midline insertion of the endotracheal tube decreases the risk of bleeding and enables easier tube location [14]. Some authors suggest the use of two endotracheal tubes — one conventional for orotracheal intubation, and the second one armoured. Th e latter is inserted through the submental skin incision. Th e conventional oro-tracheal tube is then replaced with the armoured one. Th e advantage of this technique is limiting the risk of the hypoxia during the intubation procedure, but concurrently this manoeuvre may result in introduction of the infection into the lower respiratory tract [7, 15].A trend of increasing attention on the subject of TSI can be observed over the last 30 years. Nearly 90% of the publications regarding this way of intubation have ap-peared in PubMed in the last decade. Nevertheless, most retrospective studies investi-gating outcomes and complications of TSI include only relatively small study groups. According to the literature review [13], from 1984 to 2011 (25 years) 41 papers have been published on this topic, which altogether analysed 842 patients (on average 20.5 patient per one publication). Considering this, our 20 year experience with the use of TSI in the fi eld of cranio- and maxillofacial surgery, with 316 successfully performed  Airway management using submental intubation in head and neck surgery 85intubations, comprises one of the largest bodies of material analysed in the literature so far.ConclusionsTSI is considered to be a  safe and simple technique of intubation, which makes it possible to avoid tracheotomy complications when it is diffi  cult or impossible to perform orotracheal or nasotracheal intubation. In the fi eld of aesthetic, plastic and reconstructive surgery this technique allows operation in the fi eld free from an in-tubation tube, with the possibility of full control of facial symmetry. Th erefore, TSI facilitates the simultaneous performance of complex procedures including both mid-face and lower face correction in a one-step procedure. In addition, if prolonged intu-bation is required, the tube may be left  in place for 72 hours. TSI is the best solution for general anaesthesia in patients with multi- and comminuted fractures of the facial skeleton (simultaneous fractures of the mid- and lower face) and in patients requir-ing orthognatic surgery, providing complete intraoperative control of occlusion with proper protection of the airway. It is also useful in surgical oncology, allowing abla-tion and reconstruction in patients with tumours infi ltrating the region of the nose and lips.Confl ict of interestNone declared.References 1.  Diaz Martinez J.C., Diaz Martinez A.M., Hinojosa Jimenez A., Narvaez de Linares A., Yañez Vilas J.I., Carmona Aurioles J.: Submental intubation: an alternative to tracheostomy when orotracheal and nasotracheal intubation are contraindicated and long-termi intubation is not required. European Journal of Anaesthesiology. 2013 June; 30: 255–265. 2.  Thorne C.H. (ed.): Grabb and Smith’s Plastic Surgery, Seventh Edition, Lippincott Williams & Wilkins, Philadelphia 2014. 3.  Hernandez Altemir F.: The submental route for endotracheal intubation. A new technique. J Maxillofac Surg. 1986 Feb; 14 (1): 64–65. 4.  Johnson T.R.: Submental versus tracheostomy. Br J Anaesth. 2002; 89: 344–345. 5.  Bartkowski S.B., Zapała J., Kurek M., Szuta M., Kuchta K., Witkowski R.: Intubacja tchawiczo-podbródkowa jako nowy sposób znieczulenia ogólnego. Pol Prz Chir. 2001: 73 (6): 521–528. 6.  Das S., Das T.P., Ghosh P.S.: Submental intubation: A journey over the last 25 years. J Anaesthesiol Clin Pharmacol 2012; 28: 291–303. 7.  Paetkau D.J.: Submental orotracheal intubation for maxillofacial surgery. Anesthesiology. 2000; 92: 912. 8.  Arya V.K., Kumar A., Makkar S.S., Sharma R.K.: Retrograde submental intubation by pharyngeal loop technique in a  patient with faciomaxillary trauma and restricted mouth opening. Anesth Analg. 2005; 100: 534–537.86 Aleksandra Szantyr, Mariusz Szuta, et al. 9.  Hernandez Altemir F.: Conversion from nasotracheal intubation to orotracheal. J Cran Max Fac Surg. 1998; 26: 7.10.  Anwer H.M., Zeitoum I.M., Shehata E.A.: Submandibular approach for tracheal intubation in patients with panfacial fractures. Br J Anaesth. 2007; 98: 835–840.11.  Durbin C.G. Jr.: Early complications of tracheostomy. Respir Care. 2005; 50: 511–515.12.  Caron G., Paquin R., Lessard M.R., Trepanier C.A., Landry P.E.: Submental endotracheal intubation: An alternative to tracheotomy in patients with midfacial and panfacial fractures. J Trauma Inj Infect Crit Care. 2000; 48: 235–240.13.  Jundt J.S.: Submental intubation: a  literature review. Int J Oral Maxillofac Surg. 2012 Jan; 41 (1): 46–54.14.  MacInnis E., Baig M.: A modifi ed submental approach to oral endotracheal intubation. Int J Oral Maxillofac Surg. 1999; 28: 269–272.15.  Mak P.H., Ooi R.G.: Submental intubation in a  patient with betathalassaemia major undergoing elective maxillary and mandibular osteotomies. Br J Anaesth. 2002; 88: 288–291.

Airway management using submental intubation in head and neck surgery

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Airway management using submental intubation in head and neck surgery

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