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Journal of Cranio-Maxillofacial Surgery (2006) 34, 362365 r 2006 European Association for Cranio-Maxillofacial Surgery doi:10.1016/j.jcms.2006.04.003, available online at http://www.sciencedirect.com

Submental endotracheal intubation in concurrent orthognathic surgery: A technical note

Zoltan NYARADY1, Ferenc SARI2, Lajos OLASZ1, Jozsef NYARADY3 , Department of Dentistry, Oral and Maxillofacial Surgery (Head: by. Szabo DMD, PhD); 2Department of r, Anaesthesiology and Intensive Care (Head: Prof. L. Boga MD, PhD); 3Department of Traumatology and Hand ra cs, cs, Surgery (Head: Prof. J. Nya dy, MD, PhD), University Pe Pe Hungary
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SUMMARY. Introduction: Achieving the necessary occlusion for orthognathic surgery is not possible with conventional oral intubation since the tube interferes with the occluding teeth. Sometimes nasotracheal intubation is impossible due to developmental malformations requiring repair. Also, the oral or nasotracheal tube may interfere with the operation or may be damaged during the procedure. In 1986, Hernandez Altemir described a method of submental endotracheal intubation. His intentions were to avoid tracheostomy in maxillofacial trauma cases where short-term intermaxillary xation was required. Patients: Between January 2000 and May 2003, 13 patients were operated on, using submental intubation. Eight of these (three females and ve males) had surgery for orthognathic malformations. Methods: The Hernandez Altemir technique was modied to ease the procedure: a sterile nylon guiding tube and the 222 rule incision were introduced. Eight cases with concurrent complex orthognathic surgery, using this modied technique are reported in this paper. Results: There were no operative or postoperative complications related to the procedure. Conclusion: The technique is easy to use, rapid and free of complications compared to alternative intubation methods (tracheostomy, retromolar location of tube, etc.). Submental scarring is acceptable. It is recommended for orthognathic procedures in selected cases. r 2006 European Association for Cranio-Maxillofacial Surgery

Keywords: intubation; submental route; orthognathic surgery; nasal surgery; maxillary surgery

INTRODUCTION Conventional oral intubation precludes achieving the necessary occlusion in orthognathic surgery. The tube interferes with the occlusal checks when surgeons need to position the mandible and/or the maxilla intraoperatively. Nasotracheal intubation may be impossible in cases of developmental malformations (deviated nasal septum, narrow or twisted nasal canal, obstructive mucosal swelling or polyposis of the nasal cavity) which themselves require repair. The use of alternative intubation methods such as tracheostomy, cricothyro(ido)tomy or retromolar location of the tube is preferally avoided in elective cases, due to the high rate of morbidity, aesthetic and/or functional compromise (Taicher et al., 1996; Martinez-Lage et al., 1998; Johnson, 2000). In 1986 Hernandez Altemir described a method of submental endotracheal intubation. His intention was to avoid tracheostomy in maxillofacial trauma cases where short-term intermaxillary xation was required. His method has since received wide acceptance for facial trauma cases (ManganelloSouza et al., 1998; Amin et al., 2003; Hernandez Altemir and Hernandez Monotero, 2003; Meyer et al., 2003). We wish to describe our experiences with a
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slightly modied version of his method in orthora gnathic surgery (Nya dy et al., 2004). PATIENTS Between January 2000 and May 2003, 13 patients were operated on using submental intubation. Eight (three females and ve males) were elective orthognathic cases. This method was selected when nasal intubation was impossible and/or simultaneous nasal reconstruction was to be performed. The average age was 20.4 years (min 18, max 23). In four cases a Le Fort I osteotomy in conjunction with ObwegeserDal Pont sagittal split osteotomy was performed, in two cases only a Le Fort I osteotomy, in one case posterior maxillary osteotomy, in one case an ObwegeserDal Pont and in one case a sagittal split osteotomy was combined with bone grafting for an oro-nasal defect (Table 1). SUBMENTAL INTUBATION After intravenous induction of anaesthesia, traditional orotracheal intubation and insertion of a throat pack was performed. Anaesthesia was maintained with a mixture of oxygen, nitrous oxide and

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Submental endotracheal intubation in concurrent orthognathic surgery 363 Table 1 Patients No. 1 2 3 4 5 6 7 8 Sex M M F M F M F M Age (years) 21.1 23.5 18.1 19.4 19.3 20.8 20.6 20.2 Treatment Le Fort I osteotomy Distal maxillary osteotomy SSO+oro-nasal defect bone grafting Le Fort I+SSO Le Fort I+SSO SSO Le Fort I+SSO Le Fort I+SSO

M, male; F, female; SSO, ObwegeserDal Pont sagittal split osteotomy.

the soft tissues of the oor of the oral cavity, as near to the mandible as possible. A sterile nylon tube was pulled through the submental tunnel by grasping it with the haemostat (Fig. 2), which was pushed back through the nylon guiding tube into the oral cavity (Fig. 3). The orotracheal tube was disconnected and pulled through the previously introduced nylon tube, reconnected and secured with a suture (Fig. 4). All operations could then be performed as planned, the occlusion checked with a prefabricated splint and intermaxillary xation. At the end of the operation the tube was disconnected, pulled back into the oral cavity and reconnected. Extraorally the wound was sutured and the patients were extubated.

RESULTS The intubation never interfered with the planned orthognathic operation. Intraoral manipulation was free in all procedures. The interdental occlusion could be easily checked. The introduction of the sterile nylon guiding tube made the pulling-through easier and reduced trauma to the soft tissues, when compared with earlier experiences. There was no inammation, poor scar formation and/or bleeding at the intubation site in any case. The wounds healed nicely. The patients accepted the remaining small submental scar.

Fig. 1 Moving the haemostat into the oral cavity to grasp the guiding tube through the 2-2-2 incision (2 cm long, 2 cm away from the centreline and 2 cm medial to the mandible).

DISCUSSION There are several submental intubation alternatives to the original Hernandez Altemir method (Bo and gi Incze, 1996; MacInnis and Baig, 1999; Drolet et al., 2000; Mahmood and Lello, 2002). Since 1986 Hernandez Altemir himself introduced modications to his original method (Hernandez Altemir and Hernandez Monotero, 2000, 2003). The submental intubation technique was widely recommended for midfacial trauma cases when short-term intermaxillary xation was needed (Manganello-Souza et al., 1998; Amin et al., 2003; Meyer et al., 2003). Despite the widespread use of submental intubation for other purposes, it was Bo and Incze in gi 1996 who recommended the use of submental intubation in elective osteotomies. MacInnis and Baig (1999) published a single elective case of simultaneous Le Fort III midface advancement and sagittal ramus osteotomy for mandibular setback. In 2002, Nwoku et al. described ten cases that were submentally intubated. Two of his cases were elective orthognathic ones. He also recommended submental intubation for facial aesthetic surgery. In the same year, Mak and Ooi (2002) also published a single case undergoing multiple osteotomies, when anatomical difculties made nasal intubation impossible. Koudstaal et al. (2002) published two orthognathic cases and Amin and

Fig. 2 Pulling the guiding nylon tube through the incision. The endotracheal tube is then easily pulled through the nylon tube.

sevourane in all cases. A 2 cm long incision was made 2 cm from the midline, 2 cm medial to and parallel with the mandible in the submental region 222 rule (Fig. 1). A haemostat was pushed through

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Fig. 3 Schematic view. Pulling the endotracheal tube by grasping it with a haemostat through the guiding nylon sac (legend: 1, guiding nylon tube; 2, haemostat; 3, intubation tube).

According to the experience with eight patients, the method is free of complications when compared to alternative intubation methods (Gordon and Tolstunov, 1995; Taicher et al., 1996; Martinez-Lage et al., 1998; Johnson, 2000). Whartons ducts, the facial artery, the marginal mandibular branch of the facial nerve and the submandibular glands are avoided. The genioglossus and geniohyoid muscles do not need to be crossed. Introduction of the nylon guiding tube decreases traumatization of the submental soft tissues. Reintubation as described by Drolet et al. (2000) becomes avoidable, thus further increasing safety. However, cooperation between surgeon and anaesthesiologist requires forward planning.

Fig. 4 The endotracheal tube submentally, prior to surgery.

CONCLUSION The technique described is fast, safe and easy to use. The complete procedure takes less than 4 min and disconnection time of the endotracheal tube is less than 10 s. This technique is recommended not only for trauma but also for carefully selected orthognathic cases.
ACKNOWLEDGEMENT

coworkers (2003) described 11 trauma and one Le Fort III maxillary advancement case. Those authors used minor modications of submental intubation. They all agree on the ease, safety and speed of the technique. In this department the original method was modied by introducing the 222 rule and a nylon guiding tube to make the procedure safer and easier. The nylon guiding tube decreases trauma to the submental soft tissues and facilitates the pulling through of the endotracheal tube. This method is recommended not only in trauma but also in elective orthognathic operations.

We thank our former colleague Ms. E. Pasztor for the introduction of the original Hernandez Altemir method to this department and Prof. G. Szabo for

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his motivating suggestions and kind review of the manuscript.

References
Amin M, Dill-Russel P, Manisali M, Lee R, Sinton I: Facial fractures and submental tracheal intubation. Anaesthesia 58: 496497, 2003 Bogi I, Incze F: Submental tube guiding in tracheal intubation (modied intubation method in panfacial multiple fractures). Fogorvosi Szemle 89: 36, 1996 Drolet P, Girard M, Poirier J, Grenier Y: Facilitating submental endotracheal intubation with an endotracheal tube exchanger. Anesth Analg 90: 222223, 2000 Gordon CN, Tolstunov L: Submental approach to oroendotracheal intubation in patients with midfacial fractures. Oral Surg Oral Med Oral Pathol 79: 269272, 1995 Hernandez Altemir F: The submental route for endotracheal intubation. J Maxillofac Surg 14: 6465, 1986 Hernandez Altemir F, Hernandez Monotero S: The submental route revisited using the laryngeal mask airway: a technical note. J Cranio-Maxillofac Surg 28: 343344, 2000 Hernandez Altemir F, Hernandez Monotero S: Combitube SA through submental route. A technical innovation. J CranioMaxillofac Surg 31: 257259, 2003 Johnson TR: Submental tracheal intubation versus tracheostomy. Br J Anaesth 89: 344345, 2000 Koudstaal MJ, van der Wal KG, Mallios C, Ruprecht J: Submental intubation: surgical and anesthesiological aspects. Ned Tijdschr Geneeskd 147: 199202, 2002 MacInnis E, Baig M: A modied submental approach for oral endotracheal intubation. Int J Oral Maxillofac Surg 28: 344346, 1999 Mahmood S, Lello GE: Oral endotracheal intubation: median submental (retrogenial) approach. J Oral Maxillofac Surg 60: 473474, 2002

Mak PH, Ooi RG: Submental intubation in a patient with betathalassaemia major undergoing elective maxillary and mandibular osteotomies. Br J Anaesth 88: 288291, 2002 Manganello-Souza LC, Tenorio-Cabezas N, Piccinini L: Submental method for orotracheal intubation in treating facial trauma. Rev Paul Med 116: 18291832, 1998 Martinez-Lage JL, Eslara JM, Cebrecos AI, Marcos O: Retromolar intubation. J Oral Maxillofac Surg 56: 302306, 1998 Meyer C, Valfrey J, Kjartansdottir T, Wilk A, Barriere P: Indication for and technical renements of submental intubation in oral and maxillofacial surgery. J CranioMaxillofac Surg 31: 383388, 2003 Nyarady Z, Sari F, Olasz L, Nyarady J: Modied submental endotracheal intubation in concurrent orthognathic surgery (case report) Mund-, Kiefer- und Gesichtschirurgie 8: 387389, 2004 Nwoku AL, Al-Balawi SA, Al-Zahrani SA: A modied method of submental oroendotracheal intubation. Saudi Med J 23: 7376, 2002 Taicher S, Givol N, Peleg M, Ardekian L: Changing indications for tracheostomy in maxillofacial trauma. J Oral Maxillofac Surg 54: 292295, 1996

` ` Zoltan NYARADY, MD, DMD, PhD Department of Dentistry, Oral and Maxillofacial Surgery University Pecs Pecs H-7625 Dischka Gy. u. 5. Hungary Tel.: +36 72 535901 Fax: +36 72 535920 E-mail: zoltan.nyarady@aok.pte.hu Paper received 9 November 2004 Accepted 10 April 2006