This presentation shows the steps required in submental intubation and the advantages of the procedure. The author thinks that submental intubation is an effective way to manage airway in cases of panfacial trauma with concomitant naso orbito ethmoidal fractures and skull base fractures.

1. Submental Intubation :
An Essential Procedure in Pan Facial Trauma
Oral & Maxillofacial And Head & Neck Surgery
Dr. Saikat Saha

3. Introduction
Management of airway is a
significant issue in :-
 **Panfacial fractures
Or
**Concomitant
nasoethmoidal injuries.

4. Submental Intubation An Alternative To Tracheostomy
Can be easily performed
Little or lesser post-operative complications.

5. Submental Intubation involves lesser expenses as it does
away with longer post-operative stay in the hospital as
compared to tracheostomy patients.

6. Francisco Hernandez Altemir
In 1986
The Pioneer

7. [1]. His technique consisted of passing the endotracheal tube through the
anterior floor of the mouth to allow free intraoperative access to the dental
occlusion and to the nasal pyramid without endangering patients with skull
base trauma

8. [2]. This technique allows for the avoidance of
tracheal dissection and eliminates the risks associated
with nasotracheal intubation in the setting of facial
trauma.

9. Methods & Procedures

10. Profile Picture
A patient with pan facial trauma
© Dr. Saikat Saha

11. The Side Profile
© Dr. Saikat Saha

12. 3D -CT- SCAN

13. Standard Orotracheal Intubation Done

14. Sterile painting and draping of chin and mouth done with Betadine

15. 2 ml of 2% Lidocaine with adrenaline infiltration

16. A small 1.5 cm transverse skin crease incision made in
the medial region of submental area, 2 cm behind the
mental symphysis and adjacent to lower border of
mandible.

17. Curved Artery Forcep Was Used For Blunt Dissection

18. Through-and-through passage created into the floor of the mouth by
blunt dissection from the submental incision close to the lingual cortex
of mandible, anterior to the sublingual caruncle.

19. The balloon is deflated

20. The deflated balloon is dragged out of the incision

21. Endotracheal Tube Disconnected From the Ventilator End

22. Assistant Swings The Tube End Towards The Tip Of The Artery Forceps
At The Floor Of The Mouth

23. The tube is now being taken out through the incision

24. The tube is now out through the incision. (Cuff Is Inflated)

25. The internal surface of the tube is cleansed with gauze to clear off
blood and mucous

26. The tube taken out through the submental route and immediately
connected with the ventilator tube

27. Airway is secured and the tube needs to be secured with stay sutures

28. (In another Case) - The tube is secured with stay sutures and the
intraoral position of the tube is clearly seen

29. The Advantage Is, Occlusion can now be corrected without
interference from the endotracheal tube

30. It allows practitioners to avoid the risk of
Nasotracheal Intubation
1) Epistaxis
2) Iatrogenic Meningitis
3) Trauma Of The Anterior Skull Base
Advantages
© Dr. Saikat Saha

31. Avoids Some other complications tracheostomy, such as :-
1) Tracheal Stenosis
2) Injury To Cervical Vessels Or The Thyroid Gland
3) Subcutaneous Emphysema
4) Recurrent Laryngeal Nerve Injury
The scar from the submental incision is thought to be less
visible than a tracheostomy scar and has been well tolerated
by patients .
Advantages
© Dr. Saikat Saha

32. •Hypertrophy of the submental scar
•Accidental Extubation
•Accidental advancement of the endotracheal tube
Into a main stem bronchus
•Bleeding
•Infection
•Mucocele Formation
•Damage to salivary ducts and glands
Disadvantages
© Dr. Saikat Saha

33. This method cannot be used in all cases as it is not
without limitations.
In spite of these, submental intubation can be a
useful alternative to tracheostomy, especially in
regions where cost cutting is a major factor in
health care infrastructure.
Discussion
© Dr. Saikat Saha

34. •Submental Intubation avoids some of complications
associated with nasal intubation and tracheostomy.
•It also avoids the need of longer post operative care
needed in cases of tracheostomy
•Escapes associated risk of complications of
tracheostomy.
•This technique can be easily carried out even in
hospital setups with limited resources.
© Dr. Saikat Saha

35. Bibliography
[1] A. Hernandez, “The submental route for endotracheal intubation”,
Journal of Oral and Maxillofacial Surgery, vol. 14, p. 645,1986.
[2] Kar, C. and Mukherjee, S. (2010). Submental Intubation: An Alternative and Cost-Effective
Technique for Complex Maxillofacial Surgeries. Journal of Maxillofacial and Oral Surgery, 9(3),
pp.266-269.
[3 Davis, C. (2004). Submental intubation in complex craniomaxillofacial trauma. ANZ J Surg, 74(5),
pp.379-381.
[4] Z. Nyárády, F. Sári, L. Olasz, and J. Nyárády, “Submental endotracheal intubation in
concurrent orthognathic surgery: a technical note,” Journal of Cranio-Maxillofacial
Surgery, vol. 34, no. 6, pp. 362–365, 2006.
[5] C. Davis, “Submental intubation in complex craniomaxillofacial trauma,”
ANZJournalofSurgery,vol.74,no.5,pp.379–381, 2004.
[6 Amin, M., Dill-Russell, P., Manisali, M., Lee, R. and Sinton, I. (2002). Facial fractures and
submental tracheal intubation. Anaesthesia, 57(12), pp.1195-1199.
[7] F. Biglioli, P. Mortini, M. Goisis, A. Bardazzi, and N. Boari, “Submental orotracheal
intubation: an alternative to tracheotomy in transfacial cranial base surgery,”
Skull Base, vol.13, no. 4, pp. 189–195, 2003.
[8] Biglioli, F., Mortini, P., Goisis, M., Bardazzi, A. and Boari, N. (2003). Submental Orotracheal
Intubation: An Alternative to Tracheotomy in Transfacial Cranial Base Surgery. Skull Base, 13(4),
pp.189-196.

36. For Any questions or queries you can mail me at shaikatmail@gmail.com