Efficacy and Complications of Submental Tracheal Intubation Compared with Tracheostomy in Maxillofacial Trauma Patients

Journal of Oral Science, Vol. 58, No. 1, 23-28, 2016

Original Efficacy and complications of submental tracheal intubation compared with tracheostomy in maxillofacial trauma patients Ryosuke Kita1,2), Toshihiro Kikuta2), Masahiro Takahashi3), Taishi Ootani2), Masao Takaoka2), Michitaka Matsuda2), Hiroki Tsurushima1), and Izumi Yoshioka1)

1)Department of Oral Medicine, Kyushu Dental University, Kitakyushu, Japan 2)Department of Oral and Maxillofacial Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan 3)Department of Dentistry, Self Defense Forces Kure Hospital, Kure, Japan

(Received September 2, 2015; Accepted November 10, 2015)

Abstract: Submental tracheal intubation is a technique for use in patients with maxillofacial trauma. The purpose of this retrospective study was to eval- Introduction uate the efficacy and complications of this technique There are specific problems associated with airway compared with tracheostomy. Twenty-five patients management in patients with severe maxillofacial underwent submental tracheal intubation since 2001. trauma. In maxillofacial trauma cases, intermaxillary Submental tracheal intubation was performed in fixation is needed intraoperatively for correct reduc- cases needing intermaxillary fixation complicated by tion. Therefore, mandibular fracture patients are almost a nasal pyramid or anterior skull base fracture. No all managed with nasotracheal intubation. However, in severe perioperative or long-term complications were patients with midfacial fractures, nasotracheal intubation noted. Intra- and postoperative complications were may interfere with surgical reconstruction of fractures. observed in three patients. In one case, the tube was Tracheotomy is considered the treatment of choice for accidentally dislodged into the right main bronchus patients with severe maxillofacial injuries. On the other during submental tracheal intubation. Two patients hand, tracheotomy is associated with various complica- developed skin infections. Submental scarring was tions (1-7). undetectable, except for one patient with slight Altemir first described submental tracheal intubation as scarring. Submental tracheal intubation avoids the an alternative to nasotracheal intubation and tracheotomy complications associated with tracheostomy and the (8). This technique avoids the potential complications difficulty of nasal intubation during intubation and associated with tracheostomy and the difficulty of nasal surgery. Therefore, submental tracheal intubation is intubation during intubation and surgery. The purpose of useful in the intraoperative management of patients this retrospective study was to evaluate the efficacy and with complex maxillofacial trauma. complications of this technique compared with trache- (J Oral Sci 58, 23-28, 2016) ostomy.

Keywords: submental tracheal intubation; maxillofacial Materials and Methods trauma; tracheostomy, complications. From November 2001 to October 2013, 269 patients underwent surgery under general anesthesia for maxillofacial trauma at Fukuoka University Hospital. Of these, Correspondence to Dr. Izumi Yoshioka, Department of Oral Medicine, Kyushu Dental University, 2-6-1 Manazuru, 25 patients underwent submental tracheal intubation, and Kokurakita-ku, Kitakyushu, Fukuoka 803-8580, Japan 10 underwent tracheostomy. Another 234 patients were Fax: +81-93-582-1286 E-mail: [email protected] intubated nasally. All patients had maxillofacial fractures doi.org/10.2334/josnusd.58.23 and required a period of intraoperative intermaxillary DN/JST.JSTAGE/josnusd/58.23 fixation. 24

Fig. 2 Surgical scar after submental tracheal intubation.

was removed, and the pilot tube cuff was grasped by the forceps and pulled through the passage in the floor of the mouth. The tip of the forceps was then quickly re-inserted through the submental incision to grasp the Fig. 1 Submental tracheal intubation technique. A: A curved end of the endotracheal tube (Fig. 1C). The endotracheal forceps is passed from the submental incision through the floor tube was then reconnected to the anesthetic tubing. A stay of the mouth. B: A silicone tube (outer diameter: 12 mm) slightly larger than the endotracheal tube is pulled through the submental suture was placed through tape positioned around the tunnel. C: Endotracheal tube in the right paralingual groove. D: endotracheal tube using 2.0 silk to minimize periopera- Tube positioning in the submental area at the end of the procedure. tive movement (Fig. 1D). At the end of the procedure, the stay suture was removed, and both the endotracheal tube and the pilot tube cuff were reversed intraorally. The skin All cases were under the care of one oral surgeon wound was sutured, while the intraoral wound was left to (T.K.). Hospital records of patients having maxillofacial heal secondarily. trauma were reviewed retrospectively. The research protocol was approved by the Ethical Committee of Results Fukuoka University Hospital (16-1-23). Twenty-five patients (18 men and 7 women; age range 17 to 69 years) underwent submental tracheal intubation, Submental tracheal intubation technique and 10 patients (9 men and 1 woman; age range 7 to 63 After oral endotracheal intubation by standard direct years) underwent tracheostomy. All patients required laryngoscopy, temporary draping of the mouth and face intensive care unit (ICU) treatment. The patients had a was performed. A 2-cm-long incision was made medial Glasgow Coma Scale (GCS) score ranging from 3-15/15 to the inferior border of the mandible in the submental when first seen at our hospital. The most frequent etiology region. A curved forceps was pushed through the of the trauma was traffic accidents in both groups. These platysma and mylohyoid muscles, as closely as possible patients were neurologically cleared on the day of maxil- to the lingual surface of the mandible to avoid damaging lofacial surgery. the sublingual gland, submandibular duct, and lingual In the submental tracheal intubation group, the patients nerve. The mucosal layer in the floor of the mouth was did not require ventilation support in the ICU. Twenty- incised over the distal end of the forceps, located antero- two (88%) of the 25 cases had minor or moderate head lateral to the submandibular duct and orifice (Fig. 1A). injury (GCS: 8-15). The average total duration from oral We have slightly modified the technique in order to check endotracheal intubation to submental tracheal intubation whether there is interference to the tunnel. A silicone tube was 36.9 min (SD: 18.7 min). No severe perioperative or (outer diameter: 12 mm) slightly larger than the endo- long-term complications were noted. In particular, there tracheal tube was pulled through the submental tunnel was no tube obstruction, no postoperative hemorrhage, into the oral cavity by grasping it with the forceps (Fig. and no salivary gland or lingual nerve injury. Intra- and 1B). After confirming the smooth insertion of the silicone postoperative complications were seen in three patients. tube, the tube was removed. The universal connector In one case, the tube was accidentally dislodged into the 25 right main bronchus during submental tracheal intubation. Urgent tracheostomy was performed in seven patients Two patients developed skin infections (Table 1). None with decreased level of consciousness or with an airway of the patients developed hypertrophic scar or keloid jeopardized by severe bleeding at the oral cavity. Elec- formation. Submental scarring was undetectable in all tive tracheostomy was performed in 3 patients who cases except for one patient with slight scarring. In this were already intubated and who were undergoing a case, because spinal leakage was found intraoperatively, tracheostomy for prolonged intubation. The average the submental tracheal tube was removed 2 days after procedure time was 35.2 min (SD: 6.0 min). Complica- surgery. Furthermore, a skin infection developed. There tions were observed in four cases. One patient presented were no postoperative esthetic complaints. Twenty-four with subcutaneous emphysema. In two cases, there patients were extubated at the end of the procedure after was granulation formation, and in one case, there was switching the tracheal tube from the submental to the oral hemorrhage (Table 2). Additionally, in all 10 cases, the route. No patients required a tracheostomy (Fig. 2). cutaneous scar resulted in cosmetic damage. The average In the tracheostomy group, all patients underwent required postoperative intubation duration for patients urgent or elective tracheostomy in the ICU. Four (40%) was 7.3 days (SD: 5.7 days). of the 10 patients had severe head injury (GCS: 3-6).

Table 1 Clinical profile and complications of 25 patients who underwent submental tracheal intubation No. Age Gender Maxillofacial injury Other injury Etiology of the trauma GCS at the first visit Complications 1 43 M LeFort I, II, III fracture Anterior skull base fracture Traffic accident 15 No Left tibia fracture 2 26 M LeFort I, II, III fracture Spinal leakage Fall 14 (4,4,6) No Emphysema Bilateral ankle open fracture Cervical vertebral fracture 3 23 M LeFort I, II, III fracture Pelvic fracture Traffic accident 15 No Right femoral fracture Right tibia open fracture Right ankle open fracture 4 59 F LeFort I, II fracture Frontal bone fracture Traffic accident 15 No Left zygomatic arch fracture Anterior skull base fracture 5 39 F LeFort I, II, III fracture Anterior skull base fracture Traffic accident 14 (3,5,6) No Right femoral fracture 6 16 M LeFort I, II fracture Left femoral fracture Fall 13 (4,4,5) No Right zygomatic arch fracture Left radial fracture Carpal bone fracture 7 17 F LeFort I, II, III fracture Anterior skull base fracture Traffic accident 7 (1,2,4) No Spinal leakage Cervical vertebral fracture 8 18 M LeFort I, II fracture Anterior skull base fracture Fall 13 (3,4,6) Skin infection Mandibular fracture Spinal leakage Scar formation 9 59 M LeFort I, II fracture Anterior skull base fracture Industrial accident 15 No Spinal leakage 10 35 M LeFort I, II fracture Lung contusion Traffic accident 8 (1,2,5) Unilateral Mandibular fracture intubation Tongue laceration 11 25 M LeFort I, II fracture Right patella open fracture Fall 7 (1,2,4) No Right zygomatic arch fracture Diffuse axonal injury Mandibular fracture Lip laceration 12 40 M LeFort I, II fracture No Industrial accident 15 No Right zygomatic arch fracture Lip laceration 13 20 M LeFort I, II fracture Frontal bone fracture Traffic accident 15 No Left zygomatic arch fracture Cervical vertebral fracture Mandibular fracture 14 25 M LeFort I, II fracture No Traffic accident 14 (3,5,6) Skin infection Left zygomatic arch fracture 26

Table 1, continuation No. Age Gender Maxillofacial injury Other injury Etiology of the trauma GCS at the first visit Complications 15 28 F LeFort I, II fracture Corneal erosion Traffic accident 14 (3,5,6) No Right zygomatic arch fracture Lip laceration Mandibular fracture 16 23 M LeFort I, II fracture Right petrous bone fracture Traffic accident 14 (3,5,6) No Left zygomatic arch fracture Left ulna fracture 17 30 F LeFort I, II fracture Right wrist abrasion Traffic accident 11 (4,2,5) No Palatine bone fracture Cervical vertebral fracture Lip laceration 18 69 M LeFort I, II fracture Bilateral lung contusion Fall 15 No Mandibular fracture 19 48 M LeFort I, II, III fracture Mediastinal emphysema Fall 15 No Mandibular fracture Right lung contusion Liver injury Pelvic fracture Bilateral femoral fracture Integration disorder syndrome 20 20 F Right zygomatic arch fracture Frontal bone fracture Traffic accident 15 No Nasal fracture Cervical vertebral fracture Mandibular fracture 21 23 M LeFort I, II fracture Anterior skull base fracture Fall 14 (3,5,6) No Spinal leakage Temporal bone fracture Frontal bone fracture Right optic nerve injury 22 24 F LeFort I, II fracture Depressed skull fracture Traffic accident 15 No Anterior skull base fracture Spinal leakage 23 19 M LeFort I, II fracture Forehead contused wound Traffic accident 14 (3,5,6) No Bilateral zygomatic arch Femoral area abraded wound fracture 24 19 M LeFort I, II fracture Bilateral pneumothorax Fall 9 (1,2,6) No Mandibular fracture Bilateral radial fracture Bilateral patella fracture 25 33 M LeFort I, II fracture No Industrial accident 15 No Mandibular fracture

Discussion Although this is a very rare complication, it is dreaded Patients with extensive craniomaxillofacial and multi- by anesthesiologists (13,14). Therefore, nasotracheal system trauma usually require long-term ventilation intubation is not always feasible in cases of craniofacial support for neurological and pulmonary reasons. Early trauma, especially when a nasal pyramid or anterior tracheostomy is performed on these patients in the skull base fracture is involved, and when intra-operative ICU. On the other hand, patients with minimal or no control of occlusion is necessary. neurological deficit do not require early tracheostomy; On the other hand, tracheostomy is a traditional method therefore, these patients require airway management only for airway control in such cases. Despite being one of in the operating room for maxillofacial surgery. the most common surgical procedures, tracheostomy Intermaxillary fixation is needed intraoperatively for may lead to various complications, such as hemorrhage, adequate reduction of maxillofacial fractures. Therefore, surgical emphysema, tube blockage, tracheal stenosis, in most maxillofacial trauma cases, the airway is secured and poor scar appearance (1,2,4,6,7). Tracheostomy has by nasotracheal intubation. However, nasotracheal intu- a complication rate of 14 to 45 (3,5). bation sometimes interferes with the surgical approach Submental tracheal intubation was first described by (9). Altemir in 1986 (8). The advantage of this technique is Furthermore, nasotracheal intubation after maxillofa- its ability to avoid a tracheostomy and its complications. cial trauma can result in the passage of the tracheal tube Submental tracheal intubation is a simple technique with into the cranium with consequent brain damage (10-12). low morbidity, and complications from this technique are 27

Table 2 Clinical profiles and complications of 10 patients who underwent tracheostomy No. Age Gender Maxillofacial injury Other injury Etiology of the trauma GCS at the first visit Complications 1* 63 M LeFort I, II fracture Laceration of the face Traffic accident 15 No Oral hemorrhage 2* 7 M LeFort I, II fracture Upper limb fracture Traffic accident 14 (4,4,6) Granulation Oral hemorrhage 3* 17 M Mandibular fracture Anterior skull base fracture Traffic accident 6 (1,1,4) Subcutaneous Oral hemorrhage Cerebral contusion emphysema Spinal leakage 4* 54 M Right zygomatic arch fracture Diffuse axonal injury Traffic accident 6 (1,1,4) No Mandibular fracture 5* 19 M LeFort I, II fracture Cerebral contusion Traffic accident 3 (1,1,1) Hemorrhage Right zygomatic arch fracture Anterior skull base fracture Mandibular fracture Right clavicle fracture Oral hemorrhage Right femoral fracture 6* 54 M LeFort I, II, III fracture Bilateral pulmonary contusion Traffic accident 6 (1,1,4) No Mandibular fracture Liver injury 7* 22 M LeFort I, II, III fracture Cerebral contusion Fall 8 (1,2,5) Granulation Mandibular fracture Anterior skull base fracture 8 32 M LeFort I, II, III fracture Anterior skull base fracture Fall 13 (3,4,6) No Mandibular fracture Right radial fracture Right femoral fracture Spinal leakage 9 22 F Mandibular fracture Right femoral fracture Fall 11 (4,1,6) No Anterior skull base fracture Right pulmonary contusion 10 41 M LeFort I, III fracture Diffuse axonal injury Traffic accident 14 (5,3,6) No Left zygomatic bone fracture Mandibular fracture *Urgent tracheostomy relatively rare (15,16). Reported complications include tube was tested to determine whether it could be pulled accidental extubation (17,18), detachment of the pilot through smoothly. In the present study, no complications balloon (19) or its damage during externalization (20), were observed during externalization of the endotracheal damage to the cuff of the tracheal tube (15), skin infec- tube. tion (15,21), scar formation (22), tube dislodgement (17), The disadvantage of this technique is that the total lingual nerve paresthesia, venous bleeding (23), salivary duration of the intubation procedure was longer than for fistula (21,24), and mucocele formation (25). In the nasotracheal intubation. In the present study, the average present study, minor complications included dislodge- duration from oral endotracheal intubation to submental ment, skin infection, and scar formation. Satisfactory tracheal intubation including temporary draping was 36.9 functional and esthetic treatment outcomes are clinically min. However, there was no significant difference in the important for patients with maxillofacial trauma. Scar average time between this technique and tracheostomy. formation after submental tracheal intubation is by far Furthermore, it was previously reported that the mean less visible than the scar after a tracheostomy. required time for submandibular intubation not including The previously reported serious complications associ- oral endotracheal intubation and draping was 9.9 min ated with this technique included accidental extubation (range 4 to 30 min) (26). (17,18) or difficulty with the pilot balloon (19) or the cuff The contraindications of this technique include the of the tracheal tube (15) when the tube was being pulled likelihood that patients will require a long period of through the submental incision. With this technique, assisted ventilation, that is, multiple trauma patients difficulty in withdrawing the tube through the submental presenting with severe neurological damage, patients tunnel for any reason could result in prolonged apnea with major thoracic trauma, patients for whom repeated time. We used a minor modification of this technique operations could be anticipated, or patients with severe to minimize the risk of apnea and prevent injury to soft traumatic wounds on the floor of the mouth. In these tissue during externalization of the endotracheal tube. cases, tracheostomy should be the standard procedure. In A silicone tube slightly larger than the endotracheal the present study, urgent tracheostomy was performed in 28

13. Muzzi DA, Losasso TJ, Cucchiara RF (1991) Complication patients with severe bleeding at the oral cavity. In other from a nasopharyngeal airway in a patient with a basilar skull cases, such as severe neurological damage or pulmonary fracture. Anesthesiology 74, 366-368. contusion, oral endotracheal intubation was performed 14. Marlow TJ, Goltra DD Jr, Schabel SI (1997) Intracranial first, and then elective tracheostomy was performed for placement of a nasotracheal tube after facial fracture: a rare prolonged intubation. complication. J Emerg Med 15, 187-191. Submental tracheal intubation avoids the complica- 15. Taglialatela Scafati C, Maio G, Aliberti F, Taglialatela Scafati tions associated with tracheostomy and the difficulty of S, Grimaldi PL (2006) Submento-submandibular intubation: nasal intubation during intubation and surgery. Therefore, is the subperiosteal passage essential? Experience in 107 submental tracheal intubation is useful in the intraopera- consecutive cases. Br J Oral Maxillofac Surg 44, 12-14. tive management of patients with complex maxillofacial 16. de Toledo GL, Bueno SC, Mesquita RA, Amaral MB (2013) trauma. Complications from submental endotracheal intubation: a prospective study and literature review. Dent Traumatol 29, 197-202. Conflict of interest 17. Amin M, Dill-Russell P, Manisali M, Lee R, Sinton I (2002) The authors have no conflict of interest to declare. Facial fractures and submental tracheal intubation. Anaes- thesia 57, 1195-1199. References 18. Sharma RK, Tuli P, Cyriac C, Parashar A, Makkar S (2008) 1. Hafez A, Couraud L, Velly JF, Bruneteau A (1984) Late Submental tracheal intubation in oromaxillofacial surgery. cataclysmic hemorrhage from the innominate artery after Indian J Plast Surg 41, 15-19. tracheostomy. Thorac Cardiovasc Surg 32, 315-319. 19. Yoon KB, Choi BH, Chang HS, Lim HK (2004) Management 2. Viau F, Lededente A, Le Tinier JY (1988) Complications of of detachment of pilot balloon during intraoral repositioning tracheotomy. Rev Pneumol Clin 44, 24-32. of the submental endotracheal tube. Yonsei Med J 45, 3. Waldron J, Padgham ND, Hurley SE (1990) Complications of 748-750. emergency and elective tracheostomy: a retrospective study 20. Drolet P, Girard M, Poirier J, Grenier Y (2000) Facilitating of 150 consecutive cases. Ann R Coll Surg Engl 72, 218-220. submental endotracheal intubation with an endotracheal tube 4. Hönig JF, Braun U (1993) Laterosubmental tracheal intu- exchanger. Anesth Analg 90, 222-223. bation. An alternative method to nasal-oral intubation or 21. Caron G, Paquin R, Lessard MR, Trépanier CA, Landry PE tracheostomy in single-step treatment of panfacial multiple (2000) Submental endotracheal intubation: an alternative to fractures or osteotomies. Anaesthesist 42, 256-258. tracheotomy in patients with midfacial and panfacial frac- 5. Taicher S, Givol N, Peleg M, Ardekian L (1996) Changing tures. J Trauma 48, 235-240. indications for tracheostomy in maxillofacial trauma. J Oral 22. Meyer C, Valfrey J, Kjartansdottir T, Wilk A, Barrière P Maxillofac Surg 54, 292-295. (2003) Indication for and technical refinements of submental 6. Bernard AC, Kenady DE (1999) Conventional surgical intubation in oral and maxillofacial surgery. J Craniomaxil- tracheostomy as the preferred method of airway management. lofac Surg 31, 383-388. J Oral Maxillofac Surg 57, 310-315. 23. Agrawal M, Kang LS (2010) Midline submental orotracheal 7. Chandu A, Smith ACH, Gebert R (2000) Submental intuba- intubation in maxillofacial injuries: a substitute to trache- tion: an alternative to short-term tracheostomy. Anaesth ostomy where postoperative mechanical ventilation is not Intensive Care 28, 193-195. required. J Anaesthesiol Clin Pharmacol 26, 498-502. 8. Altemir FH (1986) The submental route for endotracheal 24. Gadre KS, Waknis PP (2010) Transmylohyoid/submental intubation. A new technique. J Maxillofac Surg 14, 64-65. intubation: review, analysis, and refinements. J Craniofac 9. Hall CEH, Shutt LE (2003) Nasotracheal intubation for head Surg 21, 516-519. and neck surgery. Anaesthesia 58, 249-256. 25. Stranc MF, Skoracki R (2001) A complication of 10. Zmyslowski WP, Maloney PL (1989) Nasotracheal intubation submandibular intubation in a panfacial fracture patient. J in the presence of facial fractures. JAMA 262, 1327-1328. Craniomaxillofac Surg 29, 174-176. 11. Taher AA (1992) Nasotracheal intubation in patients with 26. Jundt JS, Cattano D, Hagberg CA, Wilson JW (2012) facial fractures. Plast Reconstr Surg 90, 1119-1120. Submental intubation: a literature review. Int J Oral Maxil- 12. Green JD, Moore UJ (1996) A modification of sub-mental lofac Surg 41, 46-54. intubation. Br J Anaesth 77, 789-791.