Abstract
A literature review was performed to analyse the evidence supporting submental intubation and to aid in the development of a new airway algorithm in craniofacial surgery patients. A systematic search of Pub Med, OVID, the Cochrane Database and Google Scholar between January 1984 and April 2011 was performed. Measured variables included the outcome, complications, publishing specialty journal and method of intubation including technique modifications, indications for the procedure, devices utilized and the total procedure time to complete the submental intubation. Of the 842 patient cases from 41 articles represented in the review, the success rate was 100%. Minor complications were reported in 60 patients and included superficial skin infections ( N = 23), damage to the tube apparatus ( N = 10), fistula formation ( N = 10), right mainstem bronchus tube dislodgement/obstruction ( N = 5), hypertrophic scarring ( N = 3), accidental extubation in paediatric patients ( N = 2), excessive bronchial flexion ( N = 2), lingual nerve paresthesia ( N = 1), venous bleeding ( N = 2), mucocele ( N = 1), and dislodgement of the throat pack sticker in the submental wound ( N = 1). The average reported time to complete a submental intubation was 9.9 min. Submental intubation is a safe, effective and time efficient method for securing an airway when increased surgical exposure or restoration of occlusion is a priority.
Submental intubation was first reported by Francisco Hernandez Altemir in 1986 as a procedure that could avoid tracheostomy and allow for the concomitant restoration of occlusion and reduction of facial fractures in patients ineligible for nasotracheal intubation . This procedure consists of exteriorizing an oral endotracheal tube through the floor of the mouth and submental triangle. The original surgical protocol dictated a 2 cm incision in the submental, paramedial region extending cephalad until the lingual mucosa was tented with a hemostat after which another 2 cm incision parallel to the mandible is made in the lingual gingivae. The breathing circuit is briefly disconnected as the tube is externalized through the submental region and reconnected to the circuit and secured to the patient. Many aspects of submental intubation make it a useful surgical adjunct in a variety of settings including facial trauma, pathology and elective facial surgery. Currently, no systematic literature reviews exist on the topic of submental intubation.
In recognition of this deficiency, a systematic literature review was performed to analyse the evidence supporting submental intubation. The first aim of this review is to summarize the outcomes, complications, method of intubation including technique modifications, indications for the procedure, devices utilized and the total procedure time to complete the submental intubation. A second aim of this review is to introduce a maxillofacial trauma airway algorithm based on these findings and to discuss the benefits of submental intubation over tracheostomy in select patient populations.
Materials and methods
A systematic search of Pub Med, OVID, Cochrane Database and Google Scholar Beta between January 1984 and 10 April 2011 was performed. The Pub Med search utilized the following National Library of Medicine Medical Subject Headings (MeSH): adult, chin, humans, intubation/methods, maxillofacial injuries/surgery, surgery, and oral/methods. Keywords searched in other databases included submental intubation, submental endotracheal intubation, submental orotracheal intubation and maxillofacial surgery, faciomaxillary surgery, and trauma and tracheostomy. A preferred reporting items for systematic reviews and meta-analyses (PRISMA) flowchart diagram outlines the number of articles identified, screened, deemed eligible and included in this review ( Fig. 1 ). Exclusion criteria included non-English language articles, duplicates and articles that did not contribute to the measured variables. No blinded randomized controlled trials have been published on submental intubation, therefore, observer bias must be considered when reviewing the evidence.
The level of evidence (LOE) was ranked for each article on a scale from 1 to 5 ( Table 1 ). Level 1 evidence included well constructed meta-analyses of high quality randomized controlled trials of sufficient size. Level 2 evidence included lesser quality randomized controlled trials. Level 3 evidence included case control studies, retrospective and prospective analyses. Level 4 evidence included case series, case reports and surgical techniques. Level 5 evidence included expert opinion including correspondences and letters to the editor. The average LOE in this report was 3.81 comprising the most comprehensive and best available literature on submental intubation.
| Reference | Type of study | Level of evidence |
|---|---|---|
| A grawal & K ang | Prospective study | 3 |
| A min et al. | Retrospective study | 3 |
| B iglioli et al. | Retrospective study | 3 |
| C aron et al. | Retrospective study | 3 |
| C aubi et al. | Retrospective study | 3 |
| C handu et al. | Retrospective study | 3 |
| D avis | Retrospective study | 3 |
| G adre & W aknis | Retrospective study | 3 |
| J únior et al. | Retrospective study | 3 |
| N avaneetham et al. | Retrospective study | 3 |
| S chütz & H amed | Retrospective study | 3 |
| T aglialatela et al. | Retrospective study | 3 |
| B abu et al. | Case report | 4 |
| D rolet et al. | Case report | 4 |
| E ipe et al. | Case report | 4 |
| G ordon & T olstunov | Case report | 4 |
| G reen & M oore | Case report | 4 |
| K im et al. | Case report | 4 |
| K im et al. | Case report | 4 |
| L angford | Case report | 4 |
| M acInnis & B aig | Case report | 4 |
| M ak & O oi | Case report | 4 |
| M anganello-Souza et al. | Case report | 4 |
| M eyer et al. | Case report | 4 |
| U ma et al. | Case report | 4 |
| Y oon et al. | Case report | 4 |
| C hoi et al. | Case report | 4 |
| N yárády et al. | Case report | 4 |
| G arg et al. | Case series | 4 |
| S harma et al. | Case series | 4 |
| A ltemir et al. | Surgical technique | 4 |
| A rya et al. | Surgical technique | 4 |
| A ltemir et al. | Surgical technique | 4 |
| L im et al. | Surgical technique | 4 |
| M ahmood & L ello | Surgical technique | 4 |
| N woku et al. | Surgical technique | 4 |
| N yárády et al. | Surgical technique | 4 |
| A hmed & M itchel | Correspondence | 5 |
| B all et al. | Correspondence | 5 |
| B iswas et al. | Letter to the editor | 5 |
| P aetkau et al. | Letter to the editor | 5 |
Measured variables in this review included outcomes, complications, publishing specialty journal, method of intubation, technique modifications, indications for the procedure, device utilized and the total procedure time to complete the submental intubation.
Results
The search strategies yielded a total of 359 abstracts of which 48 remained after duplicate, non-English and unrelated citations were removed. 48 Full text articles on submental intubation were assessed for inclusion eligibility in this review. Published between January 1986 and April 2011, these papers included 12 retrospective reviews, two case series, 16 case reports, 10 surgical techniques, six correspondences and two letters to the editors. Four journal correspondences and three surgical technique articles were eliminated based on exclusion criteria . 41 English language articles were qualitatively and quantitatively assessed in this review and the results are presented in Table 2 .
| Article citation | Study type | Journal type | # Pts | Complications | Intubation method | Device utilized | Indication for procedure | Average time |
|---|---|---|---|---|---|---|---|---|
| A grawal M, K ang L. J J Anesthesiol Clin Pharmacol 2011: 26 : 498–502 | PR | ANES | 25 | Venous bleeding (1) Superficial infection (2) |
AS | Reinforced ETT | Maxillofacial trauma | 7.08 ± 0.81 min |
| C hoi S, S ong SH, K ang NH. J Korean Soc Plast Reconstr Surg 2011: 38 : 127–129 | CR | PRS | 1 | None | AS | Non-Reinforced ETT | Maxillofacial trauma | 30 min |
| J únior SM, A sprino LT. J Oral Maxillofac Surg 2011 [Epub ahead of print] | RR | OMS | 15 | None | AS | Reinforced ETT | Maxillofacial trauma | 10 min |
| N avaneetham A, T hangaswamy AV, R ao N: J Oral Maxillofac Surg 2011: 9 : 61–67 | RR | OMS | 15 | ETT obstruction (2) | AS | Reinforced ETT | Maxillofacial trauma | 7 min |
| G arg M, R astogi B. Dental Traumatol 2010: 26 : 90–93 | CS | OMS | 10 | Superficial infection (1) | AS | Reinforced ETT | Maxillofacial trauma | 8 min |
| G adre KS, W aknis PP. J Craniofac Surg 2010: 21 : 516–519 | RR | OMS | 400 | Fistula (2), Damage to ETT apparatus (1), Keloid (2) | AS | Reinforced ETT | Maxillofacial trauma, Elective LF | 10 min |
| U ma G, V iswanathan PN, N agaraja PS. Indian J Anaesth 2009: 53 : 84–87 | CR | ANES | 1 | None | AS | NR | Maxillofacial trauma | NR |
| L angford R. Anaesth Intensive Care 2009: 37 : 325–326 | CR | ANES | 1 | Pilot balloon entrapment (1) | AS | LMA | Maxillofacial trauma | NR |
| S harma RK, T uli P, C yriac C, et al. Indian J Plast Surg 2008: 41 : 15–19 | CS | PRS | 20 | Partial extubation paediatric (1) Superficial infection (1) |
AS | Reinforced ETT | Maxillofacial trauma | 9 min |
| B abu I, S agtani A, J ain N, et al. Br J Oral Maxillofac Surg 2008: 46 : 561–563 | CR | OMS | 1 | None | AS | Reinforced ETT | Maxillofacial trauma | 5 min |
| C handu A, W itherow H, S tewart A. Br J Oral Maxillofac Surg 2008: 46 : 561–563 | RR | OMS | 44 | Superficial infection (2) Mucocele formation (1) Lingual nerve paresthesia (1) Dislodged ETT (2) |
AS | Reinforced ETT | Orthognathic surgery | 20 min |
| S chütz P, H amed HH. J Oral Maxillofac Surg 2008: 66 : 1404–1409 | RR | OMS | 8 | Damage to ETT apparatus (1) | AS | Reinforced ETT | Maxillofacial trauma | NR |
| C aubi AF, V asconcelos BC, V asconcellos RJ, et al. Med Oral Patol Oral Cir Bucal 2008: 13 : E197–E200 | RR | Oral Med/Path/Surg | 13 | Increased tracheal pressure due to ETT compression (1) | AS | Non-Reinforced ETT | Maxillofacial trauma | <10 min |
| B iswas BK, J oshi S, B hattacharyya P, et al. Anesth Analg 2006: 103 : 1055 | LE | ANES | 2 | None | AS | Reinforced ETT | NR | NR |
| N yárády Z, S ári F, O lasz L, et al. J Craniomaxillofac Surg 2006: 34 : 362–365 | ST | CMF | 13 | None | AS | NR | Orthognathic surgery | 4 min |
| E ipe N, N euhoefer ES, L a Rosee et al. Paediatr Anaesth 2005: 15 : 1009–1012 | CR | ANES | 1 | None | AS | Non-Reinforced ETT | Cancrum Oris Sequlae | NR |
| T aglialatela Scafati C, M aio G, A liberti F, et al. Br J Oral Maxillofac Surg 2006: 44 :12–14 | RR | OMS | 107 | Superficial infection (11) Fistula (8) Damage to ETT apparatus (6) |
GMS | Reinforced ETT | Maxillofacial trauma | 10 min |
| K im KJ, L ee JS, K im HJ, et al. Yonsei Med J 2005: 46 : 571–574 | CR | ANES | 2 | None | AS | Reinforced LMA | Maxillofacial trauma | 7 min |
| K im KF, D oriot R, M orse MA, et al. J Craniofac Surg 2005: 16 : 498–500 | CR | PRS | 4 | None | AS | Reinforced ETT | Maxillofacial trauma | 10 min |
| B iglioli F, M ortini P, G oisis M, et al. Skull Base 2003: 13 : 189–195 | RR | Skull Base Surgery | 24 | Superficial infection (1) | AS | Reinforced ETT | Maxillofacial trauma/clivus chordomas/chordosarcoma | 5 min |
| A rya VK, K umar A, M akkar SS, et al. Anesth Analg 2005: 100 : 534–537 | ST | ANES | 1 | None | Pharyngeal Loop Technique | Non-Reinforced ETT | Maxillofacial trauma | NR |
| N yárády Z, S ári F, O lasz L, et al. Mund Kiefer Gesichtschir 2004: 8 : 387–389 | CR | OMS | 8 | None | AS | Reinforced ETT | Orthognathic surgery | NR |
| Y oon KB, C hoi BH, C hang HS, et al. Yonsei Med J 2004: 45 : 748–750 | CR | ANES | 1 | Pilot balloon detachment (1) | GMS | Reinforced ETT | Maxillofacial trauma | NR |
| D avis C. ANZ J Surg 2004: 74 : 379–381 | RR | PRS | 11 | None | GMS | Reinforced ETT | Maxillofacial trauma | 7 min |
| A hmed FB, M itchell V. Anaesthesia 2004: 59 : 410–411 | C | ANES | NR | Right mainstem bronchus neck flexion (1) Throat pack sticker dislodged (1) |
NR | NR | NR | NR |
| M eyer C, V alfrey J, K jartansdottir T, et al. J Cranio-maxillofac Surg 2003: 31 : 383–388 | CR | CMF | 25 | Hypertrophic scarring (1) Superficial infection (2) |
AS | Reinforced ETT | Maxillofacial trauma | <8 min |
| L im HK, K im IK, H an JU, et al. Yonsei Med J 2003: 44 : 919–922 | ST | ANES | 1 | None | AS | Reinforced ETT | Maxillofacial trauma | NR |
| A ltemir FH, H ernández Montero S, et al. J Cranio-maxillofac Surg 2003: 31 : 257–259 | ST | CMF | 2 | None | AS | Combitube | Maxillofacial trauma | NR |
| B all DR, C lark M, J efferson P, et al. Anaesthesia 2003: 58 : 189 | C | ANES | NR | NR | AS/ILM | NR | NR | NR |
| A min M, D ill-Russell P, M anisali M, et al. Anaesthesia 2002: 57 : 1195–1199 | RR | ANES | 12 | Right mainstem dislodged (1) Venous bleeding (1) Extubation paediatric (1) |
AS | Reinforced ETT | Maxillofacial trauma, Elective LF III | NR |
| N woku AL, A l-Balawi SA, A l -Z ahrani SA. Saudi Med J 2002: 23 : 73–76 | ST | OMS | 10 | None | AS | Reinforced ETT | Maxillofacial trauma, Orthognathic surgery | NR |
| M ahmood S, L ello GE. J Oral Maxillofac Surg 2002: 60 : 473–474 | ST | OMS | 5 | None | AS | Non-reinforced ETT | Maxillofacial trauma | NR |
| M ak PH, O oi RG. Br J Anaesth 2002: 88 : 288–291 | CR | ANES | 1 | None | GMS | Reinforced ETT | Orthognathic surgery | NR |
| A ltemir FH, M ontero SH. J Craniomaxillofac Surg 2000: 28 : 343–344 | ST | CMF | 3 | None | AS | LMA | Maxillofacial trauma | NR |
| P aetkau DJ, S tranc MF, O ng BY. Anesthesiology 2000: 92 : 912 | LE | ANES | 1 | None | GMS | Non-Reinforced ETT | Maxillofacial trauma | <10 min |
| C aron G, P aquin R, L essard MR, et al. J Trauma 2000: 48 : 235–240 | RR | Trauma | 25 | Superficial infection (1) | AS | Reinforced ETT | Maxillofacial trauma | Few minutes |
| D rolet P, G irard M, P oirier J, et al. Anesth Analg 2000: 90 : 222–223 | CR | ANES | 1 | None | AS | Reinforced ETT | Maxillofacial trauma | NR |
| M acInnis E, B aig M. Int J Oral Maxillofac Surg 1999: 28 : 344–346 | CR | OMS | 15 | None | AS | Reinforced ETT | Maxillofacial trauma, Elective LF III | 6 min |
| M anganello-Souza LC, T enorio-Cabezas N, et al. Sao Paulo Med J 1998: 116 : 1829–1832 | CR | OMS | 10 | Superficial infection (2) | AS | NR | Maxillofacial trauma | NR |
| G reen JD, M oore UJ. Br J Anaesth 1996: 77 : 789–791 | CR | ANES | 1 | None | GMS | Reinforced ETT | Maxillofacial trauma | NR |
| G ordon NC, T olstunov L. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1985: 79 : 269–272 | CR | Oral Med/Path/Surg | 2 | None | AS | Reinforced ETT | Maxillofacial trauma | NR |
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