Submental intubation: a literature review

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.

Fig. 1
Submental intubation PRISMA flow diagram.

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.

Table 1
Level of evidence.
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 .

Table 2
Literature review results.
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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Jan 26, 2018 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Submental intubation: a literature review
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