Optimal Airway Management in Severe Maxillofacial Trauma: A Case Report on Submental Intubation

Introduction

Securing the airway in maxillofacial injuries is considered a top priority in saving the patient’s life [1], but multiple modalities are available according to the complexity of the injury, including conventional orotracheal intubation, nasotracheal intubation, and tracheotomy [2]. Our patient was intubated in the Emergency Department (ED) by oral endotracheal tube for securing the airway, followed by submental intubation in the OT to facilitate surgical needs. Submental intubation was shown to be superior to other methods in specific circumstances, with lower morbidity, mainly in maxillofacial and dental procedures [3,4], maximizing the surgical field and reliability of the anesthesiologist in managing the airway. Here, we present a case of submental intubation in a patient with maxillofacial trauma.

Case Report

A 37-year-old man was brought to the ED by national ambulance after sustaining trauma during demolition of a building, when a large concrete wall fell on him. On arrival he was awake, alert, conscious, and moving all 4 limbs.

Examination revealed a Glascow Coma Scale (GCS) of 15/15, symmetric, equally reactive pupils with 2 millimeters, severe swelling of the face more on the right side, with raccoon eyes, bleeding from the mouth, jaw deformity, neck crepitus suggesting subcutaneous surgical emphysema, and multiple body abrasions. Airway protection was the first priority; therefore, immediate oral endotracheal tube insertion (ETT) by the ED physician was successfully done with some difficulty due to active bleeding in the airway. Other examinations were unremarkable, with stable vital signs. Afterwards, patient was taken to the Radiology Department for computed tomography (CT) imaging.

The CT confirmed a Le Forte I fracture (Figure 1) consisting of bilateral medial and lateral pterygoid plates fractures, right mandibular angle fracture, bilateral maxillary sinuses wall fractures (anterior, medial, and lateral walls), transverse fracture line of maxillary upper part, right zygomatic arch fracture, right frontal process of zygomatic bone, right lateral orbital wall, bilateral nasal bones, and bilateral inferior orbital walls fractures with orbital edema and air loculi. The patient had large cheek edema, subcutaneous hematoma, and hemosinuses in nasal sinuses, and subcutaneous air loculi along the left side of the neck due to surgical emphysema inflicted by the injury. Chest CT showed a left 4th rib fracture and right lobe consolidation due to aspiration. Other CT results appeared to be unremarkable. X-ray of the humerus showed a left minimally displaced fracture in the distal shaft.

Oral and maxillofacial (OMF) consultation resulted in an initial plan to achieve hemostasis with 4 gauzes with nasal packing and primary suture of facial lacerations, and advised maintaining BP in the lower-normal range to avoid bleeding, along with orthopedic consultation, in which a posterior slab was applied. This was followed by Intensive Care Unit (ICU) admission. Definitive treatment of the facial bone fractures was planned after 1 week with a submental intubation due to the extensive injury.

Intraoperatively, a submental incision was made 2 cm below the mandible, and blunt dissection was performed to reach the sublingual area (Figure 2). Then, oral ETT was changed to reinforced ETT over a bougie, followed by disconnecting the ETT from the T-piece and passing the head of the ETT from the submental wound (Figure 3) and the patient was connected again to the ventilator and the tube was secured with silk suture (Figure 4).

Custom-made arch bars were prepared and fixed to the upper and lower arches, and inter-maxillary fixation was done with elastics. A right lateral brow incision was made and, dissection was done to expose the right frontozygomatic region. A fracture at the F–Z suture was identified, and anatomical reduction was done. A 2.0-mm, 4-holed titanium plate was placed, fixed with 4 screws (Figure 5). The patient had a degloved wound with comminuted anterior wall of the maxilla, with a missing part of the anterior wall (bone loss) in the right maxillary vestibule. The vestibular incision was extended to the right side, and the maxillae were bilaterally exposed until the buttresses. The Le Forte I fracture was anatomically reduced, and plates were fixed at bilateral zygomatic buttresses and canine buttresses with L-shaped and straight 4-holed 2.0-mm titanium plates, respectively (Figure 6). Cut and lacerated wound in the right cheek (15 cm in largest dimension); which passes through the right oral commissure extending to the chin present. Right Stenson’s duct injured and could not be identified. The wound was debrided of foreign bodies and closed in layers, and the vestibular incision was closed in layers. Facial contours achieved and occlusion achieved. Then submental ETT was changed to oral ETT by the anesthesia team, and the submental wound was closed in layers. Pressure dressing was applied at the right parotid region and submental region, and the patient was shifted back to the ICU intubated, sedated, and paralyzed.

After 2 days in the ICU, the muscle relaxant was stopped, and a leak test was done to assess the feasibility of extubation, with a positive result. Initially, due to the edema and possible difficulty of reintubation, the ICU team advised keeping the patient intubated. On the 4th postoperative day, the patient was successfully extubated and shifted to the ward on the 7th postoperative day. During his stay in the ward, he was started on a liquid diet and advanced in the following days as tolerated. The Orthopedics team performed humerus shaft fracture open treatment internal fixation on the 13th postoperative day. He was discharged on the 23rd postoperative day.

Discussion

Airway management in craniofacial trauma had been always a predominant concern to all anesthesiologists, as the surgeon and the anesthesiologist are working in the same surgical field [1]. Many approaches of securing the airway in maxillo-facial fractures have been used, such as orotracheal intubation, nasotracheal intubation, and surgical airway, including tracheostomy [2].

Orotracheal intubation was not appropriate for our patient as it would impede the surgical field to the surgeon and prevent the creation of a dental occlusion, which is an essential step in treating maxillofacial fractures [2,5].

Nasotracheal intubation was not performed as the patient had bilateral nasal bones fracture, which increases the possibility of nasal mucosa trauma and epistaxis, leading to bleeding in the glottic area and increasing the risk of laryngospasm [6]. Moreover, nasotracheal intubation is contraindicated in patients with a fracture in base of the skull, as it might increase the risk of accidental intracranial insertion of the tube [7], cerebral spinal fluid leakage, or meningitis [8].

Conversely, tracheostomy is a possible alternative for securing the airway in complex maxillofacial injuries, especially for patients requiring prolonged ventilation postoperatively, those with severe neurological damage, and patients with damage to the floor of the mouth [9]. However, tracheostomy increases the possibility of pneumothorax, subcutaneous emphysema, laryngeal and tracheal stenosis, tracheomalacia, and infection [2,9,10].

Numerous studies in the literature describe submental intubation as a simple, safe, and quick method of securing the airway in cases of complex maxillofacial injuries, and it is associated with lower morbidity than any other modality [3,4]. It was developed by Hernandez Altemir in 1986 [11]. A systematic review conducted by Jaundt et al included 812 patients and reported that the most common indication of submental intubation is jaw fractures associated with nasal, naso-orbital-ethmoidal, or skull base fractures [12]. Additionally, submental intubation is indicated in cases of facial cosmetic surgeries, rhinoplasty, congenital defects, or deformities of the throat [9], but it is contraindicated in cases of prolonged ventilatory support, severe neurological deficits, repeated surgeries, or damage to the floor of the mouth [9]. In such cases, tracheostomy is preferrable.

Regarding the advantages of submental intubation in comparison with other alternatives, submental intubation can be done in as quickly as 10 minutes [13] with a range of 49.7±24.8 seconds for the passage of the tube through the submental wound and reattaching it to the anesthetic circuit, as per Tidke et al [14]. Submental scars are less noticeable than tracheostomy scars [6,9]. Avoidance of the previously discussed complications of tracheostomy is a huge advantage of submental intubation. It permits a surgical field clear of the ETT, allowing for therapeutic dental occlusion and avoiding injuries to the ETT [2].

The systematic review by Jaundt et al included an 842 patients from 41 articles, found a 100% success rate of submental intubation, with only slight complications documented [12]. Some of the complications reported by Szantyr et al were infection (2.7%), fistula formation (1.1%), ETT damage (1.1%), hypertrophic scar formation (0.4%), premature extubation (0.3%), excessive bleeding (0.3%), damage to the lingual nerve (0.1%), and mucocele formation (0.1%) [15]. Of these, the worst complication is accidental extubation, which can be prevented by use of stay sutures, as in our case. Furthermore, a literature review and analysis conducted by Cubai et al detected a rise in the peak airway pressure as a result of the extreme angulation of the ETT through its passage to the oropharynx to the larynx [16], which can be prevented by inserting an armored reinforced ETT, as in our patient.

Conclusions

Submental intubation is an acceptable alternative to secure the airway intraoperatively in facial trauma or dental cases, with a better outcome, especially in patients with a shorter duration of postoperative ventilatory support, maximizing the surgical field, and improving the overall prognosis.