Submandibular approach for tracheal intubation in patients with panfacial fractures

The oral route for tracheal intubation can interfere with some maxillofacial surgical procedures. At the same time, the nasal route can be contraindicated or impossible. Tracheostomy is the usual solution in these circumstances, but it carries a high incidence of complications. We tested the submandibular route for tracheal intubation as an alternative to tracheostomy in such situations. The procedure was performed in 13 patients suffering from panfacial fractures associated with a fracture of skull base or a displaced nasal fracture, and in one patient with post-caustic burn scar affecting most of the face including the nose and requiring a full thickness skin flap surrounding the mouth. The technique was found easy and satisfactory for both the surgeon and the anaesthetist. It allowed uninterrupted surgical techniques and a secure airway. In six of the 13 patients, the submandibular tracheal tube was left in place for up to 44 h in the intensive care unit after the operation without complications or difficulties. Accidental dislodgement of the tube to the right main bronchus occurred in two patients while carrying out the procedure; it was rapidly detected and corrected. In another two patients, postoperative superficial infection occurred that responded well to local treatment. No other complications were encountered. Submandibular tracheal intubation is a simple and effective technique for upper airway management in some maxillofacial surgical patients when both oral and nasal tracheal intubations are not convenient.