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Introduction: Submental intubation allows for the passage of an endotracheal tube through the anterior floor of the oral cavity. This allows for adequate surgical access to the regions of the mouth and the nasal pyramid with minimal to no hindrance in airflow to the lungs. Aim of the Study: To explore the perception of an anaesthetist regarding the submental intubation. Materials and Methods: A questionnaire‑based prospective randomized analysis was formatted and carried out in Odisha, India, between 20 Jan 2023 and 20 may 2023. A self-structured questionnaire consisting of 16 questions was distributed to the anaesthetists of the medical colleges in Odisha. Results: Out of 97, 42 (43%) male and 45 (46%) female were familiar with the submental infiltration technique. Among the participants, 56% females and 43% males have performed and assisted in a submental intubation procedure. None of them encountered any complications or adverse events related to submental intubation (p = 0.0001). Discussion: Out of all, 20% females and 19% males were very confident in performing submental intubation. Conclusion: Submental intubation is a simple, safe, quick, and relatively harmless alternative to tracheostomy for securing the airway in selected patients with craniofacial trauma. Familiarity with the submental intubation technique will help the anaesthetists to avoid tracheostomy in selected patients with craniofacial trauma who do not require long-term mechanical ventilation. But, this procedure is technique sensitive as well. [ABSTRACT FROM AUTHOR]

In complex maxillofacial fractures in which orotracheal and nasotracheal intubation are otherwise contraindicated, alternatives for airway management include tracheostomy and submental intubation (SMI). In this case, SMI was used successfully, although it did result in accidental endobronchial intubation intraoperatively that was quickly recognized and managed appropriately. SMI can be a useful method for securing a patient's airway, but like all surgical approaches, it does carry the potential for complications. We report a case involving the use of SMI during which an unintended endobronchial intubation occurred. [ABSTRACT FROM AUTHOR]

Purpose: To propose a novel technique of fixation and stabilization of the nasoendotracheal tube for maxillary osteotomies. Method: The technique utilizes a flexible Portex north pole endotracheal tube size 6, elastic adhesive tape, a catheter mount and a head cap made of cloth in the fixation and stabilization of the nasoendotracheal tube for maxillary osteotomies. Result: It is a simple method of fixation and stabilization of the nasoendotracheal tube, particularly for maxillary osteotomies that essentially eliminates distortion of the nasal, labial and perinasal areas and facilitates good nasolabial control during maxillary osteotomies. Conclusion: This technique is simple, safe and versatile and may be employed for maxillary osteotomies. [ABSTRACT FROM AUTHOR]

Background: Submental intubation is an airway management technique wherein an endotracheal tube is guided through incisions in the floor of the mouth and the submental skin after normal orotracheal intubation. Case presentation: A 20‐year‐old man with a history of pharyngeal flap construction for a cleft palate was planned for orthognathic surgery. Preoperative nasopharyngoscopy showed that the space lateral to the flap was too narrow for nasotracheal intubation; then submental intubation was performed. No intra‐ or postoperative complications were observed. Conclusion: Submental intubation is a useful alternative to tracheotomy in patients with difficulty in nasotracheal intubation during surgeries requiring occlusal confirmation. [ABSTRACT FROM AUTHOR]

This study aims to describe our refined technique of submental intubation to avoid the recorded intraoperative complications related to tube passage and pilot balloon rupture. This is a retrospective case series of 21 patients with complex maxillofacial trauma who underwent submental intubation from January 2019 to January 2023. All the patients underwent to the same procedure with a new technique of pilot balloon protection: the pilot balloon was not deflated because, once the connector was removed, only the tube was curved and passed through the incision extraorally while the cuff remained inflated. The wire of the pilot balloon was passed behind the last tooth so as not to interfere with the maxillary-mandibular fixation, remaining extraorally under the anesthetist's view. Only 2 patients (9.5%) reported complications related to submental intubation: in particular a patient (4.8%) reported oral floor infection, and in another patient (4.8%) an unesthetic skin scar was observed. No patients reported intraoperative complications related to the procedure. The technique of pilot balloon protection that we have proposed seems to be effective in reducing the intraoperative complications related to the passage of the pilot balloon, such as rupture, damage or early extubation. [ABSTRACT FROM AUTHOR]

Introduction: After introduction of ultrasound, there is paradigm shift towards under vision performance of procedures in anaesthesia. Blind puncture and dissection of submental space may lead to vascular injury and injury to salivary glands. We describe the ultrasound guided Seldinger technique assisted submental intubation for panfacial trauma. Methodology: Modified ultrasound guided Seldinger technique for submental intubation in 10 patients, who were posted for open reduction and fixation of panfacial fractures. Total procedural time, peri-procedural complications such as bleeding, dislodgment of tube, desaturation and postoperative complications such as injury to sublingual glands/submandibular glands, hematoma, cheloid or hypertrophic scar formation or skin site infection were noted. Results: The mean time to perform submental intubation was 8.9 ± 0.94 minutes (range, 8-11 minutes). Only one patient had minor bleeding during procedure which was stopped after local application of pressure. All patients had a clean scar with no formation of cheloid or hypertrophic scar in the postoperative follow up. Conclusion: Ultrasound assisted submental intubation increases safety of the procedure in patients presenting with maxillafacial trauma. [ABSTRACT FROM AUTHOR]

Abstract Submental intubation has been established as a useful technique in securing the airway and is also less invasive as compared to a tracheostomy. This approach is especially useful in cases of fractures involving the naso-orbito-ethmoid complex, where a nasotracheal intubation would be contraindicated. Also, in case of orthognathic surgeries, where occlusion is considered to be the key to success, an orotracheal intubation could hinder the surgical procedure. In this technical note, we have described a modified submental intubation technique that is less invasive and at the same time facilitates successful airway management, thus reducing postoperative complications.

Background Submental intubation has been the recommended airway management procedure for maxillofacial surgery since proposed by Altemir in 1986. We adopted various submental intubation modifications based on modified intubation protocols and report on the effectiveness and problems of each modified method. Case Among a total of 13 submental intubation cases during the last five years, five representative methods are described. The proximal end of the endotracheal tube was protected by a nelaton catheter in case 1, by a suction connector in case 2, and by a dental needle cap in case 3. In case 4, a nasal speculum was used to expand a single route, and in case 5, a laparoscopic trocar was used to secure a single route. Conclusions Use of a laparoscopic trocar might be the most effective way to obtain a single submental route. However, considering cost, use of a nasal speculum is also an effective suboptimal solution.

Airway management in maxillofacial surgery is a critical aspect of anesthesia and perioperative care, demanding a broad array of techniques to ensure effective ventilation and oxygenation. The anatomical and physiological complexities of maxillofacial procedures necessitate a deep understanding of airway management strategies. Patients undergoing maxillofacial surgery often face heightened risks of airway compromise due to trauma, congenital abnormalities, or the surgical interventions themselves, requiring clinicians to be proficient in both routine and advanced techniques. This narrative review synthesizes current evidence and clinical practices in airway management for maxillofacial surgery. It examines the anatomical and physiological considerations, preoperative assessment protocols, intraoperative management, and postoperative care strategies. Preoperative assessments are crucial for identifying potential airway management difficulties, utilizing risk assessments, physical examinations, and imaging. Intraoperative strategies include endotracheal intubation while surgical techniques such as tracheostomy, cricothyroidotomy, submental, and retromolar intubation offer alternatives for securing the airway. Postoperative care focuses on meticulous planning and coordination to prevent complications such as airway obstruction and hypoxemia. Extubation is identified as a particularly high-risk phase, necessitating advanced techniques and multidisciplinary collaboration to ensure patient safety. The review underscores the importance of a comprehensive, multidisciplinary approach to airway management in maxillofacial surgery, highlighting the need for ongoing advancements in techniques and technologies to enhance patient outcomes., Competing Interests: Declaration of competing interest The authors declare that they have no competing interest., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

A secure airway is always a challenging task in the management of facial trauma. Open reduction and Internal fixation in Lefort II and III warrants airway patency during general anesthesia. Unobstructed surgical field provided by submental intubation helps in open reduction internal fixation (ORIF) and achieving intermaxillary fixation (IMF) during the procedure. However, submental intubation poses few complications such as bleeding, flexometallic tube damage, and obstruction of the tube. We report an unusual complication of pilot cuff fracture and retrieval during submental intubation with exact localization by computed tomography. Even though the technique is safer, it carries a number of rare risks depending on the exact techniques used and act as a reminder of unusual complications that might occur and be aware of the unusual risks of this surgery.

Airway management of patients with maxillofacial trauma remains a challenging task for an anesthesiologist in the emergency and perioperative settings due to anatomical distortion. Detailed knowledge of maxillofacial and airway anatomy is desired for the correct diagnosis of extent and severity of the injury. Basic principles of advanced trauma life support protocols should be followed while managing such patients. Establishing unobstructed airway remains the top priority while maintaining C-spine immobilization and preventing aspiration. Although multiple options exist for securing the airway, a universal technique of airway management may not be applicable to all the patients. Hence, a high index of suspicion along with timely and skillful management is warranted. In this brief review, issues affecting the airway management in cases of maxillofacial trauma are addressed with the possible uses of a wide range of airway management devices available in emergency and elective scenarios.

Ravish Mishra,1 Deepak Yadav,1 Shashank Tripathi,1 Laxmi Kandel,1 Pawan Puspa Baral,2 Snigdha Shubham,3 Abhishek Karn,4 Kishor Dutta5 1Department of Oral and Maxillofacial Surgery, UCMS College of Dental Surgery, Bhairahawa, Rupandehi, Nepal; 2Department of Anaesthesiology and Critical Care, Universal College of Medical Sciences, Bhairahawa, Rupandehi, Nepal; 3Department of Conservative Dentistry and Endodontics, UCMS College of Dental Surgery, Bhairahawa, Rupandehi, Nepal; 4Department of Forensic Medicine and Toxicology, Universal College of Medical Sciences, Bhairahawa, Rupandehi, Nepal; 5Department of Orthodontics and Dentofacial Orthopaedics, UCMS College of Dental Surgery, Bhairahawa, Rupandehi, NepalCorrespondence: Ravish MishraDepartment of Oral and Maxillofacial Surgery, UCMS College of Dental Surgery, Bhairahawa, Rupandehi, NepalTel +977 98 44616364Email drravishmishra84@gmail.comIntroduction: Airway management in patients with panfacial fracture remains a challenge to anesthesiologists and surgeons. Submental intubation is an effective and less invasive alternative to tracheostomy during intraoperative airway management where orotracheal and nasotracheal intubation are not appropriate options. In addition, submental intubation allows proper access to oronasal airways and occlusion during intraoperative management.Methods: The descriptive retrospective study was carried out and evaluated the outcomes of submental intubation in the management of panfacial fracture, complex maxillary or mandible fracture associated with nasal bone fracture and naso-orbito-ethmoid (NOE) fracture. The medical records of 23 patients who received submental endotracheal intubation were reviewed at UCMS College of Dental Surgery, Bhairahawa, Rupandehi, Nepal from March 2014 to December 2018. The following parameters were evaluated: mode of trauma, time required for intubation, accidental extubation, accidental perforation of the pilot balloon during its insertion, period of hospital stay, post-operative complications, such as the healing of submental scars both intraorally and extraorally.Results: The submental intubation was successfully done in all patients with minimal obvious post-operative complications. The mode of trauma for majority of cases of panfacial fracture who underwent submental intubation was road traffic accident (69.56%). The mean time required for intubation was 8.43 (± 0.84) minutes. No accidental extubations occurred. Accidental perforation of the pilot balloon was seen in one patient (4.35%) during tube manipulation which was managed successfully by changing the tube. The healing of submental scars was uneventful intraorally and extraorally in almost every case. The mean period of hospital stay in patients with submental intubation was 7.95 (± 1.49) days.Discussion: Submental intubation is an effective and safe method as it is not associated with complications of tracheostomy during management of panfacial fracture, NOE fracture and craniofacial fracture. In addition, it does not interfere with IMF during intraoperative period.Keywords: panfacial fracture, submental intubation, intermaxillary fixation, airway management

Airway management of patients with maxillofacial trauma remains a challenging task for an anesthesiologist in the emergency and perioperative settings due to anatomical distortion. Detailed knowledge of maxillofacial and airway anatomy is desired for the correct diagnosis of extent and severity of the injury. Basic principles of advanced trauma life support protocols should be followed while managing such patients. Establishing unobstructed airway remains the top priority while maintaining C-spine immobilization and preventing aspiration. Although multiple options exist for securing the airway, a universal technique of airway management may not be applicable to all the patients. Hence, a high index of suspicion along with timely and skillful management is warranted. In this brief review, issues affecting the airway management in cases of maxillofacial trauma are addressed with the possible uses of a wide range of airway management devices available in emergency and elective scenarios. [ABSTRACT FROM AUTHOR]

A secure airway is always a challenging task in the management of facial trauma. Open reduction and Internal fixation in Lefort II and III warrants airway patency during general anesthesia. Unobstructed surgical field provided by submental intubation helps in open reduction internal fixation (ORIF) and achieving intermaxillary fixation (IMF) during the procedure. However, submental intubation poses few complications such as bleeding, flexometallic tube damage, and obstruction of the tube. We report an unusual complication of pilot cuff fracture and retrieval during submental intubation with exact localization by computed tomography. Even though the technique is safer, it carries a number of rare risks depending on the exact techniques used and act as a reminder of unusual complications that might occur and be aware of the unusual risks of this surgery. [ABSTRACT FROM AUTHOR]

Competing Interests: CONFLICTS OF INTEREST: None

The choice of intubation for a patient with maxillary/mandibular fracture concomitant with nasal bone fracture is submental or retromolar intubation or tracheostomy. These methods facilitate unhindered surgical access to the fracture sites for reduction and fixation as well as to perform Inter Maxillary Fixation to achieve ideal occlusion. This article presents a new technique of using a pre-fabricated "Splint with Port for Endotracheal Tube" (SPET) as an effective modality to achieve oral intubation which permits surgical manipulation of the naso-maxillomandibular complex while ensuring ideal dental occlusion. [ABSTRACT FROM AUTHOR]

Submental intubation (SMI) is useful in surgical procedures where nasotracheal intubation is contraindicated and orotracheal intubation is not ideal, making it an alternative to tracheostomy since it is performed in less time, with less morbidity and mortality, minimal postoperatory care, as well as an aesthetically acceptable scar. We present 2 cases of pediatric patients with a successful SMI. In addition, we briefly review current literature regarding pediatric population. [ABSTRACT FROM AUTHOR]

Objective: To compare submental intubation with tracheostomy in patients with maxillofacial fractures who were operated under general anesthesia and nasotracheal intubation was contraindicated. Patients and methods: This prospective comparative study was conducted on 32 patients undergoing maxillofacial operations. All patients had a panfacial trauma (including naso-ethmoid orbital fracture combined with mandibular fracture). Patients who had unstable cervical vertebra, laryngeal trauma, urgent tracheostomy, and patients with expected prolonged postoperative ventilation were excluded from the study. Patients were randomly assigned to elective tracheostomy and submental intubation groups. The patients were evaluated according to the time required to do elective tracheostomy or submental intubation, the operation comorbidity and complications, and the postoperative scar. Results: The average time required to do submental intubation was 8.35 min versus 30.75 min required to do elective tracheostomy with significant difference (p < 0.0001). No complication was reported with submental intubation while in elective tracheostomy group, surgical emphysema was registered in two patients. The submental scar was acceptable in all patients while the tracheostomy scar needs scar revision in four cases (p = 0.0325). Conclusion: Submental endotracheal intubation appeared to be a simple, safe, and significantly faster reliable alternative to tracheostomy during surgical reconstruction of selected cases of maxillofacial fractures without indication for prolonged postoperative ventilation support with significantly lower morbidity. [ABSTRACT FROM AUTHOR]

Introduction: Armored removable connector tubes are not always available in operating rooms for routine Altemir submental intubation (SMI) technique. The present study addresses a fiber-optic glidoscopy assisted 2-tubes modification of Green & Moore sequence for submandibular intubation. Methods: The sample was composed of 11 patients (8 males and 3 females) with panfacial fractures where neither the oral and nasal intubation techniques nor tracheostomy were feasible. The inter-operative procedure duration was recorded and a comparison was made between the present results with those obtained in similar studies. Moreover, postoperative complications were assessed over a duration of6 months. Results: The average duration of this modified procedure was 8-13 min. (Mean, 10.54 ± 1.75 min). No perioperative or postoperative complications were observed. Based on the findings in this study, it is suggested that this new technique is safe, quick and reliable for submandibular intubation. Conclusion: This modification establishes a secure airway for treatment of maxillofacial panfacial fractures, where traditional methods are impossible due to non-detachable connector tubes. No perioperative or postoperative complications were observed. This study suggests that this new technique is safe, quick and reliable for submandibular intubation [ABSTRACT FROM AUTHOR]

Aim: This study was designed to evaluate the efficacy of awake oral to submental conversion over asleep technique. Materials and Methods: This randomized clinical study was conducted in maxillofacial department of a tertiary care hospital in patients who had panfacial or mandibular fractures requiring elective surgical correction. The patients were randomly divided into two groups of 12 patients each, asleep fiberoptic-assisted submental intubation (SMI) (Group G; n = 12) and awake fiberoptic-assisted SMI (Group A; n = 12). The primary predictor was mean conversion time of oral to SMI while other predictors were overall success rate, ease of conversion, and complications. Data are presented as mean (±standard deviation) and frequencies (%) as appropriate. Statistical analysis done using unpaired f-test or Chi-square test was performed and P < 0.05 was considered statistically significant. Results: Twenty-four patients (19:5;Male:Female) aged 18-55 years (Group G = 35.96; Group A = 32.43 years) were included in the study. SMI was successful in all except two patients in group G. Overall success rate was similar in both groups. Time to convert orotracheal intubation to SMI was significantly less in group A (Group G = 9.55 ± 1.42, Group A = 5.67 ± 1.73; P < 0.001). Ease of SMI was found Grade I in 30% and 83% of the patients of group G and A, respectively. No serious complications were observed except 2 cases of bleeding, and 1 case of tube damage. Conclusion: Awake oral to submental conversion requires lesser time in comparison to asleep technique besides improving the ease (A = 53%) of the procedure. [ABSTRACT FROM AUTHOR]

Purpose: Submental intubation is widely accepted as a safe and effective alternative to nasal intubation or tracheostomy in head and neck surgery patients. Forceful or careless technique can cause significant bleeding and trauma to the soft tissues at this point, increasing the likelihood of troublesome sublingual haematoma. Methods: We describe the use of a percutaneous tracheostomy horn (Cook Medical Blue Rhino) to allow minimally traumatic submental intubation without the need for serial dilations. A patient with severe midfacial injuries requiring surgery was intubated via a standard oral technique. Following this, submental access was achieved using a novel dilational technique with a tracheostomy dilator. This resulted in a very secure and safe submental intubation and unrestricted access to the entire surgical field. Results: The single instrument, one-pass dilation technique to achieve submental intubation was found to be easy, quick, and avoided excessive trauma to the floor of mouth. Conclusion: Patients will sometimes require a protected airway that allows surgeons unrestricted and simultaneous access to the dental occlusion, oral cavity, midface, and nose. In our case, this simple, easy, and quick adaptation of an established technique using a tracheostomy dilator is an excellent alternative to the traditional blunt dissection used to achieve submental intubation. [ABSTRACT FROM AUTHOR]

In 1986 Altemir, for the first time, described submental intubation for maxillofacial cases. A problem with the technique is that the edges of the tube may damage the anatomic tissues of the mouth floor. To avoid such damages, a modification of this technique using nasal speculum is presented here. Moreover, with this technique blood and detached tissues cannot enter into the endotracheal tube while passing through submental tissues.

Submental intubation is an interesting alternative to tracheostomy, especially when short-term postoperative control of airway is desirable with the presence of undisturbed access to oral as well as nasal airways and a good dental occlusion. Submental intubation with midline incision has been used in 10 cases from October 2008 to March 2010 in the Department of Oral and Maxillofacial Surgery, Manipal College of Dental Sciences, Mangalore. All patients had fractures of the jaws disturbing the dental occlusion associated with fracture of the base of the skull, or/and a displaced nasal bone fracture. After standard orotracheal intubation, a passage was created by blunt dissection with a haemostat clamp through the floor of the mouth in the submental area. The proximal end of the orotracheal tube was pulled through the submental incision. Surgery was completed without interference from the endotracheal tube. At the end of surgery, the tube was pulled back to the usual oral route. There were no perioperative complications related to the submental intubation procedure. Average duration of the procedure was less than 6 minutes. Submental intubation is a simple technique associated with low rates of morbidity. It is an attractive alternative to tracheotomy in the surgical management of selected cases of panfacial trauma.

Background: Submental intubation is an alternative to nasal intubation and tracheostomy in maxillofacial trauma. In this case report, we present our middle submental intubation experience in a maxillofacial trauma patient. Case: A 29-year-old ASA-1 female patient who had an in-vehicle traffic accident was admitted to the operating room with internal fixation and close reduction plan of the zymotic bone, multiple nasal bones, and LeForte fractures. She had bilateral femur fractures and a right elbow fracture. Her mouth opening was limited to 2 cm due to temporomandibular joint pain. After standard monitoring and anesthesia induction, orotracheal intubation with a 7.5 mm spiral endotracheal tube was performed by video laryngoscope. After intubation, a 1.5 cm midline submental incision was made and a foley catheter was inserted into the oropharynx through this incision by the help of the surgeon. Intubation tube was attached to foley catheter and pulled out from incision (Figure). At the end of surgery, the endotracheal tube was pushed back into the oropharynx and incision was sutured. Extubation was performed after reversing muscle relaxation with sugammadex. After a 4-day follow-up, patient was discharged. Incision was healed with a cosmetic minimal scarring and without any infection. Discussion: Nasal intubation is contraindicated during maxillofacial injuries that involves Leforte fracture and nasal area when occlusion should be supplied during fracture reduction and fixation. Although tracheotomy is an alternative in this patient group, submental intubation is a better way to supply the airway with minimal trauma and scarring. Submental intubation, described by Altemir in 1986, is a fast and simple technique with minimal morbidity and complication rate that can be used as an alternative to nasal intubation and tracheostomy. There are limited numbers of case series and reviews about submental intubation in the literature. We chose midline incision because it is anatomically safer and less scarring than lateral. Furthermore, we used a Foley catheter as a guide to endotracheal tube to reduce tissue damage. Conclusion: Submental intubation is a good, safe, less invasive and easy alternative in maxillofacial surgeries when oral or nasal intubation is not possible or tracheotomy is required. [ABSTRACT FROM AUTHOR]

Purpose: For nearly four decades, submental intubation (SI) has been introduced and employed to avoid tracheostomy in facial trauma cases where nasal/oral intubation is infeasible or associated with possible risks. The purposes of this study were to estimate the frequency and to identify variables associated with complications of SI (CSI)., Methods: The authors organised a retrospective cohort study and enrolled a group of patients with facial trauma and SI during a seven-year interval at two German level one trauma centres where SI has routinely been used in complex facial trauma cases. The predictor variables included demographic, medical, dental, fracture-related, operative, and postoperative parameters. The outcome variable was CSI. We used descriptive, bivariate, and multivariate analyses at the 0.05 significant level., Results: The sample included 339 patients (24.5% females, 9.4% had complications) with an average age of 58.2 ± 12.0 years (range, 17-89). Bivariate analyses revealed nine significant variables. However, forward stepwise multiple logistic regression modelling identified three variables statistically associated with CSI: smoking (OR, 691.8; 95% CI, 75.9 to 6303.9; P < 0.0001; number needed to harm [NNH], 6), moderate to high gingival inflammation (OR, 786.7; 95% CI, 66 to 9378.9; P = 0.002; NNH, 12), and postoperative use of chlorhexidine mouthwash (OR, 0.03; 95% CI, 0.001 to 0.77; P = 0.0003; number needed to treat [NNT], 2)., Conclusions: smokers and subjects with gingivitis were more likely to experience CSI. Postoperative chlorhexidine rinsing was the potentially modifiable, albeit low-OR, factor. These findings could help to draw an effective guideline against the CSI., Competing Interests: Declaration of Competing Interest The authors indicate full freedom of investigation and manuscript preparation. There was no potential conflict of interest as regards this study., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)

Patients with multiple fractures involving upper third of the face, the mid-face and the lower third are generally referred to as Panfacial fractures and managing these cases is extremely complicated. Proximity of the maxillofacial region to the important features or senses such as visual function (diplopia), olfaction, respiration (airway management), chewing or mastication (occlusion), deglutition and aesthetics; makes the scenario a little more complex for the surgeon operating in this particular region than the surgeon operating any other part of the body. Inability to directly visualize and reduce all the components of a pan facial injury along with inadequate stability of the fractured bones leads to persistent deformity. It is challenging to follow an established pattern for repairing the pan facial fractures. Each case with this type of fracture is unique and requires skill and expertise of the surgeon to restore the pre-traumatic anatomy and facial aesthetics. Despite all the aggressive treatment, most of the patient’s with pan facial trauma may have some residual deformity which may require another correction surgery later. This article briefs about the management and simple approaches used to reduce and fix a case of pan facial trauma in a 23-yearold male.

In patients with concomitant occurrence of maxillofacial and basilar skull fractures, open reduction and internal fixation is the treatment. It requires intermittent intra operative dental occlusion which precludes oral or nasal intubation. In such cases submental intubation (SMI) is a recognized technique in practice. We describe a modified technique for smooth exteriorization of the endotracheal tube (ETT) during SMI. As the SMI technique is unusual for the performer, emphasis is laid on the applied aspects to minimize probable complications during the procedure. With the modified technique we performed SMI uneventfully on five patients. [ABSTRACT FROM AUTHOR]

Introduction: Securing an airway in maxillofacial injuries remains a challenge and is an important objective on the part of a maxillofacial surgeon to thoroughly understand its management. Purpose: The aim of this study was to evaluate the efficacy and complications of submental intubation in the management of midfacial/panfacial trauma patients where oro-endotracheal or naso-endotracheal intubation is contraindicated and tracheostomy can be avoided. Patients and Methods: Twenty patients with maxillofacial injuries were selected for submental intubation who were admitted in Kamineni Hospital, Narketpally, Nalgonda during a 2 year period (2010-2012). The parameters used to assess the efficacy were; restoration of the occlusion, duration of the surgery, presence of scar, presence of infection, damage to vital structures or any post-operative salivary fistula. Results: Submental intubation allowed reduction and fixation of all fractures without the interference of the tube during surgical procedure in all of the patients. There were no intra-operative complications and none of the patients required post-operative ventilation. There were no significant post-operative complications. However, in one of the cases (case 4) infection of submental wound was seen and in another case (case 11) salivary fistula was formed. Both the cases were appropriately managed without any difficulty. The submental scar was well accepted by all the patients. Conclusion: Submental intubation is a safe and extremely useful procedure in severe maxillofacial injuries. It presents a low incidence of operative and post operative complications. It allows both the surgeon and the anaesthetist to deliver a better quality of patient care. [ABSTRACT FROM AUTHOR]

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Background: Maxillofacial trauma is an apt example of a difficult airway. The anesthesiologist faces challenges in their management at every step from airway access to maintenance of anesthesia and extubation and postoperative care. Methods: A retrospective study was done of 288 patients undergoing surgery for maxillofacial trauma over a period of five years. Demographic data, detailed airway assessment and the method of airway access were noted. Trauma scores, mechanism of injury, duration of hospital stay, requirement of ventilator support were also recorded. Complications encountered during perioperative anaesthetic management were noted. Results: 259 (89.93%) of the patients were male and 188 (62.85%) were in the 21-40 year range. 97.57% of the cases were operated electively. 206 (71.53%) patients were injured in motor vehicular accidents. 175 (60.76%) had other associated injuries. Mean Glasgow coma scale score (GCS), injury severity score (ISS) and revised trauma score (RTS) were 14. 18, 14. 8 and 12, respectively. Surgery was performed almost nine days following injury. The mean duration of hospitalization was 16 days. ICU admission was required in 22 patients with mean duration of ICU stay being two days. Majority of patients had difficult airway. 240 (83.33%) patients were intubated in the operating room and fibreoptic guided intubation was done in 159 (55.21%) patients. Submental intubation was done in 45 (14.93%) cases. Conclusions: Maxillofacial injuries present a complex challenge to the anaesthesiologist. The fibreoptic bronchoscope is the main weapon available in our arsenal. The submental technique scores over the time-honored tracheostomy. Communication between the anaesthesiologist and the surgeon must be given paramount importance. [ABSTRACT FROM AUTHOR]