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*Departments of Anaesthesia & Intensive Care and Plastic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
Address correspondence and reprint requests to Virendra K. Arya, MD, Assistant Professor, Department of Anesthesia & Intensive Care, PGIMER Chandigarh-160012, India. Address e-mail to aryavk_99{at}yahoo.com.
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Introduction |
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Case Report |
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In view of the surgical considerations (i.e., the presence of LeFort II fracture, palatal split and history of cerebrospinal fluid rhinorrhea) nasal intubation was excluded. Orotracheal intubation was not possible because of the locked jaw and the need for intraoperative maxillomandibular fixation to check dental occlusion. Tracheostomy would have been an appropriate option to secure the airway under these circumstances if multistage reconstructive surgery was planned, with challenges of a difficult airway each time and significant risk of prolonged postoperative airway compromise resulting from soft tissue edema. However, our surgical team planned a single-stage corrective procedure, as they felt that this would normalize mouth opening, improve airway caliber, and provide a better supportive framework to the soft tissues. Moreover, edema associated with trauma had subsided at this time and application of internal fixators to the fractured bones did not involve much tissue handling. Hence, submental intubation, if safe and feasible, was considered as a suitable alternative to avoid a short-term tracheostomy. However, in this case the conventional technique (4) and subsequent modifications (9–16) of submental intubation were impracticable, as the initial step of orotracheal intubation was not possible because of restricted mouth opening.
We planned to attempt an awake retrograde submental intubation with the aid of a pharyngeal loop, a device we designed and described (17). In case of failure of this technique or an urgent need for airway control, a cricothyroidotomy set designed by us was ready for use (Fig. 3). The procedure was explained in detail to the patient and an informed consent was obtained both for the procedure and for an emergency cricothyroidotomy.
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Preoperative preparations of the patient included 8-h fasting, and aspiration prophylaxis with oral ranitidine 150 mg and metoclopramide 10 mg the night before and 2 h before surgery with a sip of water. An injection of glycopyrrolate 0.4 mg IM was used as an antisialagogue. To obtain oropharyngeal anesthesia the patient sipped 4% viscous lidocaine, held it in his mouth, moved his tongue around inside his mouth, extended his neck, and attempted to gargle. On arrival in the operating room, routine monitoring (electrocardiography, pulse oximetry, and automated noninvasive blood pressure cuff) was applied and oxygen was supplemented through a Ventimask. An IV line was secured and an injection of morphine sulfate 7.5 mg was administered to produce mild sedation and anxiolysis. Using an aseptic technique the skin of the neck and submandibular area was cleaned with 2% Betadine solution and sterile drapes were applied. Laryngeal anesthesia was provided by 4 mL of transtracheal 4% lidocaine injected through cricothyroid membrane puncture and by blocking the internal branch of the superior laryngeal nerve using 1 mL of 2% lidocaine on either side. A 14F disposable suction catheter was passed into the oropharynx through the retromolar space whenever required by retracting the cheek with a spatula and was used to remove any secretions or blood.
A pharyngeal loop (17) (ureteral guide wire threaded through a 3 mm uncuffed polyvinyl chloride endotracheal tube [ETT] and doubled up to form a small loop) was introduced through the minimal inter-incisor gap orally at the point of maximal width (Fig. 2, black arrow). Once inside, the loop was expanded to the maximum to touch the posterior pharyngeal wall. Afterwards, the cricothyroid membrane was punctured with an 18-gauge cricothyrotomy minitrach needle, and a radio-opaque ureteral guidewire with soft J-tip (0.89 mm x 150 cm; Terumo-Europe NV, Leuven, Belgium) was advanced retrograde through it until some resistance was felt. The pharyngeal loop was then gently tightened and slowly withdrawn, orally retrieving the guidewire that was passed through the cricothyrotomy puncture.
After local infiltration with 2% lidocaine, a 1.5-cm skin crease incision was subsequently made in the left submental region by the operating plastic surgeon, just medial to the lower border of the mandible approximately one-third of the way from the symphysis to the angle of mandible, as described by Amin et al. (8) and Altemir et al. (18). Blunt dissection with a curved artery forceps was carefully performed to enter the oral cavity, and proper hemostasis was achieved. The same pharyngeal loop was now introduced through this incision and directed towards the incisors and taken out through the mouth. Using this loop the retrograde guidewire was brought out of the submental incision.
Afterwards, keeping the head and neck in full extension, a tube exchanger (Cook Critical Care, Bloomington, IN) was threaded and advanced over the guidewire through the submental incision into the trachea. The guidewire was removed and the intratracheal position of the tube exchanger was confirmed using end-tidal carbon dioxide waveform. Subsequently, a 32F flexometallic (Rusch, Germany) ETT with its connector was successfully threaded over the well-lubricated tube exchanger using gentle rotational movement. The ETT cuff was inflated, the tube exchanger was removed, and the breathing system was connected. After ensuring bilateral equal air entry, the ETT position was secured with skin sutures (Fig. 4). General anesthesia was induced and ventilation was controlled.
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The 6-h surgery proceeded uneventfully and dental occlusion was restored by means of intraoperative maxillomandibular fixation. The neuromuscular blockade was reversed at the end of the surgery and the patient was transferred to the postanesthesia recovery room with the submental ETT in situ. The patient was successfully tracheally extubated after 6 h once he was fully awake and able to cough and protect his airway. The submental incision was closed using two monofilament skin sutures, and sterile dressing was applied. The patient received broad-spectrum antibiotics perioperatively and was advised to do oral washes with 0.12% chlorhexidine mouthwash. The submental incision healed with good cosmetic appearance and without specific complications.
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Discussion |
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When a fiberscope is not available for difficult intubations, we usually use the pharyngeal loop designed by us for retrograde intubation (17). It was decided to use this device for a retrograde submental intubation in the present situation. With the restricted mouth opening, suctioning and maintaining a clear airway would be very difficult in the event of an oropharyngeal bleed initiated from the submandibular incision or other invasive manipulations. Inserting a suction catheter through the retromolar space into the oropharyngeal cavity and using a stand-by cricothyroidotomy set was our contingency plan in the event of such oral bleeding. However, no problems were encountered.
In view of the nature of faciomaxillary injuries, and the possibility of the retrograde guidewire inadvertently entering the traumatized soft tissue planes or coming out through the nares, the oral pharyngeal loop was intentionally used to retrieve the retrogradely inserted guidewire. A tube exchanger helped us correctly and easily place the flexometallic tube. Drolet et al.(13) have also reported using a lubricated tube exchanger to replace a tracheal tube that was damaged while being pulled through the submental incision.
There are technical problems with the original techniques described (4,9–16). Because of the tight seal of the connector with the flexometallic ETT, it is difficult to separate the connector and tube during the transfer from the oropharynx through the submandibular tract. Moreover, damage to the ETT and pneumatic cuff as a result of being grabbed with forceps during retrieval through the submental tract has been reported (13,16). Amin et al. (8) recommended the Euro-Medical ILM ETT designed for use with an intubating laryngeal mask airway as ideal for submental intubation as the connector is specially designed for detachment and reattachment. In our technique, the ETT was inserted submentally directly over a previously positioned tube exchanger, thus avoiding the need for connector detachment or first securing the airway with a regular orotracheal tube, which was also unfeasible in our patient.
Retromolar intubation has been described as an alternative to submental intubation (19). We could have positioned the thin guidewire in the retromolar space after its successful oral retrieval. However, we deferred this, as the subsequent steps of negotiating the tube exchanger and ETT through this tract could have been difficult and very painful for the patient because of his dislocated jaw and his inability to open his mouth.
We did not tracheally extubate our patient in the postoperative period until he was fully awake and able to protect his airway, considering the maxillomandibular fixation and the possibility of soft tissue edema. During ETT suction, difficulty was encountered in negotiating the suction catheter because of the acute curvature of the ETT. This was overcome by extension of the patient’s head and lubricating the suction catheter.
Gordon and Tolstunov (20) have reported a case in which the submental tube was left in place for 3 days without complications. In the series of 25 submental intubations reported by Caron et al. (6), two patients had their tubes maintained postoperatively for approximately 30 hours.
The indications and contraindications for conventional submental intubation are outlined by Chandu et al. (7) and Meyer et al. (21). They described this technique as contraindicated when long-term control of the airway is required postoperatively. In our case there was no indication for prolonged postoperative airway control or risk of losing the airway; hence, preventing a short-term tracheostomy by retrograde submental intubation was justified. The modification of submental intubation to the retrograde technique with the use of a pharyngeal loop saved our patient from the morbidity associated with a short-term tracheostomy. The indications and contraindications for retrograde submental intubation technique are outlined in Table 1.
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In conclusion, the successful use of a pharyngeal loop assembly made it possible to perform retrograde submental tracheal intubation in a patient in whom oral and nasal intubations were either contraindicated or not possible, thus broadening its utility as an important aid to difficult airway situations.
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This article has been cited by other articles:
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  P. Saravanan and J. E. Arrowsmith Retrograde Submental Intubation After Faciomaxillary Trauma Anesth. Analg., December 1, 2005; 101(6): 1892 - 1893. [Full Text] [PDF]
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V. K. Arya, A. Kumar, S. S. Makkar, and R. K. Sharma Retrograde Submental Intubation After Faciomaxillary Trauma Anesth. Analg., December 1, 2005; 101(6): 1893 - 1894. [Full Text] [PDF]
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