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LETTER TO THE EDITOR

Retrograde Submental Intubation After Faciomaxillary Trauma

Department of Anaesthesia, Papworth Hospital, Cambridge, UK, jarrowsmith{at}doctors.org.uk

To the Editor:

We read with great interest the case report (1) describing the successful use of retrograde submental tracheal intubation in a patient with faciomaxillary trauma. We congratulate the authors for their successful management of their patient and agree that their novel technique is relatively safe and produces acceptable cosmetic results. We are curious, however, to know why the authors completely discounted the use of fiberoptic nasotracheal intubation (NTI). Although every student of anesthesia and virtually every textbook states that NTI is contraindicated in the presence of a basal skull fracture, the evidence for this is surprisingly sparse (2). Contrary to conventional wisdom, what published evidence there is suggests that NTI in patients with cerebrospinal fluid rhinorrhea does not adversely affect outcome (3,4). In patients with an untraumatized airway, the morbidity associated with NTI is reported to be low (5). In patients with faciomaxillary trauma, reports of successful fiberoptic NTI stress the importance of assessing the patency of the nasal passages with computed tomography (2,6,7). We would be very interested to know whether the patient described by Arya et al. had specific computed tomography findings that absolutely precluded fiberoptic NTI. If the nasal passages were not distorted or obliterated, might NTI have been feasible?

References

1. Arya VK, Kumar A, Makkar SS, Sharma RK. Retrograde submental intubation by pharyngeal loop technique in a patient with faciomaxillary trauma and restricted mouth opening. Anesth Analg 2005;100:534–7.[Abstract/Free Full Text]
2. Arrowsmith JE, Robertshaw HJ, Boyd JD. Nasotracheal intubation in the presence of frontobasal skull fracture. Can J Anaesth 1998;45:71–5.[Web of Science][Medline]
3. Bahr W, Stoll P. Nasal intubation in the presence of frontobasal fractures: a retrospective study. J Oral Maxillofac Surg 1992;50:445–7.[Web of Science][Medline]
4. Rhee KJ, Muntz CB, Donald PJ, Yamada JM. Does nasotracheal intubation increase complications in patients with skull base fractures? Ann Emerg Med 1993;22:1145–7.[Web of Science][Medline]
5. O’Connell JE, Stevenson DS, Stokes MA. Pathological changes associated with short-term nasal intubation. Anaesthesia 1996;51:347–50.[Web of Science][Medline]
6. Ng KF, Lo CF. The bamboo skewer: airway management in a patient with penetrating injury of the floor of mouth. Can J Anaesth 1996;43:1156–60.[Web of Science][Medline]
7. Joly LM, Oswald AM, Disdet M, Raggueneau JL. Difficult endotracheal intubation as a result of penetrating cranio-facial injury by an arrow. Anesth Analg 2002;94:231–2.[Abstract/Free Full Text]

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