Anesth Analg 2005;101:1893-1894
© 2005 International Anesthesia Research Society
LETTER TO THE EDITOR
Retrograde Submental Intubation After Faciomaxillary Trauma
Virendra K. Arya, MD*,
Arun Kumar, MD*,
Surinder S. Makkar, MS, MCh
, and
Ramesh K. Sharma, MS, MCh
Departments of *Anaesthesia and Intensive Care and Plastic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India, aryavk_99{at}yahoo.com
In Response:
The craniofacial injuries described in our case report included a depressed fracture frontal bone left side, bilateral fracture zygoma, fractured nasal bones, LeFort II fracture, midpalatal split, and symphyseal mandibular fracture with bilateral temporomandibular joint dislocation leading to immobility of the lower jaw (1). In this patient the nasal airways were grossly distorted because of extensive nasoethmoidal fractures. This is quite obvious from the preoperative three-dimensional reconstruction computed tomography and axial cut scans (Fig. 1). The patient had extensive saddling of the nose resulting from loss of support to the nasal dorsum from the injury. Our surgical team planned a single-stage reconstructive surgical procedure for his faciomaxillary injuries. The nasoethmoidal fractures were also managed at the same time utilizing cantilever cranial bone graft in addition to mandibular and intermaxillary fixation. This would not have been possible with nasal intubation. The postoperative picture of the patient (Fig. 2) shows improvement in the nasal profile that could only be achieved as a result of free surgical access to nose and the whole of the face with submental intubation.
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Figure 1. Preoperative three-dimensional reconstruction computed tomography and axial cut scans showing grossly distorted nasal airways because of extensive nasoethmoidal fractures. The arrows point to the fracture lines in nasoethmoidal bones.
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Figure 2. Picture of the patient at 6 month follow-up showing improvement in the nasal profile. The nasoethmoidal fractures were also managed at the same time utilizing cantilever cranial bone graft in addition to mandibular and intermaxillary fixation facilitated by retrograde submental intubation. The arrow indicates the postoperative improved profile of the nose by one-stage repair of nasoethmoidal fracture along with other facial fractures.
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There are case reports of successful fiberoptic nasotracheal intubation in trauma victims with frontobasal fractures with or without cerebrospinal fluid rhinorrhea without any adverse sequel (2–6). However, in all these case reports, surgical repair was limited to mandibular, palatal and intermaxillary fixation without nasoethmoidal fractures being managed surgically at the same time. Our case was unique in that the patient had midfacial injuries in addition to other craniofacial injuries that were managed simultaneously.
The finding of midpalatal split, nasoethmoidal bone fractures along with midface motion abnormality and surgical considerations of single-stage repair in a difficult airway situation discouraged us from attempting fiberoptic assessment in an awake patient for feasibility of fiberoptic nasotracheal intubation. We were not sure about the adequacy of topical anesthesia in traumatized inflamed nasal mucosa and any bleeding during nasal manipulation of fiberscope would have ruined the whole exercise. Moreover, even if fiberoptic nasotracheal intubation had been possible in our case, it would not have benefited the patient to repair all the facial injuries in one stage.
In conclusion, it was not a question of possibility of fiberoptic nasotracheal intubation in our case but an overall assessment of the patient’s condition, difficult airway situation, patient’s ability to cooperate in a particular technique of intubation, benefits of single versus multistage surgical repair, and our previous experience of dealing with difficult airway situations (7) that led us to attempt retrograde submental intubation by pharyngeal loop technique.
References
- 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]
- Arrowsmith JE, Robertshaw HJ, Boyd JD. Nasotracheal intubation in the presence of frontobasal skull fracture. Can J Anaesth 1998;45:71–5.[Abstract/Free Full Text]
- Bahr W, Stoll P. Nasal intubation in the presence of frontobasal fractures: a retrospective study. J Oral Maxillofac Surg 1992;50:445–7.[ISI][Medline]
- 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.[ISI][Medline]
- 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.[Abstract/Free Full Text]
- 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]
- Arya VK, Dutta A, Chari P, Sharma RK. Difficult retrograde endotracheal intubation: the utility of a pharyngeal loop. Anesth Analg 2002;94:470–3.[Abstract/Free Full Text]
