orotracheal intubation is not suitable for assessing the dental relationship and occlusion , and nasotracheal intubation is contraindicated in patients with nasoorbitoethmoidal fractures or fractures of the base of the skull owing to potential complications such as cerebrospinal fluid leakage and meningitis .
tracheostomy provides an alternative , surgical intervention , but can be associated with increased post - operative care , complication rates , and morbidity .
we present two cases of submental intubation using a reinforced endotracheal tube with non - detachable universal connector in patients with complex maxillofacial trauma .
an 18-year - old male patient ( 60 kg , 170 cm ) was scheduled for open reduction and internal fixation of a nasoorbitoethmoidal fracture ( fig .
preliminary investigations indicated that he was otherwise healthy , with preanesthetic evaluation being unremarkable except for signs of sinus bradycardia ( 41 bpm ) .
as intra - operative assessment of dental occlusion was required , orotracheal intubation was not indicated , with nasotracheal intubation also being inappropriate due to his nasoorbitoethmoidal fracture . in order to avoid tracheostomy ,
the patient was monitored with pulse oximetry , electrocardiography , and noninvasive blood pressure measurements . before anesthetic induction ,
after preoxygenation with 100% oxygen for 3 minutes , anesthesia was induced with propofol ( 100 mg ) and fentanyl ( 100 g ) .
after successful ventilation with a facial mask , rocuronium ( 50 mg ) was administered intravenously .
prior to intubation , the universal connector of a reinforced endotracheal tube ( ett ) was detached gently from the tube and reattached so that it could be easily disconnected during the procedure ( fig .
orotracheal intubation was performed using a 7.5-mm - internal diameter reinforced ett ( lo - contour oral / nasal tracheal tube cuffed , mallinckrodt , ireland ) .
anesthesia was maintained with sevoflurane and 100% oxygen to increase the apneic reservoir during the procedure .
approximately 3 cm lateral to the mandibular midline , a submental horizontal incision ( of 1.5 cm ) was placed a fingerbreadth below the mandibular inferior border .
blunt dissection toward the mouth floor was performed using a thin mosquito hemostat , forming an orocutaneous tunnel .
a kelly forceps was then introduced through the tunnel from the outside to widen it .
at that moment , the ett was disconnected from the ventilator circuit , and its connector was removed .
the ett was then grasped by the tip of the kelly forceps and pulled out through the tunnel of the sub - mental incision , followed by the pilot balloon . after the ett was shifted ,
then , the ett was repositioned using magill forceps , and a stay suture was applied with silk in order to fix the tube to the skin to prevent accidental extubation ( fig .
, the stay suture was removed , and the ett with a pilot balloon was retracted from the oral cavity , removed via the mouth , and brought back to the orotracheal position .
the submental incision was layer - sutured , and wet gauze dressing was applied at the site of the wound at the mouth floor to facilitate secondary healing .
following the procedure , extubation was performed , and the patient was transferred to the post - anesthetic care unit .
the post - operative period was unremarkable , and there was negligible submental scarring at two months post - operation . a 48-year - old male patient ( 65 kg , 175 cm ) sustained bilateral orbital wall and maxillary fractures with a skull - base fracture after a motor vehicle accident .
he had undergone brain surgery for epidural hematoma removal 11 days prior . as his level of consciousness was alert , intubation following the operation was unnecessary .
the patient was monitored with pulse oximetry , electrocardiography , and noninvasive blood pressure measurements .
after preoxygenation with 100% oxygen for 3 minutes , anesthesia was induced with propofol ( 80 mg ) and rocuronium ( 50 mg ) .
following orotracheal intubation with a reinforced ett ( internal diameter , 7.5 mm ) , the tube was removed through the submental area using the aforementioned method .
after the operation , the patient was transferred to the intensive care unit and was extubated at post - operative day 1 .
an 18-year - old male patient ( 60 kg , 170 cm ) was scheduled for open reduction and internal fixation of a nasoorbitoethmoidal fracture ( fig .
preliminary investigations indicated that he was otherwise healthy , with preanesthetic evaluation being unremarkable except for signs of sinus bradycardia ( 41 bpm ) .
as intra - operative assessment of dental occlusion was required , orotracheal intubation was not indicated , with nasotracheal intubation also being inappropriate due to his nasoorbitoethmoidal fracture . in order to avoid tracheostomy ,
the patient was monitored with pulse oximetry , electrocardiography , and noninvasive blood pressure measurements . before anesthetic induction ,
after preoxygenation with 100% oxygen for 3 minutes , anesthesia was induced with propofol ( 100 mg ) and fentanyl ( 100 g ) .
after successful ventilation with a facial mask , rocuronium ( 50 mg ) was administered intravenously .
prior to intubation , the universal connector of a reinforced endotracheal tube ( ett ) was detached gently from the tube and reattached so that it could be easily disconnected during the procedure ( fig .
orotracheal intubation was performed using a 7.5-mm - internal diameter reinforced ett ( lo - contour oral / nasal tracheal tube cuffed , mallinckrodt , ireland ) .
anesthesia was maintained with sevoflurane and 100% oxygen to increase the apneic reservoir during the procedure .
approximately 3 cm lateral to the mandibular midline , a submental horizontal incision ( of 1.5 cm ) was placed a fingerbreadth below the mandibular inferior border .
blunt dissection toward the mouth floor was performed using a thin mosquito hemostat , forming an orocutaneous tunnel .
a kelly forceps was then introduced through the tunnel from the outside to widen it .
at that moment , the ett was disconnected from the ventilator circuit , and its connector was removed .
the ett was then grasped by the tip of the kelly forceps and pulled out through the tunnel of the sub - mental incision , followed by the pilot balloon . after the ett was shifted ,
then , the ett was repositioned using magill forceps , and a stay suture was applied with silk in order to fix the tube to the skin to prevent accidental extubation ( fig .
, the stay suture was removed , and the ett with a pilot balloon was retracted from the oral cavity , removed via the mouth , and brought back to the orotracheal position .
the submental incision was layer - sutured , and wet gauze dressing was applied at the site of the wound at the mouth floor to facilitate secondary healing .
following the procedure , extubation was performed , and the patient was transferred to the post - anesthetic care unit .
the post - operative period was unremarkable , and there was negligible submental scarring at two months post - operation .
a 48-year - old male patient ( 65 kg , 175 cm ) sustained bilateral orbital wall and maxillary fractures with a skull - base fracture after a motor vehicle accident .
he had undergone brain surgery for epidural hematoma removal 11 days prior . as his level of consciousness was alert , intubation following the operation was unnecessary .
the patient was monitored with pulse oximetry , electrocardiography , and noninvasive blood pressure measurements .
after preoxygenation with 100% oxygen for 3 minutes , anesthesia was induced with propofol ( 80 mg ) and rocuronium ( 50 mg ) .
following orotracheal intubation with a reinforced ett ( internal diameter , 7.5 mm ) , the tube was removed through the submental area using the aforementioned method .
after the operation , the patient was transferred to the intensive care unit and was extubated at post - operative day 1 .
although orotracheal intubation is the most frequently used route in securing the airway , it interferes with the surgical field and disturbs intra - operative assessment of dental occlusion . as an alternative to orotracheal intubation , nasotracheal intubation
nasotracheal intubation is contraindicated in cases of skull - base trauma due to the incidence of accidental intracranial placement , possible cerebral spinal fluid leakage , and/or meningitis .
tracheostomy is a good route to secure the airway in patients with complex maxillofacial injuries , particularly for those who need prolonged intubation .
however , the procedure is associated with the risk of hemorrhage , pneumothorax , infection , and tracheal stenosis .
, it has been used as an attractive option for intra - operative airway control in specific , complex maxillofacial injuries .
submental intubation is also applied to bimaxillary orthognathic surgeries with simultaneous rhinoplasty or orthognathic surgeries in patients with large pharyngeal flaps or other anatomic anomalies precluding nasotracheal intubation .
other possible indications for this technique are certain base of skull procedures   or cancrum oris .
submental intubation is contraindicated in patients who have severe neurological defects or those who require long - term airway support and maintenance . in these cases ,
tracheostomy should be considered . in patients with a history of severe keloid formation , this technique can be contraindicated . in the first case ,
endotracheal intubation was not indicated because of circumstances that prevented the intra - operative assessment of dental occlusion , with nasotracheal intubation also being inappropriate due to his nasoorbitoethmoidal fracture . as he was healthy , with the exception of his nasoorbitoethmoidal fracture , and
did not require prolonged ventilatory support , the decision to choose submental intubation over tracheostomy had greater significance . in the second case ,
nevertheless , submental intubation was chosen because of his alert mental status in addition to his unrequired use of long - term airway support .
flexible and kink - resistant ett is required to maintain airway patency despite the acute angle of the airway , particularly in the submental route .
ball et al .   reported submental intubation using the flexible tracheal tube supplied with the intubating laryngeal mask ( ilm , intavent , uk ) .
however , it is rare in the market and expensive compared to our reinforced tube ( lo - contour oral / nasal tracheal tube cuffed , mallinkrodt , ireland ) .
the universal connector of a standard reinforced ett , which we used , is bounded firmly to the tube to prevent accidental detachment .
prior to intubation , it is important to detach and reattach the connector gently from ett using mosquito forceps so that it can be easily disconnected during the procedure .
as discussed , tracheostomy is associated with increased postoperative care , complication rate , and morbidity . in comparison ,
the complications associated with submental intubation are less severe and lower in frequency . with respect to surgery ,
as maxillofacial trauma can often result in dental disarrangement , dental occlusion becomes clinically important .
submental intubation removes the ett from the surgical field , thereby providing a clear surgical field that also assists in preventing injuries of the ett .
additional advantages of submental intubation include its minimally invasive nature and the more esthetically acceptable nature of the resulting scar .
the most serious complication is accidental extubation ; however , this can be prevented via a stay suture , as used in our cases .
other complications are superficial skin infections , damage to the ett , tube dislodgement or obstruction , transient lingual nerve paresthesia , venous bleeding , and submental scarring .
the submental intubation technique is a reliable alternative to tracheostomy in patients undergoing complex maxillofacial surgeries who do not require prolonged ventilatory support .
it has minimal morbidity , a low complication rate , and avoids the potential complications associated with tracheostomy .
 airway management in patients with complex maxillofacial injuries is a challenge to anesthesiologists . 
 submental intubation is a useful technique that is less invasive than tracheostomy in securing the airways where orotracheal and nasotracheal intubation can not be performed . 
 this procedure avoids the use of tracheostomy and bypasses its associated morbidities . 
 a flexible and kink - resistant reinforced endotracheal tube with detachable universal connector is commonly used for submental intubation . 
 herein , we report cases involving submental intubation using a reinforced endotracheal tube with a non - detachable universal connector in patients with complex maxillofacial injuries . 
INTRODUCTION
CASE REPORT
1. Case 1
2. Case 2
DISCUSSION