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Paper text:
submental intubation allows unhindered access to the airway and facilitates reduction and fixation of complex maxillofacial fractures for which simultaneous access to nasal pyramid fractures and/or dental occlusion are required .
current techniques of submental intubation involve blunt dissection in the floor of the mouth ( with its potential for injury to the vessels , nerves , and glands ) to create a submental passage through which the proximal end of a reinforced tracheal tube is pulled out after initial orotracheal intubation .
the seldinger technique using a percutaneous dilatational tracheostomy kit ( pdtk ) ( cook critical care , europe ) offers an interesting alternative to the classical blunt dissection technique .
four patients with maxillofacial trauma posted for surgery during the period from august 2012 to january 2013 were planned to be subjected to submental intubation .
institutional ethical committee approval and informed and written patient consent was obtained.thorough preanaesthetic evaluation was followed by usual preparation for anaesthesia .
a 7 mm i d reinforced endotracheal tube was selected to be used in the procedure .
its connector was removed and then reconnected to ensure that these steps would easily be carried out subsequently during the procedure .
following general anaesthesia and neuromuscular blockade , oral endotracheal intubation was performed in the standard way using the preselected tube referred to earlier and controlled ventilation was commenced following connection to the breathing system .
we passed the seldinger needle either ( 1 ) in the mid submental region ( submental approach ) just inferior to the lower border of the mandible or ( 2 ) in the paramedian submental region , directly adjacent to the medial aspect of the lower border of the mandible ( transmylohyoid approach ) depending on the surgical need as shown in figure 2a .
we then passed the guide wire through the needle so that it emerged into the oral cavity where it was grasped firmly by an assistant .
, we passed successively large serial dilators starting with the white introducer through the skin into the oral cavity as shown in the figures 2b and 3a .
over the white introducer , the lubricated blue tracheal dilators were passed to emerge into the oral cavity with a twisting motion thereby gradually dilating the path to accommodate the preselected reinforced tracheal tube .
then , the tracheal tube was disconnected from the breathing system and the connector that was pretested for easy removal was removed .
the pilot balloon after deflation was grasped with an artery forceps and pulled from within the mouth to the exterior . while stabilizing the tracheal end of tube with one hand , the proximal end of the tube
the connector was then reattached to the tracheal tube and the breathing system was reconnected .
the patients were ventilated with 100% oxygen for about 3 min during the period of interruptions to ventilation when the tube was made to emerge externally through the tract created . after ensuring bilaterally equal air entry ,
percutaneous tracheostomy set ( cook critical care ) ( a ) insertion of needle with cannula .
( b ) passing guide wire and sheath through cannula ( a ) insertion of needle with cannula .
( b ) endotracheal tube brought out at the end of the procedure , the deflated pilot balloon and the tracheal tube were pulled in reverse order into the oral cavity and the breathing system was reattached .
following extubation , the skin wound was closed and no attempt was made to close the intraoral opening .
the dilatational technique for submental intubation was performed in 4 cases on a pilot basis and the procedure could be completed in less than 10 min .
no complications such as haemorrhage , injury to the sublingual glands , wharton 's duct , lingual nerve or any fistula were encountered .
ventilation interruption lasted approximately 2 min and there was no significant desaturation in any patient .
the intraoral wound healed spontaneously without sutures and the cutaneous wound with a reasonably acceptable scar .
complex maxillofacial injuries demand special anaesthetic considerations as far as the route for securing the airway is concerned .
anaesthesia for these procedures requires securing the airway either by orotracheal or nasotracheal intubation or via a tracheostomy .
when neither nasotracheal nor orotracheal intubation is suitable , tracheostomy is a traditional method favoured by some surgeons and anaesthesiologists .
tracheostomy is also a major procedure and has its own unique complications such as haemorrhage , subcutaneous emphysema , pneumomediastinum , blockage of tracheostomy cannula , cellulitis , tracheoesophageal fistula , late tracheal stenosis , and problems with decannulation .
submental intubation has been suggested as an alternative technique that offers a secure airway to the anaesthesiologists , an optimal operating field and an opportunity to check dental occlusion for the surgeon and with limited morbidity for the patient .
the submental technique of endotracheal intubation is an accepted technique of airway management in patients with panfacial trauma undergoing corrective surgical procedures .
the existing techniques require the following steps ( 1 ) blunt dissection of the soft tissues in the submental area to create the submental passage ( with its potential for injury to the vessels , nerves , and glands in that area ) .
( 2 ) forcible manipulation of tissue to create a passage with the potential risk of greater tissue damage .
other possible complications include keloid formation , and occasionally mucocoele . in order to overcome these shortcomings , we used percutaneous dilatational tracheostomy kit to modify the technique of submental intubation in four of our patients .
we found that this modification had the following potential advantages over the classical blunt dissection technique .
( 1 ) minimal bleeding because of the use of dilators . ( 2 ) minimal scar formation due to less tissue dissection . ( 3 ) minimal effort to pull the tracheal tube from inside the oral cavity to the outside .
( 4 ) finally , the anesthesiologists would be more comfortable with this modification because of familiarity with the seldinger technique that is regularly used for central venous cannulations .
percutaneous dilatational tracheostomy kit can be used to facilitate submental intubation in maxillofacial surgeries as it causes less tissue trauma , less scarring and gentler manipulations with minimal complications .
airway management is a challenge to anesthesiologists particularly in maxillofacial surgeries . 
 the oral tracheal tube is unsuitable because it interferes with the surgical field and prevents dental occlusion . 
 nasotracheal intubation may not always be possible due to structural deformity or trauma to the nasal bones . 
 tracheostomy and submental intubation have their drawbacks . to overcome these shortcomings we used percutaneous dilatational tracheostomy kit ( pdtk ) to modify the technique of submental intubation . 
 serial dilatations were performed over the guide wire before passing the tracheal tube by submental route , using the pdt kit in four patients . 
 submental intubation could be achieved in all the four cases with this technique and there were no associated complications . 
 seldinger 's technique is a simple and easy technique with minimal bleeding , imperceptible scar , and more importantly anesthesiologists feel more comfortable because of their familiarity with the seldinger technique .