Submental IntubationVideo Type: CVideo
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Author: Clara Lee
Specialties: Oral Maxillofacial, Otolaryngology, Sleep Apnea
Schools: Emory University School of Medicine
Presented is a case of submental intubation performed prior to maxillomandibular advancement for the treatment of obstructive sleep apnea. Submental intubation is a viable alternative to tracheostomy for cases in which nasal intubation is contraindicated (e.g. trauma), or uninterrupted access to the oral cavity is preferred.  Briefly, the technique consists of performing oral intubation, and then exteriorizing the endotracheal tube through a tract created from the floor of mouth to the submental triangle. At the end of the case, the tube can be passed into the oral cavity, returning to an oral intubation.
Surgeon: Raj C. Dedhia, MD, MSCR, Department of Otolaryngology, Emory University School of Medicine
Video Production: Clara Lee, MS4, Emory University School of Medicine
First introduced by Francisco Hernandez Altemir in 1986, submental intubation was described as an alternative to tracheostomy in cases of facial trauma.  Since then, the applications of submental intubation have expanded to include elective orthognathic surgeries and skull base surgery. 
Trauma, elective facial osteotomy, transmaxillary cranial base tumor access, cancrum oris. 
Perturbed nasal anatomy, nasal-orbital-ethmoidal fractures, skull base fractures, cerebrospinal fluid rhinorrhea or extensive soft tissue swelling. 
a. Use of a reinforced endotracheal tube will prevent kinking.
b. Loosening the hub of the endotracheal tube with a mosquito prior to intubation will facilitate circuit disconnection and reconnection.
c. Placing a bite block and retracting the tongue with a Sweetheart will improve visibility.
d. Record the intraoral measurement of the endotracheal tube (cm) and ensure position has not changed following externalization.
Candidates are identified based on clinical scenario (e.g. trauma) or type of surgery.
Anatomy and Landmarks
The neck incision is placed away from midline to avoid disruption of the genioglossus insertion to the genial tubercle. The incision is also placed medial to the angle of the mandible to avoid injury to the marginal mandibular nerve or Wharton’s ducts.
Advantages: undisrupted access to the oral cavity, no risk of endotracheal tube balloon or cuff injury during surgery, avoidance of tracheostomy, time efficient (average 9.9 minutes) 
Disadvantages: postoperative edema, scar formation, potential damage to nearby anatomical structures including Wharton’s ducts and genioglossus attachment
Superficial skin infections, damage to tube apparatus, fistula formation, right mainstem bronchus tube dislodgement/obstruction, hypertrophic scarring 
Disclosure of Conflicts
1. Jundt JS, Cattano D, Hagberg CA, Wilson JW. Submental intubation: a literature review. Int J Oral Maxillofac Surg. 2012;41(1):46-54.
2. Hernandez Altemir F. The submental route for endotracheal intubation. A new technique. J Maxillofac Surg. 1986;14(1):64-65.
3. Eisemann B, Eisemann M, Rizvi M, Urata MM, Lypka MA. Defining the role for submental intubation. J Clin Anesth. 2014;26(3):238-242.