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. [1] 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. [2] Since then, the applications of submental intubation have expanded to include elective orthognathic surgeries and skull base surgery. [3]
Perturbed nasal anatomy, nasal-orbital-ethmoidal fractures, skull base fractures, cerebrospinal fluid rhinorrhea or extensive soft tissue swelling. [1]
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.
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) [1]
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 [1]
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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.
This video shows a transotic approach for a cochlear schwannoma in a 59-year-old female who presented with sudden sensorineural hearing loss in her left three years prior. She was found to have subsequent growth of her tumor on imaging and elected to undergo surgery. The transotic approach is a valuable approach within the armamentarium of a skull base team and differs from the transcochlear approach in the handling of the facial nerve. Techniques for ear canal overclosure, eustachian tube packing and mastoid obliteration are also highlighted.
Here, we have a 39 yrs old female with complaints of noisy breathing for last two years post thyroidectomy. Flexible laryngoscopy confirmed bilateral vocal cord paralysis. She was planned for coblation assisted cordectomy.
Patient was taken up for procedure under general anaesthesia. She also started having stridor after induction. Nasopharyngeal intubation with spontaneous breathing technique was used. Entropy leads were placed over forehead to monitor the depth of anaesthesia. Tube position was confirmed with endoscopic view and Benjamin lindohlm laryngoscope was suspended. As the patient was spontaneously breathing, the stridor became more prominent, with stable vitals and the procedure was continued. The vocal cord retractor was fixed and coblation wand was then used with 7:3 settings for ablation and coagulation respectively. The surgical limits were-anteriorly the junction between ant 2/3 and post 1/3 of the vocal cord, posteriorly just anterior to the vocal process of arytenoid to prevent cartilage exposure and post operative granulations. Superely till the ventricle and inferioly till the medial most surface of the subglottis. Laterally approx. 5 mm depth was defined to prevent injury to the superior laryngeal artery branch and further bleeding. Once the final airway was achieved , the topical lignocaine was used to prevent laryngeal spasm post extubation.
The patient was shifted to the ward without oxygen, the voice was assessed on post op day 2.
Patient was called for follow up on post op day 14th and good voice outcomes were achieved.
So lets have a look on some tips & tricks for the safe procedure—–
Nasopharyngeal insufflation technique with entropy monitor will give adequate and safe surgical field
2. Appropriate exposure will help you to delineate the surgical margins
3. Topical anaesthesia before and after the procedure will prevent sudden laryngeal spasm
4. Firm holding of coblation device will help to prevent injury to surrounding structures like anterior 2/3 vocal cord, opposite side vocal cord, medial surface of vocal cord or aryteroid posteriorly
5. Do not ablate more laterally to prevent bleeding, if at all it happens, use patties or coagulation switch for hemostasis.
6. And at the end of the procedure ,use catheter suction to suck out blood clots or saline from the airway if any….
To Conclude-Coblation Assisted Cordectomy( CAC) can be performed safely with good outcomes in case of bilateral vocal cord paralysis using tubeless anesthesia technique without tracheostomy !
We present the harvest of a osteocutaneous fibula free flap for head and neck reconstruction performed at the University of Cincinnati. This reconstructive technique has a wide variety of implications but has found greatest utility in the reconstruction of mandibular defects.
Review Submental Intubation.