Review Paper

Trauma
Submental intubation:
a literature review
J.S.Jundt, D.Cattano, C.A.Hagberg, J.W.Wilson: Submental intubation:
a literature review. Int. J. Oral Maxillofac. Surg. 2012; 41: 4654. # 2011
International Association of Oral and Maxillofacial Surgeons. Published by Elsevier
Ltd. All rights reserved.
J. S. Jundt
1
, D. Cattano
2
,
C. A. Hagberg
2
, J. W. Wilson
3
1
Department of Oral and Maxillofacial
Surgery, The University of Texas Dental
Branch at Houston, United States;
2
Department of Anesthesiology, The
University of Texas Medical School at
Houston, United States;
3
Department of Oral
and Maxillofacial Surgery, The University of
Texas Medical School at Houston, United
States
Abstract. A literature review was performed to analyse the evidence supporting
submental intubation and to aid in the development of a new airway algorithm in
craniofacial surgery patients. A systematic search of Pub Med, OVID, the Cochrane
Database and Google Scholar between January 1984 and April 2011 was performed.
Measured variables included the outcome, complications, publishing specialty
journal and method of intubation including technique modications, indications for
the procedure, devices utilized and the total procedure time to complete the
submental intubation. Of the 842 patient cases from 41 articles represented in the
review, the success rate was 100%. Minor complications were reported in 60
patients and included supercial skin infections (N = 23), damage to the tube
apparatus (N = 10), stula formation (N = 10), right mainstem bronchus tube
dislodgement/obstruction (N = 5), hypertrophic scarring (N = 3), accidental
extubation in paediatric patients (N = 2), excessive bronchial exion (N = 2),
lingual nerve paresthesia (N = 1), venous bleeding (N = 2), mucocele (N = 1), and
dislodgement of the throat pack sticker in the submental wound (N = 1). The
average reported time to complete a submental intubation was 9.9 min. Submental
intubation is a safe, effective and time efcient method for securing an airway when
increased surgical exposure or restoration of occlusion is a priority.
Key words: submental intubation; submental
endotracheal intubation; submental tracheal
intubation..
Accepted for publication 18 August 2011
Available online 17 September 2011
Submental intubation was rst reported by
Francisco Hernandez Altemir in 1986 as a
procedure that could avoid tracheostomy
and allow for the concomitant restoration
of occlusion and reduction of facial frac-
tures in patients ineligible for nasotracheal
intubation
8
. This procedure consists of
exteriorizing an oral endotracheal tube
through the oor of the mouth and sub-
mental triangle. The original surgical pro-
tocol dictated a 2 cm incision in the
submental, paramedial region extending
cephalad until the lingual mucosa was
tented with a hemostat after which another
2 cm incision parallel to the mandible is
made in the lingual gingivae. The breath-
ing circuit is briey disconnected as the
tube is externalized through the submental
region and reconnected to the circuit and
secured to the patient. Many aspects of
submental intubation make it a useful
surgical adjunct in a variety of settings
including facial trauma, pathology and
elective facial surgery. Currently, no sys-
tematic literature reviews exist on the
topic of submental intubation.
In recognition of this deciency,
a systematic literature review was
performed to analyse the evidence sup-
porting submental intubation. The rst
aim of this review is to summarize the
outcomes, complications, method of
intubation including technique modica-
tions, indications for the procedure,
devices utilized and the total procedure
time to complete the submental intuba-
tion. A second aim of this review is to
introduce a maxillofacial trauma airway
algorithm based on these ndings and to
discuss the benets of submental intuba-
tion over tracheostomy in select patient
populations.
Int. J. Oral Maxillofac. Surg. 2012; 41: 4654
doi:10.1016/j.ijom.2011.08.002, available online at http://www.sciencedirect.com
0101-5027/01046 +09 $36.00/0 # 2011 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Materials and methods
A systematic search of Pub Med, OVID,
Cochrane Database and Google Scholar
Beta between January 1984 and 10 April
2011 was performed. The Pub Med
search utilized the following National
Library of Medicine Medical Subject
Headings (MeSH): adult, chin, humans,
intubation/methods, maxillofacial inju-
ries/surgery, surgery, and oral/methods.
Keywords searched in other databases
included submental intubation, submen-
tal endotracheal intubation, submental
orotracheal intubation and maxillofacial
surgery, faciomaxillary surgery, and
trauma and tracheostomy. A preferred
reporting items for systematic reviews
and meta-analyses (PRISMA) owchart
diagram outlines the number of articles
identied, screened, deemed eligible and
included in this review (Fig. 1). Exclu-
sion criteria included non-English lan-
guage articles, duplicates and articles
that did not contribute to the measured
variables. No blinded randomized
controlled trials have been published
on submental intubation, therefore,
observer bias must be considered when
reviewing the evidence.
The level of evidence (LOE) was
ranked for each article on a scale from
1 to 5 (Table 1). Level 1 evidence
included well constructed meta-analyses
of high quality randomized controlled
trials of sufcient size. Level 2 evidence
included lesser quality randomized con-
trolled trials. Level 3 evidence included
case control studies, retrospective and
prospective analyses. Level 4 evidence
included case series, case reports and
surgical techniques. Level 5 evidence
included expert opinion including corre-
spondences and letters to the editor. The
average LOE in this report was 3.81
comprising the most comprehensive
and best available literature on submen-
tal intubation.
Measured variables in this review
included outcomes, complications, pub-
lishing specialty journal, method of intu-
bation, technique modications,
indications for the procedure, device uti-
lized and the total procedure time to com-
plete the submental intubation.
Results
The search strategies yielded a total of
359 abstracts of which 48 remained after
duplicate, non-English and unrelated
citations were removed. 48 Full text
articles on submental intubation were
assessed for inclusion eligibility in this
review. Published between January 1986
and April 2011, these papers included 12
retrospective reviews, two case series,
16 case reports, 10 surgical techniques,
six correspondences and two letters to
the editors. Four journal correspon-
dences and three surgical technique arti-
cles were eliminated based on exclusion
criteria
3,5,7,8,18,30,47
. 41 English language
articles were qualitatively and quantita-
tively assessed in this review and the
results are presented in Table 2.
Submental intubation: a literature review 47

Records identified through database

searching
(n =354)
S
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e
e
n
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n
g
I
n
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l
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d
e
d
E
l
i
g
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t
y
I
d
e
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t
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f
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c
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t
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o
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Additional records identified
through other sources
(n =5)
Records after duplicates/ non-English
removed
(n =48)
Records screened
(n =48)
Records excluded
(n =0)
Full-text articles assessed
for eligibility
(n =48)
Full-text articles excluded
(n =7)
Studies included in
qualitative synthesis
(n = 41)
Studies included in
quantitative synthesis
(n =41)
Fig. 1. Submental intubation PRISMA ow diagram.
Journal publication by specialty
A variety of specialty journals have pub-
lished articles on this technique (Table 3).
Anesthesiology journals published 16 arti-
cles on submental intubation representing
51 patients. Oral and maxillofacial surgery
journals have published 13 articles repre-
senting 648 patients. Craniomaxillofacial,
skull base and trauma surgery journals
have published seven articles representing
96 patients. Oral Medicine/Pathology/Sur-
gery journals published two articles com-
prising 15 patients. Three articles have
been published in plastic and reconstruc-
tive surgery and trauma journals repre-
senting 32 patients. No literature on
submental intubation was found in the
otorhinolaryngology literature. This de-
ciency in published reports in the ENT
literature may reect unfamiliarity with
the procedure or an inclination towards
tracheostomy.
Indications
The most common indication for sub-
mental intubation was trauma (N = 721)
in 86% of the reported cases followed by
elective facial osteotomy (N = 100) in
12% of patients
1,2,4,6,911,13,15,17,19
22,2528,3137,3945,4952,54
. Transmaxil-
lary cranial base tumour access
(N = 18) comprised 2% of patients
13
.
Cancrum oris (N = 1) was the reported
indication in 0.12% of patients
23
. The
indication for submental intubation was
not reported (N = 2) in two patients
14
.
Whilst nasotracheal intubation is fre-
quently employed in facial trauma and
pathology, patients reported in this
review were not candidates for this tech-
nique due to perturbed nasal anatomy,
nasal-orbital-ethmoidal fractures, skull
base fractures, cerebrospinal uid
rhinorrhea or extensive soft tissue
swelling
29,48
.
Original technique and sequential
modications
The method of intubation was classied
into two types for the purposes of this
review. The rst method referred to here
as the Altemir sequence involves a
single endotracheal tube that is exterior-
ized through the submental dissection
plane
3
. The second method, referred to
here as the Green and Moore sequence
involves two endotracheal tubes
whereby the rst oral tube is replaced
by a second tube introduced through
the submental tunnel
28
. Signicantly
more practitioners selected the rst
method (N = 719) and fewer utilized
the Green and Moore sequence
(N = 122)
21,28,38,45,51,54
. One method
involved retrograde submental intuba-
tion and utilized a pharyngeal loop tech-
nique (N = 1)
10
. The complication rate
amongst the Green and Moore sequence
was 21% (N = 26) whereas the compli-
cation rate amongst Altemir sequence
was 5% (N = 34).
Devices utilized in performing the sub-
mental intubation consisted of reinforced
spiral embedded endotracheal tubes
(N = 775), non-reinforced endotracheal
tubes (N = 22), reinforced laryngeal mask
airway (LMA) (N = 6), Combitube (N = 1)
and not reported (N = 38). Fibre or metal
reinforced tubing is preferred due to the
ability to maintain lumen patency at the
acute tube angles common in submental
intubation
1,9,1315,19,21,22,2527,31
33,35,36,38,4043,4951,54
. No correlations
were found between the type of tube uti-
lized and damage to the tube during the
procedure.
10 Articles have been published
outlining modications to the original
technique primarily aimed at reducing
complications
4,6,12,14,28,3537,42,43
. Modi-
cations were classied according to
intended benet. Four modications
were instituted to reduce the potential
for intraoperative bleeding whilst
three modications aimed at reducing
tube damage despite the relatively
low reported frequency of these
minor complications: 0.24% and
1.19%, respectively
4,14,3537,42,43
. Table
4 details the reported modications and
intended benet of each modication.
There is insufcient evidence in the
literature to identify a single modica-
tion that most reduces the risk of
complications associated with submental
intubation. Additional research is needed
to validate various technique modica-
tions aimed at reducing infrequent com-
plications.
48 Jundt et al.
Table 1. Level of evidence.
Reference Type of study Level of evidence
AGRAWAL & KANG
1
Prospective study 3
AMIN et al.
9
Retrospective study 3
BIGLIOLI et al.
13
Retrospective study 3
CARON et al.
15
Retrospective study 3
CAUBI et al.
17
Retrospective study 3
CHANDU et al.
19
Retrospective study 3
DAVIS
21
Retrospective study 3
GADRE & WAKNIS
25
Retrospective study 3
JU

NIOR et al.
31
Retrospective study 3
NAVANEETHAM et al.
41
Retrospective study 3
SCHU

TZ & HAMED
49
Retrospective study 3
TAGLIALATELA et al.
51
Retrospective study 3
BABU et al.
11
Case report 4
DROLET et al.
22
Case report 4
EIPE et al.
23
Case report 4
GORDON & TOLSTUNOV
27
Case report 4
GREEN & MOORE
28
Case report 4
KIM et al.
32
Case report 4
KIM et al.
33
Case report 4
LANGFORD
34
Case report 4
MACINNIS & BAIG
36
Case report 4
MAK & OOI
38
Case report 4
MANGANELLO-SOUZA et al.
39
Case report 4
MEYER et al.
40
Case report 4
UMA et al.
52
Case report 4
YOON et al.
54
Case report 4
CHOI et al.
20
Case report 4
NYA

RA

DY et al.
43
Case report 4
GARG et al.
26
Case series 4
SHARMA et al.
50
Case series 4
ALTEMIR et al.
5
Surgical technique 4
ARYA et al.
10
Surgical technique 4
ALTEMIR et al.
6
Surgical technique 4
LIM et al.
35
Surgical technique 4
MAHMOOD & LELLO
37
Surgical technique 4
NWOKU et al.
42
Surgical technique 4
NYA

RA

DY et al.
44
Surgical technique 4
AHMED & MITCHEL
2
Correspondence 5
BALL et al.
12
Correspondence 5
BISWAS et al.
14
Letter to the editor 5
PAETKAU et al.
45
Letter to the editor 5
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Table 2. Literature review results.
Article citation
Study
type
Journal
type # Pts Complications
Intubation
method Device utilized Indication for procedure Average time
AGRAWAL M, KANG L. J J Anesthesiol Clin
Pharmacol 2011: 26: 498502
PR ANES 25 Venous bleeding (1)
Supercial infection (2)
AS Reinforced ETT Maxillofacial trauma 7.08
0.81 min
CHOI S, SONG SH, KANG NH. J Korean Soc
Plast Reconstr Surg 2011: 38: 127129
CR PRS 1 None AS Non-Reinforced ETT Maxillofacial trauma 30 min
JU

NIOR SM, ASPRINO LT. J Oral Maxillofac

Surg 2011 [Epub ahead of print]
RR OMS 15 None AS Reinforced ETT Maxillofacial trauma 10 min
NAVANEETHAM A, THANGASWAMY AV, RAO
N: J Oral Maxillofac Surg 2011: 9: 6167
RR OMS 15 ETT obstruction (2) AS Reinforced ETT Maxillofacial trauma 7 min
GARG M, RASTOGI B. Dental Traumatol
2010: 26: 9093
CS OMS 10 Supercial infection (1) AS Reinforced ETT Maxillofacial trauma 8 min
GADRE KS, WAKNIS PP. J Craniofac Surg
2010: 21: 516519
RR OMS 400 Fistula (2), Damage to ETT
apparatus (1), Keloid (2)
AS Reinforced ETT Maxillofacial trauma,
Elective LF
10 min
UMA G, VISWANATHAN PN, NAGARAJA PS.
Indian J Anaesth 2009: 53: 8487
CR ANES 1 None AS NR Maxillofacial trauma NR
LANGFORD R. Anaesth Intensive Care 2009:
37: 325326
CR ANES 1 Pilot balloon entrapment (1) AS LMA Maxillofacial trauma NR
SHARMA RK, TULI P, CYRIAC C, et al. Indian J
Plast Surg 2008: 41: 1519
CS PRS 20 Partial extubation paediatric (1)
Supercial infection (1)
AS Reinforced ETT Maxillofacial trauma 9 min
BABU I, SAGTANI A, JAIN N, et al. Br J Oral
Maxillofac Surg 2008: 46: 561563
CR OMS 1 None AS Reinforced ETT Maxillofacial trauma 5 min
CHANDU A, WITHEROW H, STEWART A. Br J
Oral Maxillofac Surg 2008: 46: 561563
RR OMS 44 Supercial infection (2)
Mucocele formation (1)
Lingual nerve paresthesia (1)
Dislodged ETT (2)
AS Reinforced ETT Orthognathic surgery 20 min
SCHU

TZ P, HAMED HH. J Oral Maxillofac

Surg 2008: 66: 14041409
RR OMS 8 Damage to ETT apparatus (1) AS Reinforced ETT Maxillofacial trauma NR
CAUBI AF, VASCONCELOS BC, VASCONCELLOS
RJ, et al. Med Oral Patol
Oral Cir Bucal 2008: 13: E197E200
RR Oral Med/
Path/Surg
13 Increased tracheal pressure
due to ETT compression (1)
AS Non-Reinforced
ETT
Maxillofacial trauma <10 min
BISWAS BK, JOSHI S, BHATTACHARYYA P, et al.
Anesth Analg 2006: 103: 1055
LE ANES 2 None AS Reinforced ETT NR NR
NYA

RA

DY Z, SA

RI F, OLASZ L, et al. J
Craniomaxillofac Surg 2006: 34: 362365
ST CMF 13 None AS NR Orthognathic surgery 4 min
EIPE N, NEUHOEFER ES, LA ROSEE et al.
Paediatr Anaesth 2005: 15: 10091012
CR ANES 1 None AS Non-Reinforced ETT Cancrum Oris Sequlae NR
TAGLIALATELA SCAFATI C, MAIO G, ALIBERTI
F, et al. Br J Oral Maxillofac Surg 2006:
44:1214
RR OMS 107 Supercial infection (11)
Fistula (8)
Damage to ETT apparatus (6)
GMS Reinforced ETT Maxillofacial trauma 10 min
KIM KJ, LEE JS, KIM HJ, et al. Yonsei Med J
2005: 46: 571574
CR ANES 2 None AS Reinforced LMA Maxillofacial trauma 7 min
KIM KF, DORIOT R, MORSE MA, et al. J
Craniofac Surg 2005: 16: 498500
CR PRS 4 None AS Reinforced ETT Maxillofacial trauma 10 min
BIGLIOLI F, MORTINI P, GOISIS M, et al. Skull
Base 2003: 13: 189195
RR Skull Base
Surgery
24 Supercial infection (1) AS Reinforced ETT Maxillofacial trauma/clivus
chordomas/chordosarcoma
5 min
ARYA VK, KUMAR A, MAKKAR SS, et al.
Anesth Analg 2005: 100: 534537
ST ANES 1 None Pharyngeal
Loop
Technique
Non-Reinforced
ETT
Maxillofacial trauma NR
5
0
J
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n
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t
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l
.
Table 2 (Continued )
Article citation
Study
type
Journal
type # Pts Complications
Intubation
method Device utilized Indication for procedure Average time
NYA

RA

DY Z, SA

RI F, OLASZ L, et al. Mund

Kiefer Gesichtschir 2004: 8: 387389
CR OMS 8 None AS Reinforced ETT Orthognathic surgery NR
YOON KB, CHOI BH, CHANG HS, et al. Yonsei
Med J 2004: 45: 748750
CR ANES 1 Pilot balloon detachment (1) GMS Reinforced ETT Maxillofacial trauma NR
DAVIS C. ANZ J Surg 2004: 74: 379381 RR PRS 11 None GMS Reinforced ETT Maxillofacial trauma 7 min
AHMED FB, MITCHELL V. Anaesthesia 2004:
59: 410411
C ANES NR Right mainstem bronchus
neck exion (1)
Throat pack sticker dislodged (1)
NR NR NR NR
MEYER C, VALFREY J, KJARTANSDOTTIR T,
et al. J Cranio-maxillofac Surg 2003: 31:
383388
CR CMF 25 Hypertrophic scarring (1)
Supercial infection (2)
AS Reinforced ETT Maxillofacial trauma <8 min
LIM HK, KIM IK, HAN JU, et al. Yonsei Med
J 2003: 44: 919922
ST ANES 1 None AS Reinforced ETT Maxillofacial trauma NR
ALTEMIR FH, HERNA

NDEZ MONTERO S, et al. J

Cranio-maxillofac Surg 2003: 31: 257259
ST CMF 2 None AS Combitube Maxillofacial trauma NR
BALL DR, CLARK M, JEFFERSON P, et al.
Anaesthesia 2003: 58: 189
C ANES NR NR AS/ILM NR NR NR
AMIN M, DILL-RUSSELL P, MANISALI M, et al.
Anaesthesia 2002: 57: 11951199
RR ANES 12 Right mainstem dislodged (1)
Venous bleeding (1)
Extubation paediatric (1)
AS Reinforced ETT Maxillofacial trauma,
Elective LF III
NR
NWOKU AL, AL-BALAWI SA, AL-ZAHRANI SA.
Saudi Med J 2002: 23: 7376
ST OMS 10 None AS Reinforced ETT Maxillofacial trauma,
Orthognathic surgery
NR
MAHMOOD S, LELLO GE. J Oral Maxillofac
Surg 2002: 60: 473474
ST OMS 5 None AS Non-reinforced ETT Maxillofacial trauma NR
MAK PH, OOI RG. Br J Anaesth 2002: 88:
288291
CR ANES 1 None GMS Reinforced ETT Orthognathic surgery NR
ALTEMIR FH, MONTERO SH. J
Craniomaxillofac Surg 2000: 28: 343344
ST CMF 3 None AS LMA Maxillofacial trauma NR
PAETKAU DJ, STRANC MF, ONG BY.
Anesthesiology 2000: 92: 912
LE ANES 1 None GMS Non-Reinforced ETT Maxillofacial trauma <10 min
CARON G, PAQUIN R, LESSARD MR, et al. J
Trauma 2000: 48: 235240
RR Trauma 25 Supercial infection (1) AS Reinforced ETT Maxillofacial trauma Few minutes
DROLET P, GIRARD M, POIRIER J, et al. Anesth
Analg 2000: 90: 222223
CR ANES 1 None AS Reinforced ETT Maxillofacial trauma NR
MACINNIS E, BAIG M. Int J Oral Maxillofac
Surg 1999: 28: 344346
CR OMS 15 None AS Reinforced ETT Maxillofacial trauma,
Elective LF III
6 min
MANGANELLO-SOUZA LC, TENORIO-CABEZAS N,
et al. Sao Paulo Med J 1998: 116: 1829
1832
CR OMS 10 Supercial infection (2) AS NR Maxillofacial trauma NR
GREEN JD, MOORE UJ. Br J Anaesth 1996:
77: 789791
CR ANES 1 None GMS Reinforced ETT Maxillofacial trauma NR
GORDON NC, TOLSTUNOV L. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 1985:
79: 269272
CR Oral Med/
Path/Surg
2 None AS Reinforced ETT Maxillofacial trauma NR
Legend: C: correspondence, CR: case report, CS: case series, ST: surgical technique, RR: retrospective review, PR: prospective review, Letter to the editor: LE, NR: not reported, ANES: anaesthesia,
CMF: craniomaxillofacial, LMA: laryngeal mask airway, ILM: intubating laryngeal mask, ETT: endotracheal tube, LF: le fort fracture, GMS: Green and Moore sequence, AS: Altemir sequence Green
and Moore sequence refers to the technique using two tubes, whereas the AS refers to one tube externalized through the submental incision.
Duration of procedure
19 Articles included the average time
required to complete the submental
intubation
1,11,13,15,17,20,21,25,26,3133,36,40,
41,43,45,50,51
. Procedure time was reported
in 746 patients and averaged 9.9 min.
Ranges varied from less than 4 min
43
to 30 min
20
. The two largest retrospec-
tive reviews of 107 and 400 patients
independently averaged 10 min per
patient
25,51
. By comparison, a prospec-
tive, randomized study comparing per-
cutaneous dilational tracheostomy to
open surgical tracheostomy reported
average time of 20.1 2.0 min and
41.7 3.9 min, respectively
24
.
Complications
Of the 842 patient cases represented in the
review, the success rate was 100%. Minor
complications were reported in 60 patients
and included supercial skin infections
(N = 23), damage to the tube apparatus
(N = 10), stula formation (N = 10), right
mainstem bronchus tube dislodgement/
obstruction (N = 5), hypertrophic scarring
(N = 3), accidental extubation in paedia-
tric patients (N = 2), excessive bronchial
exion (N = 2), transient lingual nerve
paresthesia (N = 1), venous bleeding
(N = 2), mucocele (N = 1), and dislodge-
ment of the throat pack sticker in the
submental wound (N = 1)
1,9,13,15,17,19,25,
26,34,3941,4951,54
. Accidental extubation
has only been reported in paediatric popu-
lations (N = 2). These minor complica-
tions are summarized in Table 5. No
major complications associated with sub-
mental intubation have been reported in
the literature. Minor complications
occurred in 7% of patients undergoing
submental intubation.
Discussion
Interest in submental intubation has
slowly risen over the past 25 years. Almost
10 years passed before a second article
was published on submental intubation in
1995
27
. Between 2000 and 2011, 37 of the
41 articles included in this review were
published. Despite this steady increase in
publications, a relative paucity of litera-
ture in certain surgical specialties where
tracheostomies and facial trauma are com-
mon procedures suggests a lack of aware-
ness and potential underutilization.
The indications for submental intuba-
tion are specic and as such lend well
to incorporation in an algorithm. First,
Submental intubation: a literature review 51
Table 3. Number of articles and patients by journal type.
Journal Articles No. of patients
Anaesthesia 16 51
Oral and Maxillofacial Surgery 13 648
Craniomaxillofacial Surgery 5 47
Plastic and Reconstructive Surgery 3 32
Oral Medicine/Pathology/Surgery 2 15
Skull Base Surgery 1 24
Trauma/Surgery 1 25
Table 4. Submental intubation modications.
Author Year Modication Reason for modication
ALTEMIR et al.
3
1986 2 cm paramedial incision in a subperiosteal
plane. Nasal speculum facilitates tube
passage through submental region
First report
GREEN & MOORE
28
1995 1st tube: oral intubation 2nd tube: submental
approach. Oral tube is substituted with
submental endotracheal tube, patient is
reintubated
Allows use of endotracheal tubes with non-
detachable universal connectors
MACINNIS & BAIG
36
1999 2 cm midline incision posterior to
Whartons ducts between geniohyoid,
genioglossus and anterior belly of the
digastrics muscles
Decreased bleeding
ALTEMIR et al.
5
2000 Utilized a reinforced laryngeal mask airway
in the submental approach
Allows use in severe laryngotracheal
trauma, singers and patients with unstable
cervical fractures
NWOKU et al.
42
2001 2 cm laterosubmental incision Attempts to avoid signicant oor of mouth
structures
MAHMOOD & LELLO
37
2002 1 cm midline incision between Whartons
duct and the reection of the lingual
gingivae and the oor of the mouth
Decreased bleeding and avoidance of
important structures
ALTEMIR et al.
6
2003 Utilized a reinforced Combitube in the
submental approach
Assists in tamponade of pharyngeal
haemorrhage
BALL et al.
12
2003 Flexible tracheal tube with an intubating
laryngeal mask
Connector easily removed and retted and
tube tip design eases intubation
LIM et al.
35
2003 1.5 cm submental and paramedial incision.
A blue cap from a size 32 Fr thoracic
catheter is placed over the distal end of the
tube incorporating the pilot balloon and tube
Reduction of tube damage complications
NYARADY et al.
44
2006 A sterile nylon guiding tube is placed over
the distal end of the tube incorporating the
pilot balloon and tube
Reduction of tube damage complications
BISWAS et al.
14
2006 Percutaneous tracheostomy dilatational kit
facilitates exteriorization of the
endotracheal tube through the submental
route
Reduction of tube damage complications
submental intubation is indicated in
patients with planned or traumatic jaw
fractures necessitating the re-establish-
ment of a functional occlusion in the pre-
sence of nasal fractures, nasal-orbital-
ethmoidal fractures, skull base fractures
and congenital deformities where nasotra-
cheal, oral endotracheal intubation or tra-
cheostomy is not indicated. Second,
submental intubation is indicated in cases
where increased surgical exposure is
desired such as transmaxillary skull base
surgeries or complicated infections. These
indications provide a useful guide when
determining airway selection in maxillo-
facial surgery patients. Additional factors
to consider include the length of antici-
pated intubation. Despite several articles
reporting prolonged submental intubation
of 72 h without adverse effects and no
reports to the contrary, prolonged submen-
tal intubation greater than 72 h is not
routinely practiced due to increased risk
of laryngeal damage and pneumonia
27,36
.
Commonly, when a submental intubation
patient does not require long term
mechanical ventilation but is not extu-
bated postoperatively, the submental tube
is converted to an oral endotracheal which
may remain in place for many days or even
weeks.
The maxillofacial airway algorithm
begins with the decision to perform a
craniofacial surgery. If ventilator support
is anticipated for a period greater than 7
days and when combined with multiple
anticipated surgeries, neurological de-
cits, compromised pulmonary status or
severe polytrauma a tracheostomy should
be considered. If the anticipated duration
of mechanical ventilation is less than 7
days in patients who require isolated orbi-
tal, nasal, zygomaticomaxillary complex,
sinus fractures or soft tissue repair then an
oral endotracheal airway should be con-
sidered. This time span reects the poten-
tial for signicant complications as
reported in a prospective study of laryn-
gotracheal sequelae associated with intu-
bation longer than 7 days
46,53
. In those
patients who sustain jaw fractures or
52 Jundt et al.
Table 5. Reported complications in submental intubation.
Complication Total % Of patients
Infection 23 2.73
Endotracheal tube damage 10 1.19
Fistula 10 1.19
Right mainstem intubation/obstruction 5 0.59
Hypertrophic scarring 3 0.36
Extubation (paediatric) 2 0.24
Venous bleeding 2 0.24
Excessive bronchial exion 2 0.24
Transient lingual nerve paresthesia 1 0.12
Throat pack sticker dislodged 1 0.12
Mucocele formation 1 0.12
60 7.13

Fig. 2. Maxillofacial airway algorithm.

undergo routine orthognathic or tele-
gnathic surgery and anticipated mechan-
ical ventilation is less than 7 days, a
nasotracheal airway should be considered.
Despite 100 reported cases of submental
intubation in elective facial osteotomy
patients, aesthetic tolerance of scarring
is highly variable and in the authors
opinion limits the usefulness in this patient
subset when nasotracheal intubation is
possible. In patients with an anticipated
mechanical ventilation period of less than
7 days who sustain jaw fractures that
require the restoration of occlusion in
the setting of nasal bone, naso-orbital-
ethmoidal, skull base fractures or conge-
nital deformity or in head and neck pathol-
ogy or cosmetic cases where enhanced
surgical exposure is necessary, submental
intubation should be considered. This
algorithm is expressed diagrammatically
in Fig. 2.
In comparing submental intubation and
tracheostomy, submental intubation has
no signicant reported major complica-
tions. Tracheostomy complications
include haemorrhage, surgical emphy-
sema, wound site infection, recurrent lar-
yngeal nerve injury, tracheal stenosis,
poor scar aesthetics, tracheoarterial stula
and death
30,46,55
. The mortality rate of
tracheostomy has been reported to range
from 0.5% to 2.7%
16,49,55
. In addition to
fewer reported minor complications, sub-
mental intubation requires less time than a
tracheostomy, costs less and results in an
aesthetically well tolerated scar.
In conclusion, submental intubation is
an underutilized, safe and effective tech-
nique for establishing an airway in patients
requiring facial reconstructive surgery
where traditional methods are contraindi-
cated. Despite the low LOE in the litera-
ture, the cumulative results reported in this
manuscript include the best available evi-
dence. Additional research is necessary
to compare tracheostomy to submental
intubation and larger studies are required
to validate new modications reported
in the literature. The potential exists
to signicantly reduce morbidity by avoid-
ing a tracheostomy in selected patients.
Reported complications are minor and
resolve with minimal intervention. Tech-
nique modications aimed at reducing
tube damage may serve to reduce compli-
cations with little added risk. In choosing
a potential modication, the surgeon
should inform the anaesthesiologist of
their intended sequence. Communication
between the surgeon and anaesthesiologist
is paramount. Innovations based on the
original technique, such as the percuta-
neous dilator method described by Biswas
or enhanced pilot balloon tubing, may
further decrease complications and should
be explored in greater detail.
Competing interests
None.
Funding
None.
Ethical approval
Not applicable.
Acknowledgements. The authors would
like to thank Anne Starr for her valuable
secretarial support in the preparation of
the manuscript.
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Address:
The University of Texas Dental Branch at
Houston
6516 MD Anderson Blvd.
Houston
TX 77030
United States
Tel.: +1 713 471 6000
E-mail: Jonathon.Jundt@uth.tmc.edu
54 Jundt et al.