Submandibular Intubation: Bridging Airway Access and Surgical Precision

Introduction

Submandibular intubation, often referred to as retromandibular or submental intubation, is a specialized airway management method utilized in certain surgical settings, such as maxillofacial or craniofacial surgery. This procedure is a useful alternative to traditional oral or nasal intubation, especially when these approaches may interfere with surgical access or are contraindicated.

What is submandibular intubation?

Submandibular intubation involves creating a small incision under the mandible (in the submandibular region) to pass the endotracheal tube from the oral cavity to the external surface of the neck. This provides unobstructed access to the surgical field, particularly in cases of:

• Facial trauma requiring simultaneous access to the oral and nasal cavities.
• Orthognathic surgeries where maxillomandibular fixation is necessary.
• Pan-facial fractures, where both oral and nasal intubation may disrupt surgical workflow.
• Contraindications to nasal intubation, such as basal skull fractures or nasal obstructions.

A reinforced endotracheal tube (internal diameter 7.5 mm) 

Procedure overview

1. Preparation: After inducing anesthesia and securing an oral intubation, the surgical team identifies the submandibular or submental region.
2. Incision: A small incision is made below the mandible, usually in the submental or paramedian region.
3. Tube Passage: The tube is disconnected, passed through the incision, and reconnected to the ventilator circuit.
4. Fixation: The tube is secured externally to maintain a stable airway during surgery.
5. Closure: Once the procedure is complete, the tube is removed, and the incision is sutured.

The technique requires expertise to avoid complications like infection, bleeding, or damage to adjacent structures such as salivary glands and nerves.

Stages of orotracheal intubation with submandibular approach. A -Patient in supine position, with slightly hyperextended head. Orotracheal intubation with wire-reinforced tube. B -Adaptation of the vaginal speculum in the left submandibular access area. C -Tube passage. The endotracheal tube was disconnected and inserted through the opening for extraoral exposure. D -Fixation of the tube by suture with mononylon thread.

Historical Background

Submandibular intubation was first introduced by a Spanish maxillofacial surgeon,     Francisco Hernández Altemir in 1986 as a novel alternative to tracheostomy in cases of complex craniofacial trauma. Altemir sought to address the challenges posed by oral and nasal intubation in patients requiring access to the entire facial skeleton.

Since its inception, the technique has gained acceptance due to its ability to minimize complications associated with traditional tracheostomy, such as scarring, infection, and prolonged recovery times. Over the years, refinements in the procedure have made it safer and more effective.

Advantages

• Avoids tracheostomy: Reduces morbidity associated with invasive tracheostomies.
• Unobstructed surgical access: Facilitates complex surgeries by eliminating interference from the endotracheal tube.
• Shorter recovery: Faster wound healing compared to tracheostomy.

A) Soft tissue dissection from the submental space to the floor of the mouth; B) submental tunnel established along lingual surface of the right mandible; C) pilot balloon and endotracheal tube (ETT) pulled through the newly formed tunnel using a hemostat; D) the ETT is reconnected to the ventilator and secured to the chin.

Potential Complications

Despite its advantages, submandibular intubation is not without risks, including:

• Soft tissue infection at the incision site.
• Injury to the submandibular gland or lingual nerve.
• Airway compromise during tube transfer.

Conclusion

Submandibular intubation remains a crucial technique in modern anesthesiology and surgery, particularly in the field of maxillofacial trauma and reconstruction. Its development marked a significant milestone in airway management, offering a less invasive and effective alternative to tracheostomy.