Submental Intubation in Maxillofacial Surgery

Submental intubation is a valuable airway management technique in maxillofacial surgery that provides secure airway control while preserving unobstructed access to the oral and nasal cavities. In carefully selected cases, it offers a safe and effective alternative to nasotracheal intubation and tracheostomy.

Why Submental Intubation?

Standard oral or nasotracheal intubation can interfere with surgical access or be contraindicated in patients with facial trauma. Tracheostomy, while effective, carries higher morbidity and long-term complications. Submental intubation bridges this gap by allowing intraoperative airway control without violating the nasal passages or performing a tracheostomy.

Clinical studies have demonstrated that submental intubation is associated with:

Low complication rates
Minimal scarring
Excellent surgical access
Rapid reversal at the end of the procedure

Indications

Submental intubation is most commonly indicated when nasotracheal intubation is contraindicated and intraoperative occlusion must be assessed.

Common Indications

Contraindications to nasotracheal intubation
- Epistaxis
- Cerebrospinal fluid (CSF) leak
- Rhinorrhea
Pan-facial trauma
Basilar skull fractures
Orthognathic surgery combined with rhinoplasty
Craniomaxillofacial surgery requiring unobstructed nasal and oral access

Why a Paramedial Submental Incision?

A paramedial approach is preferred over a strict midline incision due to reduced risk to critical anatomic structures.

Advantages of a Paramedial Incision

Avoids injury to geniohyoid and genioglossus muscles
Avoids the anterior belly of the digastric muscle
Avoids the submandibular duct caruncle
Reduces risk of postoperative floor-of-mouth complications

Submental Intubation Technique (Paramedial Approach)

Key Pre-Procedure Step

Release the endotracheal tube (ETT) connector prior to intubation
Use a cuffed, armored (reinforced/anode) endotracheal tube
Ensure the T-piece connector can be removed easily

Submental Intubation

Step-by-Step Procedure

Oral Intubation
- Perform standard oral intubation with a cuffed, metallic coiled (armored) ETT
Skin Incision
- Make a ~2 cm paramedial submental incision
- Location:
  - Parallel to the inferior border of the mandible
  - Approximately one finger breadth inferior to the mandibular border
Blunt Dissection
- Pass a curved hemostat through:
  - Skin
  - Subcutaneous tissue
  - Platysma
  - Mylohyoid muscle
  - Submucosa
  - Oral mucosa
Intraoral Exit Point
- Entry into the oral cavity occurs at the junction of attached lingual alveolar mucosa and free floor-of-mouth mucosa
- Create a ~1 cm intraoral incision, parallel to the gingival margin
Exteriorization of the Tube
- Deflate the cuff
- Use a large curved hemostat or Kelly clamp
  - One prong stabilizes the cuff balloon
  - One prong stabilizes the tube
- Gently pull the tube through the submental incision
Reconnection & Verification
- Reattach the connector
- Confirm ventilation
- Anesthesia must confirm bilateral breath sounds to rule out mainstem intubation
Secure the Tube
- Suture the tube to the skin using 1-0 or 2-0 silk sutures

Intraoperative Pearls

Always use an armored (reinforced) tube to prevent kinking
Make the incision slightly larger than you think you need
Ensure the cuff is fully deflated before exteriorization
Always reconfirm tube position after repositioning
Secure the tube firmly to prevent accidental displacement

Advantages Over Tracheostomy

Avoids tracheal injury
No long-term stoma or scar
Lower infection risk
Faster postoperative recovery
Easily reversible at the end of surgery

Conclusion

Submental intubation is a reliable, low-morbidity airway technique for complex maxillofacial cases where nasotracheal intubation is unsafe and tracheostomy is undesirable. Mastery of the paramedial technique allows surgeons to safely manage the airway while maintaining optimal surgical access and minimizing patient risk.