Submental intubation
A 38-year-old male patient with panfacial trauma was planned for open reduction and internal fixation under General Anesthesia. Nasotracheal intubation was ruled out due to the presence of nasal fractures. Oral intubation was also ruled out due to the need to establish occlusion by intermaxillary fixation (IMF). Initially, a tracheostomy was planned, but in the operation theatre itself it was decided to intubate this patient through the sub-mental route as described by Mac Innis and Baig. After normal oral intubation using a tube (such as a mallinkrodt tube, US), which allows the connector to be removed, an incision measuring 2 cm was marked in the midline of the chin just anterior to the sub-mental crease close to the lower border of the mandible by the maxillofacial surgeon. Local anesthetic was infiltrated, and a 20 mm incision was made, enough to admit a size 8 tube. Blunt dissection was carried out as close as possible to the lingual aspect of the mandible into the floor of the mouth. A longitudinal incision was then made in the floor of the mouth, in the midline between the submandibular ducts at the base of the tongue, just enough to allow the passage of the tube so as to protect the facial nerve, lingual nerve and submandibular duct []. Artery forceps were passed from the extraoral to the intraoral incision and the existing flexometallic orotracheal tube drawn through the incision after grasping with the artery forceps []. This maneuver took approximately, 6 min for the maxillofacial surgeon to do. Correct tube position was confirmed with capnography and lung auscultation by the anesthetist. The cuff of the tube was inflated and the throat packed by the anesthetist. Temporary black silk sutures were placed to secure the tube extraorally, one on either side of the tube and around it by the surgical team.\nThe patient was painted and draped as usual, with full access to the facial bones and occlusion. Upon open reduction and internal fixation, which was now conveniently done in a single stage surgery, when the patient was ready to be extubated, the anchoring sutures were cut. The tube was removed extraorally and an oropharyngeal airway placed. 3-4 black silk sutures were placed in the skin extraorally. There was no need for intraoral sutures. If required, the tube can be kept in situ for a day or two. However, in this case the IMF was removed first, and then the throat-pack. The throat was suctioned thoroughly, and the tube was removed in the operation theatre through the sub-mental incision. The wound was closed with three interrupted sutures of 3-0 ethilon.