Submental intubation in complex craniomaxillofacial trauma cases


  • A. Navin Kumar Department of Oral and Maxillofacial Surgery, Army Dental Corps, India
  • P. K. Chattopadhaya Department of Oral and Maxillofacial Surgery, Army Dental Corps, India
  • Gaurav Dua Department of Oral and Maxillofacial Surgery, Army Dental Corps, India
  • Sandeep Mehta Department of Oral and Maxillofacial Surgery, Army Dental Corps, India



Panfacial trauma, Craniomaxillofacial trauma, Submental intubation, Orotracheal intubation


Background: Airway management in patient with craniomaxillofacial trauma is challenging due to disruption of components of upper airway. In complex panfacial trauma cases, especially involving naso-orbito-ethmoidal complex, the airway is shared between the maxillofacial surgeon and anaesthesiologist. Often in such severe trauma cases, both nasotracheal and orotracheal intubation are contraindicated. Previously in such situation tracheostomy was the method of choice. Though tracheostomy is time tested it has its fair share of complications, some even life threatening. Other methods were used such as retromolar intubation as an alternative, but it may not be suitable for all such cases. Another approach is submental intubation but not so much in routine practice. A retrospective study was designed to evaluate clinical criteria’s airway management in complex craniomaxillofacial trauma cases using submental intubation.

Methods: Datasheets of 14 craniomaxillofacial trauma cases who were intubated with submental intubation method were reviewed. The factors like: ease of anaesthesiologist for carrying out general anaesthesia, ease of surgeon for performing surgery and average time taken during the procedure, intraoperative and postoperative complications were evaluated and charted.  

Results: Submental intubation provides intraoperative airway control, avoids use of both oral and nasal routes, and allows intraoperative manipulation of occlusion, intramaxillary and intermaxillary fixation. This technique has minimal complications and has better patient, anaesthetists and surgeons acceptability. The limitations of this technique include longer preparation time, inability to maintain long term postoperative ventilation and unfamiliarity of technique itself.

Conclusions: This submental intubation can be used with little modifications in a variety of complicated panfacial trauma cases. 

Author Biography

A. Navin Kumar, Department of Oral and Maxillofacial Surgery, Army Dental Corps, India

Graded Specialist in Oral and Maxillofacial Dept, Army Dental Corps


Venugopal MG, Singha R, Menon PS, Chattopadhyay PK, Roychoudhary SK. Fractures in the maxillofacial region: A four year retrospective study. Med J Armed Forces India. 2010;66:14-7.

Chandra Shekar BR, Reddy CV. A five year retrospective statistical analysis of maxillofacial injuries in patients admitted and treated at two hospitals of Mysore city. Indian J Dent Res. 2008;19:304-8.

Chew JY, Cantrell RW. Tracheostomy, complication and their management. Arch Otolaryngol. 1972;96:538-45.

Walker DG. Complications of tracheostomy: Their prevention and treatment. J Oral Surg. 1973;31:480-2.

Stauffer JL, Olson DE, Petty TL. Complications and consequences of endotracheal intubation and tracheostomy. Am J Med. 1981;70:65-76.

Wood DE. Tracheostomy. Chest Surg Clin N Am. 1996;6:749.

Durbin CG Jr. Early complications of tracheostomy. Respir Care. 2005;50:511-5.

Xue FS, He N, Liao X, XU XZ, Liu JH. Further observations on retromolarfiberopticorotracheal intubation in patientswithseveretrismus. Can J Anaesth. 2011;58:868-9.

Troung A, Troung DT. Retromolar-fiberopticorotracheal intubation in patient with severe trismus undergoing nasal surgery. Can J Anaesth. 2011;58:460-3

Dutta A, Kumar V, Saha SS, Sood J, Khazanchi RK. Retromolar tracheal tube positioning for patients undergoing faciomaxillary surgeriey. Can J Anaesth. 2005;52:341.

Altemir FH. The submental route for endotracheal intubation: A new technique. J Maxillofac Surg. 1986;14:64-5.

Meyers C, Valfrey J, Kjartansdorttir T, Wilk A, Barriere P. Indication for and technical refinements of submental intubation in oral and maxillofacial surgery. J Cranio- Maxillofac Surg. 2003;31:383-8.

Schutz P, Hamed HH. Submental intubation versus tracheostomy in maxillofacial trauma patients. J Oral Maxillofac Surg. 2008;66:1404-9.

Chandu A, Witherow H, Stewart A. Submental Intubation in orthognathic surgery: initial experience. Br J Oral Maxillofac Surg. 2008;46:561-3.

Nyarady Z, Sari F, Olasz I, Nyarady J. Submentalendotracheal intubation in orthognathic concurrent surgery: a technical note. J Craniomaxillofac Surg. 2006;34:362-5.

Bigoli F, Mortini P, Goisis M, submentalorotracheal intubation: An alternative to tracheostomy in transfacial cranial base surgery. Skull base Surg. 2003;13:189-95.

Stoll P, Galli C, Watcher R, Bahr W. Submandibular endotracheal intubation in panfacial fractures. J Clin Anesth. 1994;6:83-6.

MacInnis E, Baig M. A modified submental approach for oral Endotracheal intubation. Int J Oral Maxillofac Surg. 199;28:344-6.

Taglialatela S, Maio G, Aliberti F. Submento- submandibular intubation: Is the subperiosteal passage essential? Experience of 107 consecutive cases. Br J Maxillofac Surg. 2006;44:12-4.

Biswas BK, Joshi S, Bhattacharya P, Gupta PK, Baniwal S. Percutaneous dialational tracheostomy kit: An aid to submental intubation. Anesth Analg. 2006;103:1055.

Mahmood S, Lello GE. Oral Endotracheal intubation: Median submental approach. J Oral Maxillofac Surg. 2002;60:473-4.

Lima SM Jr, Asprino L, Moreira RW, de Moraes M. A retrospective analysis of submental intubation in maxiloofacial trauma patients. J Oral Maxillofac Surg. 2011;69:2001-5.

Altemir FH, Montero SH. The submental route revistedusing laryngeal mask airway: A technical note. J Cranio-Maxillofac Surg. 2000;28:343-4.

Amin M, Dill-Russell P, Manisali M, Lee R, Sinton I. Facial fractures and submental tracheal intubation. Anesthesia. 2002;57;1195-9.

Arya VK, Kumar A, Makkar SS. Retrograde submental intubation by pharyngeal loop technique in a patient with faciomaxillary trauma ad restricted mouth opening. Anesth Analg. 2005;100:534-7.






Original Research Articles