Facilitating Submental Endotracheal Intubation with an Endotracheal Tube Exchanger

When neither nasal nor orotracheal intubation is deemed suitable, the submental route offers an alternative to tracheostomy during surgical repair of severe craniomaxillofacial trauma (1). The technique involves exteriorizing the free end of an orotracheal tube (universal connector removed) through a submental incision. Ideally, this maneuver is performed by using a reinforced tube. Unfortunately, however, some reinforced tracheal tubes are manufactured with nondetachable connectors. Removing them forcefully may be possible, but they will then stay dangerously loose after reconnection. We report a case in which a tube exchanger was used successfully to replace a tracheal tube that was damaged while being pulled through a submental incision. Case Report A 36-yr-old woman was brought to the operating room 7 days after sustaining multiple maxillofacial injuries, a cerebral concussion, and a fracture of the cervical spine in an automobile accident. She had been orally intubated shortly after her arrival at the emergency department and was subsequently sedated, and her lungs were ventilated. She wore a semirigid cervical collar and exhibited considerable facial edema. She was scheduled for repair of the maxillofacial fractures and, because intermaxillary fixation was needed, the surgeon asked to proceed with a submental approach for tracheal intubation. Anesthesia was induced with isoflurane, fentanyl, and rocuronium. The existing orotracheal tube was significantly occluded with secretions. We elected to replace it with a reinforced tube (Rush, Kemen-Rommelshausen, Germany), using a lubricated tube exchanger (Cook Critical Care, Bloomington, IN) to avoid performing a potentially difficult and complicated laryngoscopy. The tube exchanger is a semirigid catheter that can also be used as a tracheal ventilation device. After inserting the new tube, the surgeon made a 2-cm submental incision parallel to the right mandibular border and approximately a finger’s breadth from it (Fig. 1A). After careful dissection, he passed a curved hemostat through the floor of the mouth. We then pulled out the universal connector from the tracheal tube. (Although glued by the manufacturer, the connector can be forcefully removed.) The surgeon then grabbed the free extremity of the tube and its pneumatic cuff and pulled it back through the incision (Fig. 1B). We reinserted the connector, which was now fitting loosely after being unglued. We contemplated gluing it back or using tape to secure it properly when we heard an air leak around the tube. It was attributed to damage inflicted to the pneumatic cuff while being grabbed with the forceps. Still preferring to avoid direct laryngoscopy, we were left with two alternatives: 1) proceed with a tracheostomy or 2) remove the connector from the tube, pull back its free end into the mouth, use the tube exchanger to insert a new reinforced tube, and drag its unconnected end through the incision hoping to avoid damage to the new cuff. This maneuver would still have left us with a loose tube connector in need of being secured back. Although ready to proceed with direct laryngoscopy or tracheostomy, we elected to try using the tube exchanger through the damaged tube while it was still placed submentally (Fig. 1, C and D). Although we were uncertain that the exchanger would perform properly with the steep angle of insertion imposed by the submental approach, it worked well, and the damaged reinforced tube was easily replaced with a new one. We then proceeded with surgery without problem.Figure 1: Submental tracheal intubation using a tube exchanger. Submental incision (A) allows the free end of the orotracheal tube to be pulled through it (B). After insertion of the tube exchanger, the damaged tube is pulled out (C) and replaced with the new reinforced tube (D).Discussion Nasal tracheal intubation, when performed after craniomaxillofacial trauma, can result in the passage of the tube into the cranium, causing significant brain damage (2). To avoid this problem, orotracheal intubation may be preferred, but will interfere with the placement of intermaxillary fixation (necessary to establish the patient’s occlusion) during surgery. Tracheostomy may be an alternative (3) but it carries significant morbidity (4,5). The submental route for endotracheal intubation was proposed by Altemir in 1986 (6) as an alternative to tracheostomy for complex maxillofacial repair. It involves placing an orotracheal tube through a submental incision. Many reinforced tubes are not well suited for this technique, because their connectors are nonremovable. To allow their use in such circumstances, Green and Moore (7) suggested inserting the tracheal end of a reinforced tube from the outside of the submental incision and grabbing it with forceps to direct it into the trachea during direct laryngoscopy. We felt that this technique was not the best suited for our patient, because it involved performing direct laryngoscopy. Grabbing the tracheal end of the tube and directing it with the forceps may also damage the cuff. Certain disadvantages can be anticipated with the submental route. Damage to important structures of the floor of the mouth can be avoided by careful dissection and technique. Two cases of mild skin infection, responding successfully to local measures, were reported (8). Although most authors favor removing the tracheal tube quickly postoperatively (9), Gordon and Tolstunov (1) reported a case in which it was left in place for three days without complications. Tube exchangers can facilitate replacement of nasal and orotracheal tubes. Their use has even been advocated to convert nasal to orotracheal intubation (10) or facilitate tracheostomy (11). Still, their use through a submental approach, with its steep angle of insertion, had not been reported. We report such an occurrence and suggest that it can be used in a planned manner for reinforced tubes displaying nonremovable connectors or as an alternative in an emergency situation.

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