Panfacial fractures present a unique set of problems to the anaesthesiologist and the surgeon. Nasotracheal intubation is contraindicated in such cases due to associated Lefort I, II or III fractures. Endotracheal tube can be obstructed by deformed anatomical passages or can displace bony fragments distally. Oral endotracheal tube precludes one of the fundamental aspects of surgery, dental occlusion. Conventional tracheostomy has many inherent complications. With the knowledge of submental intubation most of the complications of tracheostomy can be avoided.

A 25 year old man was referred to our institute from a private hospital. History revealed patient had road traffic accident two days before referral to the institute. At the time of mishap he had nasal bleeding followed by altered consciousness for 2 days. Visible deformity of facial skeleton included depressed right zygoma. Mouth opening was more than 4 cms. Malampatti score I dental malocclusion was evident. Radiological examination showed fracture zygomatic arch, lateral margin right orbit fracture, Lefort II and III fracture on right side with comminution at right frontonasal junction.

The patients airway options were limited. Nasotracheal intubation was clearly contraindicated because of Lefort fractures. Oral intubation was precluded because of surgical prerequisite of checking dental occlusion. Submental intubation was opted against tracheostomy.

Fig. 1 : Orotracheal intubation	Fig. 2 : Orotracheal intubation, converted into submental endotracheal intubation

Patient was kept fasting for 10 hours preoperatively. Inj. Atropine 0.6 mg IM given before surgery. Preoxygenation with 100% O2 given for 5 minutes. Induction of anaesthesia done with injection Thiopentone 5 mg/kg intravenously. Ability to mask ventilate was confirmed. Injection Scoline 2 mg/kg given intravenously. After direct laryngoscopy, oral endotracheal intubation done with 38G flexometallic tube. Throat packing done. Anaesthesia was maintained with O2:N2O = 40:60 and infusion of Propofol 500 mg and vecuronium 6 mg mixed together, at the rate of 30 ml/hr. Now 3 cm incision was made in the right submental region by the plastic surgeon. It was extended intraorally. Endotracheal tube was disconnected from the non-rebreathing valve of breathing circuit. Connector was removed from the tube. The pilot balloon was grasped by the artery forceps and was pulled out gently, taking care not to damage it. Now by the pulling the pilot tube, while stabilizing the tracheal end of tube by Magill’s forceps, proximal end of tube was removed out. Connector and breathing system were attached again. Pulse oximeter and cardioscope showed no changes throughout the procedure. After reattachment, normal capnography waveform confirmed that tube manipulation did not result in change in tube position. Tube was wrapped with gauze, fixed with sutures taking care not to damage the tube. Now the surgeon could easily access both nasal and oral fields.

Throat packing gave extra margin of safety against aspiration of blood. Surgery went uneventfully for a duration of 10 hours. After the end of surgery, submental intubation was converted to oral intubation by pulling pilot tube into oral cavity, submental wound was closed.

Reversal of neuromuscular blockade was done uneventfully by injection Glycopyrolate 8 mg/kg and injection Neostigmine 0.05 mg/kg intravenously. After checking adequate recovery from neuromuscular blockade, patient was extubated.

Description of submental intubation dates back to 1986 by Altemir, a maxillofacial surgeon.1 This technique offers a secure airway to the anaesthesiologist, optimal operating field and opportunity to check dental occlusion to the surgeon and less morbidity to the patient. So this technique was appreciated, well deservedly, by all the members of the team.

Nasotracheal intubation is contraindicated usually in maxillofacial fractures since the complications are inadvertent introduction of tube into cranium, haemorrhage, obstraction to tube by distorted airway architecture, distal dislodgement of bony fragments by tube, meningitis, etc.2-4

Tracheostomy, an alternative plan, has built in complications like severe haemorrhage, damage to neuromuscular structures, pneumothorax, subcutaneous emphysema, tracheal stenosis, tracheomalacia, cosmetic disfigurement, etc.5

Submental intubation though has few complications like infection, orocutaneous fistula, can be at times challenging if attention is not paid to proper selection of tube.6 Connector should be loose enough to facilitate easy disconnection, yet tight enough not to allow accidental disconnection of continued leak. We have surpassed this problem by having separate tubes, with written labels, which are checked routinely prior to intubation.

Amin et al describes the use of capnagraphy during the process of converting orotracheal to submental and also throughout the surgery, to confirm the position of tube and to serve as warning tool against accidental extubation. Our experience also matches the authors' opinion.7

Drolet et al described the use of tracheal tube exchanger in case of limited mouth opening. But associated complications were thought to be too high and is not used in our institute.8

MacInnis et al described the use of midline incision to avoid excess bleeding, but since our previous experience with paramedian approach was uneventful, we went ahead with paramedian approach.10

Contraindications to submental orotracheal intubation are infection at the site of incision, mandibular symphysis fracture, inability to open mouth, etc.

The list of procedures, where submental intubation can be used safely wherever orotracheal or nasotracheal tube hinders surgical access are innumerable, like oral surgeries in patients with nasal obstruction, plastic surgery for cleft lip correction, rhinoplasty, etc.9

Altemir et al described the use of laryngeal mask airway via submental approach, in conditions where endotracheal tube has to be avoided, or simply is not desired.11

We conclude that knowledge of submental intubation enables anaesthesiologist and the surgeon to deliver better quality of patient care if used in appropriate cases.