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Surgical Pearls |

Submental Orotracheal Intubation—A Technique for Airway Management in Severe Facial Trauma

Benjamin D. Bradford, MD1; Jared C. Inman, MD1; Farhad Ardeshirpour, MD1
[+] Author Affiliations
1Division of Facial Plastic and Reconstructive Surgery, Department of Head and Neck Surgery, Loma Linda University Medical Center, Loma Linda, California
JAMA Facial Plast Surg. 2016;18(3):228-229. doi:10.1001/jamafacial.2015.2198.
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This Surgical Pearl presents a step-by-step description of submental orotracheal intubation to provide surgeons a clear and concise reference when managing the airway in patients with severe facial trauma.

Severe facial and anterior skull base trauma present particular challenges to the surgeon and anesthesiologist. A variety of methods have been described for airway management in cases of panfacial trauma; however, the literature is equivocal on the ideal technique. In 1986, Hernández Altemir1 described a technique that exteriorized an oral endotracheal tube through a floor-of-mouth and submental incision. Submental orotracheal intubation (SMOTI) avoids the risks, morbidity, and hindrance associated with nasotracheal intubation, orotracheal intubation, or tracheostomy. SMOTI secures the endotracheal tube and provides uninhibited access to craniofacial injuries. We present a step-by-step description with a Video of SMOTI to provide surgeons a clear and concise reference when managing the airway in patients with severe facial trauma. The intraoperative photographs and Video depicting this technique are taken from the case of a 15-year-old male who sustained left-sided LeFort III, right-sided LeFort II, naso-orbito-ethmoid, and skull base fractures with cerebrospinal fluid leak (Figure 1).

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Figure 1.
Computed Tomographic Scans of Left LeFort III, Right LeFort II, Naso-orbital-ethmoid, and Skull Base Fractures
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Figure 2.
Intraoperative Photographs

A, Site of planned incision. B, The floor-of-mouth incision is marked with dotted line. Asterisks indicate papillae. C, The clamp is advanced through submental incision into the floor of mouth. D, Endotracheal tube is shown traversing the floor of mouth and has been exteriorized through the submental incision. E, Endotracheal tube secured to submental skin with 2-0 silk suture. F, Submental incision repaired with interrupted 5-0 nylon sutures. G, Appearance of 1-cm submental scar 8 weeks after submental orotracheal intubation. H, The scar is well hidden.

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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