Anterior Submandibular Approach for Transmylohyoid Endotracheal Intubation: A Reappraisal with Prospective Study in 206 Cases of Craniomaxillofacial Fractures

Abstract

Despite a paradigm shift in anesthesia and trauma airway management, the craniomaxillofacial fracture (CMF) patients continue to pose a challenge. A prospective study was planned between April 2007 and March 2015 to investigate the safety, efficacy, utility, and complications of anterior submandibular approach for transmylohyoid intubation (TMI) in CMFs using an armored endotracheal tube (ETT). Out of 1,207 maxillofacial trauma cases reported, this study recruited 206 patients (152 males and 54 females) aged between 21 and 60 years. No episode of oxygen desaturation was noted intraoperatively. Mean time to perform TMI was 6 ± 2 minutes. The mean transmylohyoid ETT withdrawal time/disconnection time from ventilator was approximately 1.5 minutes. Accidental partial extubation of ETT was noted in two patients (0.97%), and three patients (1.45%) developed abscess formations at anterior submandibular site which were managed by incision and drainage. The anterior submandibular approach for TMI was successfully used and provided stable airway in all elective CMF surgery cases, where oral or nasal intubations were not indicated/feasible and long-term ventilation support was not required. It permitted simultaneous dental occlusion-guided reduction and fixation of all the facial fractures without interference from the tube during the surgery with unhindered maintenance of the anesthesia and airway. The advantages include easy, swift, efficient, and reliable approach with a small learning curve.