British Journal of Oral and Maxillofacial Surgery 44 (2006) 1214

Submento-submandibular intubation: Is the subperiosteal

passage essential?
Experience in 107 consecutive cases
C. Taglialatela Scafati a, , G. Maio b , F. Aliberti a , S. Taglialatela Scafati c , P.L. Grimaldi a
a Emergency Department, Unit of Maxillofacial Surgery, A. Cardarelli General Hospital, via A. Cardarelli 9, Naples 80131, Italy
b Department of Anaesthesiology, A. Cardarelli General Hospital, Naples, Italy
c Faculty of Medicine and Surgery, Federico II University, Naples, Italy

Accepted 13 July 2005

Available online 12 September 2005

Abstract

Adequate treatment of panfacial injuries often requires tracheostomy or alternating intubation through the nose and the mouth to keep the
field free during the operation. Altemirs submental technique is an attractive option in these patients. We used the method with a slight
modification in 107 operations in our unit to treat panfacial injuries. We had a low rate of complications and no increased operative time.
2005 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Panfacial trauma; Submento-submandibular intubation; Technique; Complications

Introduction
Complex midfacial or panfacial injuries often require tra-
cheostomy to ensure a free operative field.1 Oral intubation
can interfere with assessment of occlusion, and nasal tra-
cheal intubation may lead to complications (brain damage,
leakage of cerebrospinal fluid, and meningitis) when there are
also fractures of the base of the skull.24 On the other hand,
tracheostomy is associated with complications such as haem-
orrhage, pneumomediastinum or pneumothorax, injury to the
recurrent laryngeal nerve, and tracheal stenosis and should
be reserved for severely injured patients who need protracted
assistance with ventilation or further operations.5,6 A useful
alternative method of managing the airway intraoperatively
is by submental endotracheal intubation,7 which allows tra-
cheal intubation by passing the tube through a submental skin
Corresponding author. Emergency Department, Unit of Maxillofacial
Surgery, A. Cardarelli General Hospital, via A. Cardarelli 9, Naples 80131,
Italy. Fax: +39 081 5063907.
E-mail address: carminetaglia@libero.it (C. Taglialatela Scafati).
incision into the mouth (Fig. 1). We present the results in a
large series and discuss whether or not a modification of the
original technique that avoids the subperiosteal passage of
the tube causes more complications.
Patients and methods
A total of 107 patients were operated on over a 4-year period
from February 2000 to February 2004 for panfacial injuries
or maxillary fractures with involvement of the nasoorbitoeth-
moid complex and impairment of dental occlusion. There
were 72 men and 35 women, and their ages ranged from 16
to 78 years (median 25). Of the 107 patients, 31 had panfacial
fractures and 76 had midfacial fractures.
We achieved submento-submandibular intubation using
the double tracheal intubation as reported by Green and
More.8 In passing the tube from the extraoral to the intraoral
space, we stayed as close as possible to the medial aspect of
the mandible without going through the subperiosteal space,
as recommended by Altemir.7,9

0266-4356/$ see front matter 2005 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2005.07.011
 C. Taglialatela Scafati et al. / British Journal of Oral and Maxillofacial Surgery 44 (2006) 1214 13

Fig. 1. Patient at the end of intervention with intermaxillary fixation and

Fig. 3. Curved haemostatic forceps are used to grab the tip of similar forceps.
nasal packing.

Operation

Once the patient had been intubated by the orotracheal route,

we avoided damage to the facial vessels by identifying the
inferior border of the jaw in the submentomandibular area.
This area is near the junction between the 1/3 anterior and 2/3
posterior parts of the mandible, but some centimetres in front
of the anterior border of the masseter muscle. We used a pair
of curved scissors to dissect the underlying layers bluntly
(subcutaneous tissue, platysma muscle, superficial cervical
fascia, and mylohyoid muscle) until we reached the floor of
the mouth (Fig. 2). To avoid damage to the lingual nerve or the
salivary glands and their ducts, the dissection path adhered
as closely as possible to the lingual surface of the mandibular
Fig. 4. The tips of the second forceps are retracted downwards out of oral
body and was superficial to the periosteum.
cavity.
We then pierced the mucous membrane of the floor of
the mouth to create a 1.5 cm incision. This manoeuvre was
facilitated by tenting the oral mucosa and using one finger out of the oral cavity (Fig. 4). This forceps then grasped a
in the mouth to displace Whartons duct medially. Curved reinforced endotracheal tube that was passed into the mouth
haemostatic forceps (Fig. 3), rather than scissors, were used through the submento-submandibular incision and was used
to grasp the tip of a similar forceps and retract it downwards to replace the initial endotracheal tube (Fig. 5). In the mouth
the tube was settled on the floor between the tongue and the

Fig. 2. Scissors are used to dissect the underlying layers from the skin to the Fig. 5. The orotracheal tube is removed before replacing it by the second
oral cavity. tube.
14 C. Taglialatela Scafati et al. / British Journal of Oral and Maxillofacial Surgery 44 (2006) 1214
jaw and fixed to the skin with a suture of nylon 0. At the end
of the operation, the tube was withdrawn and the cutaneous
wound sutured with nylon 3/0; the mucosal wound healed
spontaneously.
Results
All the patients recovered without major complications. After
the usual learning curve, the procedure was done in less than
10 min and was not associated with impairment of the mon-
itored signs. In spite of the passage of the tube over the
periosteum, there were no lesions of Whartons duct or of
the submandibular and sublingual salivary glands, the lin-
gual nerve, or the marginal branch of the facial nerve, and
no bleeding or mucoceles.11 In 11 cases (10%), there was
suppuration in the cutaneous wound, and in eight cases (7%)
there was a salivary fistula, all of which recovered within
about 10 days. In six cases (6%), there were some difficulties
in the intubation in the phase of the exchange of tubes. These
patients were reintubated three times because the cuff of the
second tube broke twice.
Of the 107 patients, 73% (78 patients) were extubated
at the end of the intervention, 20% (21 patients) after 24 h,
and 7% (8 patients) after about 72 h, because of persistent
oedema. The cutaneous scar left no aesthetic damage.
Discussion
Tracheal intubation by the submento-submandibular route in
the treatment of complex craniofacial injuries keeps nasal and
oral orifices free and allows easy reduction and fixation of the
bones, both along the midface and on the jaw. It allows for
control of the occlusion at any time by applying and removing
the intermaxillary fixation (IMF) as needed. Additionally, it
is possible to avoid the alternating intubation procedure and
even more important, the tracheostomy. The route of the tube
does not need to be in the submental region; it can be in the
anterior submandibular region as mentioned by Stoll et al.,12
although some centimetres further along the masseter muscle.
The route at the angle of the mandible should be avoided
because of the greater risk of injury to the submandibular
salivary gland and its duct, or to the lingual nerve and the
facial blood vessels. For these reasons, we prefer to call the
technique submento-submandibular intubation.
Submento-submandibular intubation has proven effective
in terms both of results and of surgical time required, in addi-
tion to reducing stress for the patient and for the surgeon.
Complications from this approach are more hypothetical than
real.1214
Regarding the mucocele reported by Stranc and
Skoracki11 as a complication of the technique, we agree with
Altemir7,9 that it is important to prepare the surgical route
from the skin to the oral cavity to avoid introducing mucosal
fragments in the oral floor that can form a mucocele. As
Altemir noted in his original paper, the subperiosteal passage
of the tube is not essential; so mucocele as a complication
is caused by an incorrect surgical technique.10 Most sur-
geons do not pay much attention to this aspect, but almost
all of them agree in recommending that the tube be kept as
close as possible to the mandibular bone when preparing the
route.1,8,1214
The rare complications associated with submento-
submandibular intubation are attributable to errors of surgical
technique. The technique is not limited to extreme cases in
which the surgeon wishes to avoid tracheostomy in the treat-
ment of panfacial injuries. On the contrary, it is indicated even
in borderline cases, for example in isolated lesions with a
slight alteration in occlusion that require intraoperative inter-
maxillary fixation. It is also useful in the treatment of lesser
lesions, such as lesions of the nasal pyramid associated with
mandibular fractures that require an occlusive guide for treat-
ment. Submento-submandibular intubation is important even
in mild mandibular lesions in which nasal intubation is dif-
ficult or impossible because of congenital or post-traumatic
defects of the nasal pyramid.
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