JOURNAL CLUB ALTERNATIVES FOR ELECTIVE TRACHEOSTOMY

DR.ADITYA T.N. POST GRADUATE DEPT OF OMFS

NASOTRACHEAL INTUBATION IN THE PRESENCE OF FRONTRONTO BASAL SKULL FRACTURE

Robertshaw HJ Arrowsmith je Boyd JD
CAN J ANAESTH 1998 / 45: 1 / pp 71-5

Purpose: to present a case of maxillofacial trauma and basal skull fracture (BSF) in whom nasotracheal intubation (NTI) was successfully used, without complication, to facilitate surgical fixation. To present alternative methods of airway management in this situation To review the evidence supporting the notion that NTI is contraindicated in the presence of basal skull fracture.

Case report
17-yr-old man was referred to maxiilofacial surgery following a road traffic accident. Depression of conscious level (glasgow coma score: 7) - necessitated orotracheal intubation and mechanical ventilation prior to transfer. Admitted to the intensive care unit (icu) for a period of elective ventilation and observation before surgical fixation.

 Fractures of the right clavicle and both pubic rami on the left, minimally displaced fracture of the right zygoma and bilateral parasymphysial fractures. Mastoid ecchymosis (Battle's sign) indicated a clinical diagnosis of BSF. Cranial computed tomographs. (CT) demonstrated intracranial air and fluid in the right frontal, ethmoid, sphenoid and maxillary sinuses. There was no evidence of cerebral injury

 Before surgery oral tube changed to nasal tube to facilitate IMF. Tube left in situ for 8 hours after the procedure. No CSF rhinorrhea noted post operatively No postoperative meningitis

Discussion
Hazards of blind instrumentation of the nasal passages in the presence of frontobasal fractures. Most anaesthesia texts include basilar and facial fractures in the list of contraindications to nasotracheal intubation. Evidence to support this recommendation is sparse and mainly based on anecdotal reports Bahr and Stoll study of 160 patients with BSF and CSF fistula reported that the route of tracheal intubation had no influence on the postoperative complication rate

 Route of tracheal intubation no influence on the postoperative complication rate. There was no case of direct cerebral injury associated with nasotracheal intubation Incidence of meningitis was the same, 2.5%, after oral and nasal intubation. A commentary on the study, commentary on the study, published in the same journal, admitted the limitations of the retrospective study design

 Rhee etal - study of 86 patients with clinical and/or radiological evidence of BSF,. To determine whether the complications of skull base fracture were increased by blind nasotracheal intubation performed in the field by experienced flight nurses. Complications were defined as; CSF leakage of >24 hr duration and/or meningitis, cranial nerve injury, diabetes insipidus and, intracranial placement of the endotracheal tube. Although the overall incidence of complications was high, 23%, there was no difference between the two groups.

 In the authors opinion, patient spared of unnecessary tracheotomy They don not recommend NTI as a routine procedure. Each patient and situation must be individually assessed and treated. Had the facial injuries in this patient been associated with worse tissue oedema, anatomical derangement and/or haemorrhage we would not have attempted nasotracheal intubation.

 Accept limitations of present retrospective studies in literature. Stress need for well designed prospective study

Critical analysis
Disregard to prescribed standards without resorting to other methods- adventurism Adventurism is not innovation. If risks of meningitis are anecdotal, so is this case report. Fleeting mention of sub mental intubation technique. No mention of retromolar oral intubation

Current literature
Patients with panfacial trauma require specific considerations for securing airway intraoperatively. Necessity of intraoperative restoration of dental occlusion(imf) makes oral tube unfeasible Nasotracheal intubation, - contraindicated in fracture of base of skull, fracture of naso-orbital-ethmoid complex, etc. Submento-tracheal intubation avoids the need of short-term tracheostomy and its associated complications. Retromolar intubation, avoids both submento-tracheal intubation and tracheostomy

Retrograde Submental Intubation by Pharyngeal Loop Technique in a Patient with Faciomaxillary Trauma and Restricted Mouth Opening
Arya VK Kumar A, Makkar SS Sharma RK Anesth Analg 2005;100:5347

Adequate mouth opening is a prerequisite for all the techniques described for submental intubation. retrograde sub mental intubation with the help of a pharyngeal loop assembly for the first time. A 32-year-old male patient with depressed fracture frontalbone left side, bilateral fracture zygoma, fractured nasal bones, LeFort II fracture, midpalatal split, and symphyseal mandibular fracture with bilateral temporomandibular joint dislocation leading to immobility of the lower jaw

 History of cerebrospinal fluid rhinorrhea that had resolved by this time. Inter-incisor distance of 0.5 cm The retro molar space was patent and allowed passage of a 14F disposable suction catheter Orotracheal intubation was not possible because of the locked jaw Need for intraoperative maxillomandibular fixation to check dental occlusion

Technique
Awake intubation with sedation Retrograde technique Use of pharyngeal loop (17) (ureteral guide wire threaded through a 3 mm uncuffed polyvinyl chloride endotracheal tube [ETT] and doubled up to form a small loop) 1.5-cm skin crease incision was subsequently made in the left submental region by the operating plastic surgeon .

 Blunt to enter the oral cavity, and proper hemostasis was achieved. pharyngeal loop now introduced through this incision and directed towards the incisors and taken out through the mouth. Using this loop the retrograde guidewire was brought out of the submental incision. tube exchanger threaded and advanced over the guidewire through the submental incision into the trachea. 32F flexometallic ETT with its connector was successfully threaded over the well lubricated tube exchanger Anaesthesia induced

Indications and contraindications for retrograde submental intubation

Indications: Maxillofacial injuries where oral and nasal intubation are not possible Restricted mouth opening expected to become normal after surgery No indication for prolonged postoperative airway control

Contraindications: Uncooperative patient Bleeding diathesis Disrupted laryngotracheal anatomy Restricted retromolar space to allow suctioning Inability to pass pharyngeal loop assembly Gun-shot injuries of face Fresh maxillofacial trauma with soft tissue

SUBMENTAL ENDOTRACHEAL INTUBATION: A USEFUL ALTERNATIVE TO TRACHEOSTOMY Naveen Malhotra1, Neerja Bhardwaj, P. Chari
Indian J. Anaesth. 2002; 46 (5) : 400-402

Nasal endotracheal intubation is often contraindicated in the presence of fracture of base of the skull presence of nasotracheal tube can interfere with surgical reconstruction of fractures of the naso-orbital ethmoid (NOE) complex. tracheostomy may be indicated but it carries a significant morbidity. Submental endotracheal intubation described as an useful alternative to tracheostomy with minimal complications

Case report
A 16 year old, 50 kg youth with RTA Glasgow coma score of 15 (E4V5M6). O/E: facial swelling, epistaxis, bilateral periorbital oedema, bilateral subconjunctival haemorrhage and loss of left upper incisors Cerebrospinal fluid rhinorrhoea was also present. Midface mobility with palatal split Occlusal derangement

Anaesthesia procedure
Preoxygenated with 100% oxygen for three minutes, anaesthesia was induced with thiopentone 5 mgkg-1 intravenously. After induction, mask ventilation was checked and found to be adequate. Injection suxamethonium 1.5 mgkg-1 intravenously was administered. On direct laryngoscopy there was no airway oedema. Oral endotracheal intubation was performed with 32 fg cuffed flexometallic endotracheal

 2 Cm incision was made in right submental region parallel and medial to inferior border ofmandible Extended intraorally through the mylohyoid muscle by blunt dissection. Pilot balloon followed by endotracheal tube were gently pulled out through the incision. Tube was fixed with 1-0 silk suture. At the end of surgery, submental intubation was converted to oral intubation. Pilot balloon and then the endotracheal tube

 Altemir, in 1986, first described the submental route for endotracheal intubation. provided a secure airway, an unobstructed intraoral surgical field and allowed maxillomandibular fixation the drawbacks and complications of nasotracheal intubation and tracheostomy avoided.

Tracheostomy complications : Hemorrhage Subcutaneous emphysema Pneuomediastinum Pneumothorax Recurrent laryngeal nerve damage, Stomal Respiratory tract infection Tracheal stenosis Tracheal erosions Dysphagia Problems with decanulation Excessive scarring.

Submental endotracheal intubation difficulties and complications

While the endotracheal tube is passed through the incision from interior to exterior. It may be difficult to pass the tube through the incision or reattaching the connector to endotracheal tube. Green and moores modification - two endotracheal tubes in their technique. Secured the airway with conventionally placed oral tracheal tube. Reinforced endotracheal tube then drawn in from exterior to interior through the submental

 Superficial infection of the submental wound Trauma submandibular and sublingual glands or ducts Damage to lingual nerve Orocutaneous fistula hypertrophic scar

Standard technique (Altemir) complications: Bleeding difficult tube passage sublingual gland involvement. modified technique - strict midline approach

Problems
Accidental extubation tube obstruction damaged tube (leaking cuff) difficult to manage in submental route. com

RETROMOLAR INTUBATION: A TECHNICAL NOTE

Naveen Malhotra Indian J. Anaesth. 2005; 49 (6) : 467 - 468

Alternative to orotracheal, nasotracheal and submento-tracheal intubations. Non-invasive technique of securing airway Avoids the complications of submental intubation and tracheostomy.

Technique
Orotracheal intubation is done initially with a flexometallic tracheal tube using standard general anaesthesia technique. Aim - to place the orotracheal tube in the retromolar space i.E. Space behind the last upper and lower erupted molar teeth the orotracheal tube is grasped with gloved fingers and is placed into the retromolar space The tube is then fixed by a wire ligature to the molar/premolar tooth along the upper or lower jaw in a figure of eight fashion.

 At the end of surgical procedure, wire IMF is opened resulting in adequate mouth opening. The wire ligature around the reinforced tracheal tube is removed and the retromolar tracheal tube is converted back to orotracheal tube. Subsequently, trachea is extubated by the standard method.

 Advantages avoids the need of any surgical airway (tracheostomy and submento- tracheal intubation). Disadvantages In some patients, the retromolar space is not adequate. After retromolar placement of the tracheal tube dental occlusion is not possible. Therefore, intraoperative IMF cannot be done. This anatomic possibility (of adequate retromolar space) can be determined by introducing the index finger in the patients mouth and asking him or her to close the

 Tracheal tube can interfere with the main surgical field that Tracheal tube can also interfere with positioning and application of dental fixation devices Too jealous fixation of flexometallic tracheal tube by wire ligature can deform the tube.

Conclusion
Retromolar intubation, if possible, avoids the need Of any surgical airway submento-tracheal intubation and short-term tracheostomy Orotracheal intubation is not feasible, nasotracheal intubation is contraindicated and retromolar intubation is not possible Submento-tracheal intubation is indicated to avoid short term tracheostomy.

THANK YOU

Martinez et al: if the space is not adequate then, after orotracheal intubation with flexometallic tube, an angled retromolar incision is made in the mandibular trigon region. If a third molar is found, whether erupted or unerupted, it is extracted before performing a semi lunar (180-degree) osteotomy large enough for the tracheal tube to lie below the occlusal plane. During the osteotomy, the internal mucoperiosteal plane is protected to prevent injury to lingual nerve.