Submental/submandibular intubation: a journey from past to future

Abstract

In 1986, Altemir published the first article on submental intubation as an alternative to tracheostomy for managing difficult airways. This review provides an overview of submental/submandibular intubation, covering its development, techniques, and clinical outcomes. Initially devised to address difficult airways in oral and maxillofacial surgery, the technique has since evolved. Recent advancements include focused surgical incisions, ultrasound-guided imaging, and the use of improved procedural tools like the Seldinger technique. Clinical trials have demonstrated that submental/submandibular intubation is generally more efficient and quicker than tracheostomy in trauma patients. One of its key advantages is the absence of visible scarring, along with a less invasive recovery process. However, the technique has some limitations, including risks of infection, bleeding, and scarring, which require further investigation to optimize its application. While submental/submandibular intubation remains a valuable method for managing difficult airways, ongoing refinement and evaluation are necessary to maximize its clinical utility. This technique presents an excellent alternative in specific surgical scenarios and offers a simplified solution where other intubation methods may be unfeasible.

Keywords: Complications; Intubation; Safety; Submandibular; Submental; Tracheostomy.

Fig. 1.

Examination of anatomical structures surrounding submental/submandibular intubation using the Essential Anatomy 5 (3D4Medical, Elsevier) application. (A, B) Lateral view. (C, D) Submental and submandibular area. When using the paramedian approach for submandibular intubation, care is needed around the submandibular gland, though key vascular structures like the submental artery and vein are generally unaffected by the incision line.

Fig. 2.

Analysis of techniques and equipment used in submental/submandibular intubation. (A) Methods of incision approach. (B) Devices used. (C) Number of tubes used. (D) Length of the skin incision. The graph is based on data from articles by Goh et al. [5], and Lim et al. [7]. In submental/submandibular intubation, the paramedian approach was used in 51.7% of cases, with reinforced tubes being the most common (85.1%), and the one-tube technique was favored in 83.9% of cases. Incision lengths varied, with 2 cm being the most used in 59.9% of cases.

Fig. 3.

Frequency analysis of submental/submandibular intubation procedures. The graph is based on data mentioned in the article by Lim et al. [7]. For the indications for submental/submandibular intubation, maxillofacial fractures accounted for the majority, followed by orthognathic, skull base, and nasal surgery.