Submental Intubation: An Alternative and Cost-Effective Technique for Complex Maxillofacial Surgeries

Introduction  

Management of airway is a significant issue especially in cases of complex maxillofacial trauma like panfacial fractures or concomitant nasoethmoidal injuries, where the nasotracheal intubation is contraindicated or possess a significant problem. In these cases the only other alternative is tracheostomy. Submental intubation is an alternative to tracheostomy and it can be easily performed with little or lesser post-operative complications. This method involves lesser expenses as it does away with longer post-operative stay in the hospital as required by tracheostomy patients.     

咪哒唑仑用于颌面外科清醒盲探插管的研究

目的 为咪哒唑仑用作清醒插管辅助用药提供临床资料。方法 选择４０例颌面外科手术病例,随机分为两组,每组２０例,采用盲探气管插管装置施行清醒插管。在清醒插管前５ｍｉｎ,Ｉ组给予芬太尼４μｇ／ｋｇ和咪哒唑仑０．０４ｍｇ／ｋｇ静注;Ⅱ组仅用芬太尼４μｇ／ｋｇ静注。观察比较两组在用药前（Ｔ１）、操作开始前即刻（Ｔ２）、食管气管引导管就位时（Ｔ３）、光索进入气管时（Ｔ４）和气管导管进入气管时（Ｔ５）的镇静评     

Intubation Techniques: Preferences of Maxillofacial Trauma Surgeons

Objective

To evaluate the clinical outcomes of alternative techniques of intubation in patients sustaining maxillofacial injuries, where nasotracheal intubation (NTI) is best avoided.

Material and Methods

Alternative techniques to standard naso-tracheal intubation like submental intubation, orotracheal intubation-retrotuberosity/retromolar and missing dentition were used and variables of clinical outcome recorded.

Results

Submental intubation provides an unobstructed intraoral surgical field, avoids intraoperative and postoperative complications of tracheostomy, and overcomes the disadvantages of NTI. In our experience with submental intubation (6 cases), we only had complication related to tube apparatus like damage to pilot balloon. With retrotuberosity intubation (5 cases) we did not encounter any complications and the only limitations were bulbous maxillary tuberosity. Retromolar intubation (4 cases) a safe noninvasive technique has disadvantages like tube interference within the surgical field and not feasible in case of limited retromolar space. Orotracheal-missing dentition intubation (4 cases) is of great advantage i.e. it can be used in cases where NTI is contraindicated, no specialized skill required, no added cost, avoids the need for tracheostomy, no extra-oral procedures required and does not interfere with occlusion/MMF; with disadvantage of occasional tube interference within the surgical field.

Conclusion

Preferred techniques of securing an airway like orotracheal, nasotracheal may not always be applicable, thus a trauma surgeon-anesthesist team should always have alternative techniques in their armamentarium to reduce the morbidity associated with these patients without interference with occlusion, which is prime goal in jaw fracture reduction. We have used these techniques in a country with limited resources and found them equally effective and convenient to use.     

Submental intubation: our experience

Introduction  

Airway management for patients who suffered midfacial fractures is complicated. In maxillofacial injuries, a choice has often to be made between different ways of intubation when surgical access to both the nasal and oral cavities is necessary. Submental intubation technique is an alternative to nasoendotracheal intubation and tracheostomy in the management of patients with severe midfacial fractures. This procedure is simple to do and has a low morbidity.     

Fever After Maxillofacial Surgery: A Critical Review

Purpose

The aim of this paper is to review the pathophysiology of thermoregulation mechanism, various causes of fever after maxillofacial surgery and the different treatment protocols advised in the literature.

Discussion

Fever is one of the most common complaints after major surgery and is also considered to be an important clinical sign which indicates developing pathology that may go unnoticed by the clinician during post operative period. Several factors are responsible for fever after the maxillofacial surgery, inflammation and infection being the commonest. However, other rare causes such as drug allergy, dehydration, malignancy and endocrinological disorders, etc. should be ruled out prior to any definite diagnosis and initiate the treatment. Proper history and clinical examination is an essential tool to predict the causative factors for fever. Common cooling methods like tepid sponging are usually effective alone or in conjunction with analgesics to reduce the temperature.

Conclusion

Fever is a common postoperative complaint and should not be underestimated as it may indicate a more serious underlying pathology. A specific guideline towards the management of such patients is necessary in every hospital setting to ensure optimal care towards the patients during post operative period.     

颏下岛状瓣修复口腔颌面部缺损临床应用研究--附30例报告

目的：评价颏下岛状瓣修复口腔颌面部组织缺损的临床效果及其价值,为临床应用提供经验。方法：临床应用颏下岛状瓣修复口腔颌面部缺损30例,其中面部6例,颊部9例（伴下唇缺损1例,口角缺损1例）,舌部9例,口底2例,磨牙后区1例,硬腭1例,上唇1例,下唇1例。术后观察组织瓣生长情况以及修复效果。结果：男性患者组织瓣上生长胡须,2例静脉回流障碍,1例组织瓣坏死,其余成活良好。缺损部位修复后,基本恢复解剖形态和生理功能。结论：颏下岛状瓣是修复口腔颌面部组织缺损的一种良好方法。     

颏下区岛状肌皮瓣在口腔颌面部软组织缺损重建中的应用

目的:探讨颏下区岛状肌皮瓣在口腔颌面部软组织缺损重建中的临床应用效果.方法:以颌外动脉、面前静脉的分支颏下动、静脉为蒂制备颏下区岛状肌皮瓣,修复口腔颌面部软组织缺损.结果:应用该皮瓣修复的14例患者,12例全部成活,1例出现部分坏死,1例失败,成功率92.9%,全部病例切除原发灶同时行同侧颈淋巴结清扫术,术后外观与功能满意.结论:颏下岛状皮瓣具有长而可靠的血管蒂、厚薄适中、成活率高、切口隐蔽、无需血管吻合、操作简单等优点,是口腔颌面部软组织缺损一期重建的理想选择.     

Submental artery island flap in intraoral reconstruction: A review

BackgroundThe submental flap was first introduced 20 years ago (1993). Advances in techniques and new findings from anatomic studies expanded the indications and improved the flap characteristics. Indications, limitation, and all possible variants of this flap are discussed comprehensively in this article.Materials and methodsA literature review was performed. We paid attention to the anatomy of submental region, and especially to submental artery and vein, muscles and lymphatics. Surgical techniques for each possible variant of this flap and examples of each situation are presented. Indications of submental flap for facial, oesophageal, pharyngeal, laryngeal, and oral cavity reconstruction were assessed.ResultsNinety studies meeting the inclusion criteria were reviewed. Classification of the submental flap based on skin paddle composition and blood supply is presented. Major modifications such as pedicled, free, and perforator flaps are discussed comprehensively and minor variants of submental flap such as bipaddled, bipedicled, expanded, deepithelialized, and interposition submental flaps are discussed, briefly. A historical look at this topic is presented to show how and by whom advances in submental flap were done.ConclusionThe submental flap has a wide arc of rotation; it is easy to rise and has low donor site morbidity. It is a safe, simple, and predictable method for reconstruction of oral cavity.     

Evaluation of a Single Dose Intravenous Paracetamol for Pain Relief After Maxillofacial Surgery: A Randomized Clinical Trial Study

Objective

The aim of this study was to evaluate, using a single dose of intravenous paracetamol, pain relief after maxillofacial surgery.

Materials and Methods

This is a controlled, randomized, uni- blind, clinical trial study to evaluate using a single dose of IV paracetamol for pain relief after maxillofacial surgery. The subjects were randomly divided into two groups with 40 subjects in each: group I received paracetamol (Apotel)* as a single dose and group II received placebo. Subjects were randomly allocated according to randomization lists. Paracetamol was used as a single dose (20 mg/kg in 100 cc of normal saline which was infused for 10 min after surgery in recovery room just before discharging). We used a visual analogue scale to investigate pain relief at various times.

Results

Analysis of the data, did not show any significant difference for age, sex and weight between the treatment group and the control group. Pain decreased 6 h after paracetamol infusion; then it increased mildly. In the control group, pain severity increased after operation, then it decreased mildly. Results showed a correlation between duration of surgery and pain severity in both the groups.

Conclusion

Paracetamol is effective on pain relief after maxillofacial surgeries. Operation time may be an important factor for induction of pain after the surgeries.     

Indication for and technical refinements of submental intubation in oral and maxillofacial surgery

INTRODUCTION: In maxillofacial injuries, a choice has often to be made between different ways of intubation when surgical access to both the nasal and the oral cavities is necessary. Submental intubation is an interesting alternative to tracheotomy, especially when short-term postoperative control of the airway is foreseeable, and as control of the dental occlusion is complete, and access to the nose and mouth is undisturbed. MATERIAL: This kind of intubation has been used in our department in 25 cases since 1997. All patients had fractures disturbing the dental occlusion plus either an associated fracture of the skull base, or a displaced nasal fracture. RESULTS: There was no intra-operative complication, average intubation duration was 1.5 days. Post-operative complications consisted of one case with hypertrophic scarring and two cases of abscess formation in the floor of the mouth. All these completely healed following local conservative treatment. CONCLUSION: Submental intubation demands certain technical skills but it is simple, rapid and may avoid tracheotomy in selected patients.     

四种插管技术解决气道困难的比较研究

目的观察比较四种插管技术解决气道困难的效果。方法将120例口腔颌面外科气道困难病例等分为4组,分别选用不同的插管技术进行清醒插管。组1用传统盲探技术,组2用逆行引导技术,组3用盲探插管新技术,组4用纤维光导喉镜引导技术。观察其插管效果、对循环和呼吸的影响以及并发症情况。结果4组插管成功率分别为76.7%(23/30)、93.3%(28/30)、100%(30/30)和100%(30/30),组1插管成功率明显低于其它各组(P<0.05);4组2次以上操作成功率分别为65.2%(15/23)、7.1%、6.7%和10%,组1明显高于其它各组(P<0.05);4组插管时间分别为(12.1±8.6)min、(4.2±1.3)min、(3.9±2.1)min和(3.7±2.2)min,组1较其它各组明显延长(P<0.05);插管过程中,4组循环和呼吸功能无明显变化;所有病例未见严重并发症。结论掌握各有不同特点的四种插管技术,有助于提高处理气道困难的综合水平。     

Trigeminocardiac Reflex: A Reappraisal with Relevance to Maxillofacial Surgery

Purpose

The purpose of this paper was to undertake a review of literature on trigeminocardiac reflex in oral and maxillofacial online data-base and discuss the pathophysiology, risk factor assessment, presentation of the reflex, prevention, management with emphasis on the role of the attending anaesthetist and the maxillofacial surgeon.

Materials and Methods

The available literature relevant to oral and maxillofacial surgery in online data-base of the United States National Library of Medicine: Pubmed (http://www.ncbi.nlm.nih.gov/pubmed/) was searched. The inclusion criterion was to review published clinical papers, abstracts and evidence based reviews on trigeminocardiac reflex relevant to oral and maxillofacial surgery.

Results

Sixty-five articles were found with the search term "trigeminocardiac reflex" in the literature searched. Eighteen articles met the inclusion criteria for this study. The relevant data was extracted, tabulated and reviewed to draw evidence based conclusions for the management of trigeminocardiac reflex.

Conclusions

Conclusions were drawn and discussed based on the reviewed maxillofacial literature with emphasis on the anaesthetist’s and the surgeon’s role in the management of this detrimental event in maxillofacial surgical practice.     

经鼻盲探插管在颌面部手术麻醉中的应用

安定镇痛麻醉下经鼻盲探气管内插管应用于４１２０例颌面部各类手术麻醉。在随机抽取的１０００例患者中１０ｍｉｎ内顺利完成插管占７３．５％，１１～２０ｍｉｎ内完成的较困难插管占２１．２％，２１～３０ｍｉｎ完成的困难插管占４．５％，气管切开后插管仅占０．８％。插管期间患者无明显不适反应，术后无回忆，心血管副效应轻，患者易接受。此方法有效地解决了颌面手术许多疑难插管问题     

Use of 3-D Stereolithographic Models in Oral and Maxillofacial Surgery

Objective  

To assess the feasibility of the use of 3-dimensional (3-D) stereolithographic (SLA) technology in complex maxillofacial reconstructive surgery.     

基于Web 的颌面骨整形重建外科数据平台的建立

目的：建立基于Web的适用于颌面骨整形重建外科的医学专业数据平台。方法：以专业网站、远程数据传输，本地数据库、本地虚拟手术系统等模块构成数据平台，以Web形式连接入world wide web，进行基于Web的颌面骨整形重建外科专业数据处理。结果：网站架构合理，Web数据交流平稳、可靠，数据平台各模块之间数据流通顺利，数据处理准确，数据处理方式适合专科专科特点。结论：以网站、数据库、虚拟手术系统等功能模块可以初步构建起本专科的Web数据平台。     

Incidence and Pattern of Maxillofacial Trauma Due to Road Traffic Accidents: A Prospective Study

Background

The incidence and causes of road traffic accidents (RTAs) vary with geographical location, socioeconomic status, religion and era. The etiological factors and associated injury patterns may be important in planning for preventive measures and treatment planning. The aim of this study was to evaluate and analyze the etiological factors, patterns and the frequency of maxillofacial injuries due to RTAs.

Materials and Methods

This prospective study was conducted on 350 patients with facial trauma due to RTAs. Records related to age, sex, the cause of the RTA, the vehicle type, time to reach the hospital, the use of seat belts, helmets, and other safety devices were evaluated and reviewed.

Results

Two-wheelers were the most involved (53.71 %) vehicle type and negligence of traffic rules (24 %) was the most common etiological factor. Male to female ratio was 6.3:1. The age group of 21–50 (68.85 %) years was mostly affected. The nasal bone (29.14 %) was most often the site of fracture followed by mandible (28.0 %). The rate of accident was higher during 1000–1400 hours (23.14 %) period and during weekends (38.0 %). Majority (58.57 %) of victims reached the hospital within 6 h of accident.

Conclusion

The low utilization of safety devices like seat belts and helmets as well as speeding, negligence of traffic rules and reckless driving were identified as etiological factors.