An alternative for tracheostomy was first described by Hernandez Altemir in 1986.¹⁰ The submental route for endotracheal intubation¹⁰ consists of pulling the free end of an endotracheal tube (universal connector removed) through a submental incision, after a usual orotracheal intubation has been performed.^{7, 10} The use of submental intubation with Altemir's technique and its modifications has been used in a large number of patients with maxillofacial injuries.^{1, 7, 10, 11, 12, 13} Many studies have compared the disadvantages and risks of tracheostomy and submental intubation for the treatment of facial fractures.^{1, 7, 12} However, the use of Altemir's technique in cranial base surgery has not been adequately assessed. This retrospective study therefore evaluated the experience of our multidisciplinary team using submental intubation not only during the treatment of craniomaxillofacial trauma but also during transfacial approaches to the cranial base.

The medical records of 24 adults who underwent submental intubation at the Neurosurgical Department of San Raffaele Hospital in Milan and at the Maxillo–Facial Surgery Department of San Paolo Hospital in Milan from December 1996 to November 2002 were reviewed. Six patients were treated for craniofacial trauma, 12 underwent transmaxillary approaches to the clivus for clival chordomas (Figs. 1, 2, 3, 4, 5, 6, 7), and 6 underwent transmaxillary approaches to the cranial base for chondrosarcomas.

Figure 1 Preoperative Magnetic Resonance (MR).

Figure 2 Intraoperative view of the submental intubation.

Figure 3 Surgical access to the clivus. Large arrow: exposure of the lesion. Small arrow: maxilla dislocated downward.

Figure 4 Postoperative view of patient.

Figure 5 Surgical scar.

Figure 6 Postoperative dental occlusion.

Figure 7 Postoperative MR.

The following variables were evaluated to assess the results of Altemir's intubation technique: (1) time required for intubation, (2) accidental extubation, (3) postoperative complications (hemorrhage; injury to the sublingual glands, Wharton's duct, or lingual nerve; orotracheal fistula; and infection), and (4) healing of intraoral and submental scars. The time required for submental intubation was calculated starting from the completion of the orotracheal intubation to the fixation of the submental tube.

Figure 8A Illustration showing anterior view of submental intubation.

At the end of the procedure, anesthesia is discontinued and the patient is extubated in the operating room. The submental access is sutured after extubation using sutures inserted in advance or under local anesthesia. In case of maxillomandibular fixation, release of the incision at the end of surgery is unnecessary. In fact, the intraoral incision can be left to heal by second intention, and the extubation can be performed from the submental access.

Submental orotracheal intubation was completed successfully in all 24 patients. No accidental extubations or tube injuries occurred. The mean time required to place the tube was 5 minutes. No major complications (hemorrhage; injury to the sublingual glands, Wharton's duct or lingual nerve; or orotracheal fistula) were observed during the mean follow–up period of 48 months. Only one minor complication occurred. One case of superficial infection of the submental wound cleared after four days of washing with a saline solution and drainage. The submental incisions healed in all of the patients with minimal scarring.

The treatment of oncological and traumatic diseases through craniomaxillofacial surgery often implies problems with intraoperative airway management. When neither nasotracheal nor orotrachel intubation is suitable, temporary tracheostomy is frequently the option of choice.⁷ This technique, however, is associated with significant morbidity.¹² Complications include hemorrhage, recurrent laryngeal nerve damage, subcutaneous emphysema, tracheal stenosis, and a cosmetically undesirable scar.^{1, 12, 14, 15, 16, 17}

Different solutions have been proposed as an alternative to tracheostomy. In panmaxillofacial trauma, which requires maxillomandibular fixation and nasal fracture reduction, switching an endotracheal tube from the nasal route to the oral route without extubation can be a good option.^{1, 18, 19} This maneuver can be completed in less than 10 minutes.^{18, 19} The conversion can also be completed more rapidly with the use of tube exchangers.^{12, 20} Nevertheless, in patients with frontobasilar fractures associated with maxillofacial trauma, the nasotracheal intubation can lead to major complications such as meningitis, sepsis, and cerebrospinal fluid leakage. Furthermore, the nasal tube can be introduced intracranially, causing significant brain damage.^{1, 2, 3, 4, 5}

In 1998 Martinez–Lage et al proposed an alternative to nasotracheal intubation and tracheostomy during treatment of craniofacial traumas and cranial base approaches.⁶ In this technique, called retromolar intubation, a semilunar osteotomy is made in the retromolar space.⁶ The orotracheal tube is then placed in the retromolar area, lying below the occlusal plane.⁶ This intubation technique offers an unobstructed intraoral surgical field with secure airway management, and intermaxillary fixation can be performed without any impediments.¹ However bone anatomy must be destroyed to make space for the tube,¹⁹ and the procedure requires a mean of 25 minutes to perform.⁶ Besides, evaluation of the restoration of an individual occlusion can be partially impaired by the presence of the tube in the oral vestibule.

In contrast, the submental route for endotracheal intubation represents a fast and low–morbidity alternative to tracheostomy.⁷ The Altemir intubation procedure requires no more than 5 minutes to perform.^{7, 11} The technique is very easy, and the risk of damage to structures such as the sublingual and submaxillary glands, Wharton's duct, and the lingual nerve is very low. In fact, these major complications have never been reported. Our experience confirms that careful blunt dissection close to the medial border of the mandible and good knowledge of anatomy can help avoid damage to the structures of the floor of the mouth. In our experience, the one minor complication of the infected submental wound responded to local measures in 4 days.¹ This result seems to confirm the experiences of other authors^{1, 7, 10} who have reported a low morbidity associated with submental intubation in the treatment of maxillofacial trauma. No episodes of accidental extubation, leaking cuff, submental orotracheal fistulae or anomalous scars have been reported.¹

Some technical refinements can help minimize morbidity. After the normal orotracheal intubation, the tube must be firmly secured intraorally to prevent accidental extubation during the submental procedure.¹

Choosing material and equipment can represent a technical problem. For example, some reinforced tracheal tubes are manufactured with no detachable connectors. To use these tubes, a modification of Altemir's techinique was proposed by Green and Moore in 1996.²¹ They described the insertion of a reinforced endotracheal tube from outside the submental incision after orotracheal intubation with a non–reinforced tube.^{7, 21} The initial orotracheal tube is then removed, and the reinforced tube is introduced into trachea during direct laryngoscopy. In 1997 Cooper proposed the use of tube exchangers.^{12, 20}

In Altemir's original report, he suggested creating a subperiosteal passage for the tube in the lingual surface of the mandible.¹⁰ However, the passage can be created safely with an easier extraperiosteal blunt dissection near the lingual surface of the mandible. This dissection avoids lesions to the floor of the mouth structures and ensures good mobility of the mandibular segments.¹¹

We thank anesthetist Dr. Tiziana Corino for her assistance.