Dear Editor,
Submental intubation (SMI) is preferred for complex surgery involving the oro-maxillofacial region.[1] Various modifications have been made to the conventional SMI technique to make the procedure less traumatic and time-consuming.[1] This correspondence highlights using Griggs forceps to make an oro-cutaneous tunnel for SMI.
A 50-year-old male (weight: 65 kg, height: 170 cm) with a history of road traffic accident presented to the operation room (OR). He was scheduled for intermaxillary fixation of pan-facial injury under general anaesthesia with SMI. On pre-anaesthetic check-up, airway examination revealed Mallampati grade 2 with mouth opening of more than three fingers. The patient was wheeled into the OR, standard monitoring was attached, and intravenous (IV) Ringer lactate was initiated. Anaesthesia was induced with IV morphine 6.5 mg and propofol in titration and vecuronium bromide 6.5 mg to facilitate tracheal intubation with flexometallic tube (FMT) (8.0 mm cuffed) using videolaryngoscopy. Anaesthesia was maintained with 66% nitrous oxide in oxygen supplemented with isoflurane. For SMI, under strict asepsis, a 16-G needle was inserted approximately 1 cm from the lower margin of the mandible at a junction of medial 1/3rd and lateral 2/3rd of the distance between the symphysis and angle of the mandible. The needle was introduced to the sublingual part of the oral cavity after a small skin incision, and a guide wire was passed through the needle. Subsequently, Griggs forceps were guided over the guidewire and used to dilate the oro-cutaneous tract [Figure 1]. After desirable dilatation, the artery forceps was passed through it until it emerged in the oral cavity. After thoroughly suctioning the oral cavity, the cuff was deflated, and the pilot balloon was held tightly using forceps, exteriorised, and reinflated. Similarly, the FMT was exteriorised using artery forceps and connected to the anaesthesia circuit. The tube position was reconfirmed (by capnography and bilateral symmetrical air entry on auscultation) and sutured. The intra-operative and postoperative course was uneventful, and he was discharged on the 5th postoperative day.
Figure 1.
Use of Griggs forceps for creating an oro-cutaneous tunnel during submental intubation, with the guide wire in situ
SMI is preferred over tracheostomy for securing the airway and administering anaesthesia in patients with pan-facial injuries.[2] However, it may have procedural complications, such as damage to the pilot balloon, loss of tract or false tract formation, injury to sublingual ducts, glands, neural and vascular structures, infection, and abscess formation in the submental area.[1] To overcome these disadvantages, different practitioners have modified the SMI technique, including but not limited to two Kelly forceps techniques, two artery forceps techniques, silk sutures and laparoscopic trochar for tunnelling, and a Ring-Adair-Elwyn tube.[2,3] Seldinger’s technique is a recently described and exciting alternative to the classical Altemir’s technique, wherein a percutaneous dilatational tracheostomy kit is used to dilate the submental tract instead of bluntly dissecting it.[4,5] However, this kit is expensive and may not always be available. Thus, we modified this technique and used Griggs forceps, instead of a dilator, to dilate the oro-cutaneous tract. Though in our case, the use of Griggs forceps facilitated smooth exteriorisation of the pilot balloon and FMT, dilatation of tissue using Griggs forceps in a controlled way can be challenging, needing more expertise.
To conclude, Seldinger’s technique of submental intubation using the Griggs forceps can be considered an alternative technique of performing SMI.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
REFERENCES
- 1.Williams KD, Tariq M, Acharekar MV, Saldivia SEG, Unnikrishnan S, Chavarria YY, et al. Submental intubation in maxillofacial procedures: A more desired approach than nasotracheal intubation and tracheostomy. Cureus. 2022;14:e27475. doi: 10.7759/cureus.27475. doi: 10.7759/cureus.27475. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Mishra R, Yadav D, Tripathi S, Kandel L, Baral PP, Shubham S, et al. Submental intubations in panfacial fractures. Clin Cosmet Investig Dent. 2020;12:41–8. doi: 10.2147/CCIDE.S228326. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Raajesh JI, Debendra TK, Shanmugam D, Bhat RR. Modification of submental intubation using oral Ring-Adair-Elwyn tubes in faciomaxillary surgeries: A novel approach. Indian J Anaesth. 2013;57:418–9. doi: 10.4103/0019-5049.118513. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.SPS AR, Bhatia N, Jain K, Gupta T, Hazarika A. A prospective, randomized comparison of the classical Altemir’s method with the newer Seldinger’s technique of submental intubation. Anesth Analg. 2023;137:638–47. doi: 10.1213/ANE.0000000000006453. [DOI] [PubMed] [Google Scholar]
- 5.Saheb SM, Nath VN, Kumar KP, Padmaja PP. A novel method using Seldinger’s technique for submental intubation in major craniomaxillofacial fractures: A case series. Indian J Anaesth. 2014;58:48–50. doi: 10.4103/0019-5049.126795. [DOI] [PMC free article] [PubMed] [Google Scholar]