A 16-year-old male was scheduled for an open reduction and internal fixation of the panfacial fracture, consisting of a naso-orbital-ethmoidal (NOE) complex, a zygomaticomaxillary complex, a midpalatine, and mandible fracture. The tracheal intubation via the nasal route was deemed to be impossible. It was decided to perform submental endotracheal intubation for airway management. The patient's lungs were preoxygenated for 4 min, and anesthesia was induced with fentanyl 100 µg and thiopental sodium 250 mg. Manual ventilation of lungs was possible and 7 mg vecuronium were administered. After standard orotracheal intubation using a 100% silicone wire-reinforced tube (LMA-Fastrach™ETT, LMA company, Henley on Thames, UK) with an internal diameter of 7 mm, draping of the mouth and chin was carried out. Using an aseptic technique, a 2 cm skin incision was made in the submental, paramedian region, directly adjacent to the lower border of the mandible, approximately one third of the way from the symphysis to the angle of the mandible. A closed pair of artery forceps was introduced through the submental incision and into the floor of the mouth by blunt dissection. The forcep was kept close to the inner side of the mandible. Care was taken to avoid the submandibular duct and the lingual nerve, which were medial to the proposed tube entry site. The tissue layers encountered were subcutaneous fat, platysma, investing layer of deep cervical fascia and mylohyoid muscle until the tip of the artery forceps tented the mucosa of the floor of the mouth. The oral mucosa was then incised allowing easy delivery of the tip of the artery forceps into the oral cavity. The patient was ventilated for 5 min using 3% sevoflurane in 100% oxygen and the tracheal tube briefly disconnected from the breathing circuit. The connector of the LMA-Fastrach™ETT was detached. The pilot balloon (deflated) was first grabbed by the artery forceps and pulled through the passage in the floor of the mouth. Next, the tip of the artery forceps was then quickly reinserted through the submental incision to grasp the proximal end of the tube, which was pulled in a similar way. During the submental intubation procedure, the tube was firmly secured intraorally to prevent accidental extubation. After the tube was positioned, the connector was restored, the cuff re-inflated and the tube reconnected to the breathing circuit. Bilateral auscultation and proper capnography were performed to confirm that the tube was in the correct place. Intraorally, the tube lay on the floor of the mouth in the right sulcus between the tong and the mandible. There was no difficulty in passing the tube through the floor of mouth and the total duration of the submental intubation procedure was less than 7 min. Disconnection time from the ventilator was approximate 2 min. An immediate access to the oral airway or tracheostomy equipment was prepared for secure airway in case of adverse events such as tube obstruction, accidental extubation, or leaking cuff with the tube in the submental route at all times. The submental intubation was performed without any problems such as deoxygenation and the tube was fixed by suturing onto the submental area (Fig. 2). The operation proceeded without any problems and the patient was transferred to the ICU. On postoperative day (POD) 2, the submental intubation was converted into an orotracheal intubation by the endotracheal tube pulled back intraorally in the reverse order (first the endotracheal tube, then the pilot balloon). Weaning from mechanical ventilation and extubation was done in a classical manner on the following day. The patient was transferred to the general ward POD 6 and discharged 14 days after surgery without any complications.

A 19-yr-old male was scheduled for an open reduction and an internal fixation of a midfacial fracture, consisting of a NOE complex, a zygomaticomaxillary complex, a midpalatine, frontal bone, and a temporal bone fracture, via the bicoronal and transoral approach. It was believed that nasotracheal intubation would have interfered with centralization and stabilization of nasal fractures and orotracheal intubation would have compromised the reduction and maintenance of facial fractures. After inducing anesthesia with 250 mg thiopental sodium and 8 mg vecuronium, an orotracheal intubation was performed using the LMA-Fastrach™ETT with an internal diameter of 7 mm. The orotracheal intubation was converted into submental intubation in the same manner as the previous case. The procedure was completed within a few minutes and was associated with minimal bleeding. The airway was never compromised, ventilation was only interrupted for a few seconds, and no arterial desaturation occurred during the procedure. The operation proceeded without any problems. The patient was admitted to the ICU with submental intubation, which was maintained postoperatively. Extubation was carried out by pulling the tube through the skin and finally tying the sutures on POD 2. The patient remained 4 days in the ICU with no episodes of oxygen desaturation before being transferred to the general ward. His postoperative recovery in the ICU was unremarkable. He was discharged 14 days after operation with the submental incision and the intraoral wound healed uneventfully.