Submental intubation in a patient with beta-thalassaemia major undergoing elective maxillary and mandibular osteotomies

P. H. K. Mak* and R. G. B. Ooi

Department of Anaesthesiology, Queen Mary Hospital, Pokfulam, Hong Kong, People’s Republic of China*Corresponding author

Accepted for publication: October 2, 2001


    Abstract
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
A 33-yr-old woman with marked maxillo-facial deformities as a result of underlying beta-thalassaemia major was to undergo corrective maxillary and mandibular osteotomies. The placement of an endotracheal tube posed a problem in this patient because of anatomical deformities in her nasal passage, surgical constraints on using the oral route, and reluctance of the patient to have a tracheostomy. This case report describes the use of a submental tracheal intubation technique, and the associated anaesthetic difficulties encountered in patients with this pathology.

Br J Anaesth 2002; 88: 288–91

Keywords: anaesthesia; equipment, tubes tracheal; intubation tracheal, submental; complications, haemoglobinopathy; complications, beta-thalassaemia major


    Introduction
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
Thalassaemias are haematological diseases characterized by the absence or reduction in the globin chains of adult haemoglobin. Beta thalassaemia is a subset that lacks the beta chains. The excess of alpha chains causes the abnormal haemoglobin to be destroyed in the bone marrow and in the periphery. It is widespread throughout the Mediterranean, the Middle East, North Africa, the Indian subcontinent, and Southeast Asia. Inadequately treated patients develop severe anaemia, splenomegaly, bone changes, and are prone to infection. The survival of these patients is determined by the severity of iron loading in vital organs following repeated blood transfusions. Ectopic marrow expansion is another prominent feature if patients survive to adulthood. These bony abnormalities can be located in many different parts of the body and facial bone involvement is common. Patients may suffer the psychological and social stigmata of having facial deformities and there is a trend towards undertaking corrective surgery in the authors’ institution. We describe the perioperative difficulties encountered with a patient of Chinese origin with beta-thalassaemia major who presented for maxillo-facial surgery.


    Case report
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
A 33-yr-old woman with beta-thalassaemia major was to undergo elective surgery to correct her facial bone abnormalities. The patient had severe hypertrophy of the bone marrow of her maxilla, which resulted in the complete obstruction of both nasal passages (Fig. 1). Tracheal intubation via the nasal route was deemed to be impossible. The nature of her planned procedure, mandibular and maxillary osteostomies with intermaxillary fixation, precluded the use of an oral endotracheal tube. Both the operating surgeon and the patient were reluctant to have an elective tracheostomy. After detailed discussion with both parties, tracheal intubation was, therefore, planned using a technique reported previously: submental endotracheal intubation.1



View larger version (132K):
[in this window]
[in a new window]
 
Fig. 1. Nasal intubation was virtually impossible for this patient.

 
The other pertinent clinical features in this case related to the patient’s haemoglobinopathy. Her underlying haematological disorder had necessitated repeat blood transfusions every 6 weeks since childhood and, consequently, complications arising from iron overload were a concern. Her exercise tolerance was normal, and preoperative workup included a cardiology assessment. An echocardiogram showed normal function of both ventricles. Laboratory investigations revealed some minor abnormalities in coagulation with a prothrombin time of 16 s (11.3–13.2), active partial thromboplastin time of 38.2 s (27.6–37.6), and international normalized ratio of 1.3. Indices of iron storage status were all raised with serum iron of 41 µmol litre–1 (5–28), ferritin of 1600 pmol litre–1 (15–331), and transferrin saturation of 87% (15–45).

General anaesthesia was induced by i.v. injection of fentanyl 100 µg and propofol 150 mg. Direct laryngoscopy (Cormack and Lehane grade 2) and oral tracheal intubation with a size 7.0-mm ID (internal diameter) RAETM tube (Mallinckrodt Medical, Ireland) was facilitated with injection of cisatracurium 8 mg after confirmation of easy mask ventilation. Anaesthesia was maintained by nitrous oxide in oxygen and isoflurane. A 22-G arterial cannula was inserted into the left radial artery for continuous arterial blood pressure monitoring and for ease of blood sampling. A 16-G i.v. cannula and a long central venous line (Cavafix certo 375, B. Braun Medical, Germany) were inserted into the left forearm for i.v. fluid administration and central venous pressure monitoring. Surgery commenced with a 1.5-cm incision in the left submental region. Blunt dissection, whilst identifying and preserving both submandibular and lingual nerves, was carried out until the floor of the mouth was reached. Following 3 min pre-oxygenation of the patient’s lungs with 100% oxygen, a 6.5-mm ID silicone reinforced endotracheal tube (Willy Rüsch, Kernen, Germany) was inserted through the submental incision into the oral cavity. After thorough suctioning and removal of the oral tracheal tube, the reinforced tube was substituted. The process involved some degree of manipulation using a pair of Magill forceps as the new angle towards the trachea was very acute. The tube was fixed by suturing onto the submental area (Fig. 2). Surgery then preceded with Le Fort I maxillary osteotomy. To optimize surgical conditions and reduce intra-operative bleeding, the patient was positioned 15 degrees in the reverse Trendelenberg position and the systolic arterial blood pressure was maintained in the 80–90 mm Hg range. This was facilitated using aliquots of labetalol (total 15 mg).



View larger version (140K):
[in this window]
[in a new window]
 
Fig. 2. Submental entry site for the endotracheal tube.

 
At the stage of bone dissection and drilling, there was brisk and profuse bleeding into the surgical field, and the surgeons experienced difficulty in haemostasis. Despite vigorous fluid repletion, it was difficult to maintain a systolic arterial blood pressure of 80 mm Hg, and a central venous pressure above 0 cm H2O. Surgery was also technically very difficult as there were minimal bony structures for plating after the osteotomy was completed and instead, a pair of hooked K wires had to be inserted into the zygomatic arches for maxillary fixation.

The estimated blood loss was 11.8 litres. The fluid repletion regimem consisted of 4 litres of crystalloid, 3 litres of colloid, 16 units of packed red cells, and 10 units each of fresh frozen plasma and platelets. Because of concern about haemostasis and ensuing blood loss, the mandibular osteostomy and intermaxillary fixation procedures were abandoned (the mandible was overgrown with bone marrow, and attempts at applying the intermaxillary fixation plate would have resulted in further brisk bleeding). As the intermaxillary fixation procedure was no longer necessary, the endotracheal tube was removed from the submental incision and substituted with a 6.5-mm ID tracheal tube through the oral route via direct laryngoscopy at the end of surgery. The submental incision site was then closed. Mechanical ventilation of the lungs in the intensive care unit (ICU) was continued postoperatively because of the blood loss and potential airway compromise from tissue swelling. I.v. dexamethasone was continued postoperatively to reduce facial and laryngeal swelling. Her postoperative stay in the ICU was uneventful. She was weaned from ventilatory support and her trachea extubated 2 days after the procedure. The patient was discharged from the hospital on her tenth postoperative day.


    Discussion
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
This method of tracheal intubation, via the submental route, was first described by Hernandez Altemir in 1986.1 Since then, there have been several articles in the literature describing and modifying the technique. They were, however, mostly performed in patients following craniofacial trauma.2 3 In these patients, nasal intubation was contraindicated because of the possibility of basal skull fracture.

We have described a unique case of a patient with severe facial bony deformities secondary to beta-thalassaemia major requiring surgery in an elective setting mainly for cosmetic reasons. Insertion of an endotracheal tube via the nasal passage was deemed impossible, as the maxilla was so overgrown, obstructing the nasal passages. As the planned procedure involved an intermaxillary fixation, the oral route for tracheal intubation was not feasible. A tracheostomy was considered to be an aesthetically inferior option by the patient and surgeon compared with using the submental route.

Two techniques for endotracheal tube placement via the submental route have been described previously. The first involved a plain oral endotracheal tube inserted after induction of general anaesthesia. A submental incision was then made and blunt dissection carried out as close to the mandible as possible until reaching the floor of the mouth was reduced. A pair of artery forceps was then passed into the channel created and the air injection port of the endotracheal tube grasped. The endotracheal tube connector was temporarily disconnected so that the body of the tube could be pulled through the floor of the mouth by the artery forceps and out through the submental opening.4 The connector was then reattached to the rest of the breathing circuit and ventilation continued. The second technique was described in 1996 by Green and Moore5 utilizing two separate tubes.6 After general anaesthesia and placement of an oral endotracheal tube, a second endotracheal was introduced through a submental incision and subsequently substituted into the larynx. We chose the latter technique for two reasons. The first reason was to minimize the apnoea time while passing the endotracheal tube through the submental passage, removing and reconnecting the plastic connector. The second reason was that the silicone-reinforced tube that we used in this case has a big air injection port attached to a three-way stopcock. This is relatively large and the incision would have to have been much larger to facilitate the passage of the entire tube. However, one drawback of using this technique that has not been emphasized previously is the possibility of cuff damage. Because of the acute angle that one has to manoeuvre the tube intra-orally for tube exchange, a pair of Magill forceps has to be used for manipulation. Repeated contact between the forceps and the cuff of the tube may increase the risk of cuff damage.

Some of the anaesthetic problems associated with the thalassaemia-major syndrome have been reported previously.7 8 Although genetic counselling has become widely available in the developed world, the authors still encounter an increasing number of patients presenting with severe forms of haemoglobinopathy, mainly from immigrant families from mainland China. Whilst modern treatments911 have prolonged survival in these patients, a proportion now present for corrective surgery of facial deformities.

The massive blood loss in this case arose because of the nature of the procedure, rather than pre-existing coagulopathy. The operation involved an osteotomy impinging on overgrown bone marrow, and in retrospect, we should have anticipated the propensity for severe bleeding. It could be argued that elective cosmetic surgery may not have been prudent in this patient. However, as the demand for surgery from the patient was so overwhelming, and considering the psychosocial impact of her facial deformities, we agreed to proceed after discussing all the risks with the patient.

In conclusion, the submental method is a novel, but under utilized, technique for tracheal intubation and has only previously been described in patients with craniofacial trauma. We have described successful use in a patient with severe facial deformities, as a result of underlying thalassaemia major. We conclude that this technique is a useful option, and should not only be limited to trauma patients, but extended to a wide spectrum of patients and may avoid some of the problems inherent with a tracheostomy. Patients with beta-thalassaemia major can present with minimal symptoms but can have major intra-operative problems, especially if the operation involves correction to the bony structure. It may be reasonable to consider the use of intra-operative blood salvage techniques or means to rapidly replete intra-vascular volume.


    References
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
1 Hernandez Altemir F. The submental route for endotracheal intubation. A new technique. J Maxillofac Surg 1986; 14: 64–5[ISI][Medline]

2 Caron G, Paquin R, Lessard MR, Trepanier CA, Landry PE. Submental endotracheal intubation: an alternative to tracheostomy in patients with midfacial and panfacial fractures. J Trauma 2000; 48: 235–40[ISI][Medline]

3 Gordon NC, Tolstunov L. Submental approach to oroendotracheal intubation in patients with midfacial fractures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995; 79: 269–72[ISI][Medline]

4 Chandu A, Smith AC, Gebert R. Submental intubation: an alternative to short-term tracheostomy. Anaesth Intens Care 2000; 28: 193–5[ISI][Medline]

5 Green JD, Moore UJ. A modification of sub-mental intubation. Br J Anaesth 1996; 77: 789–91[Abstract/Free Full Text]

6 Paetkau DJ, Stranc M, Ong BY. Submental orotracheal intubation for maxillofacial surgery. Anesthesiology 2000; 92: 912[ISI][Medline]

7 Carrasco Jimenez MS, Gomar Sancho MC, Nalda FelipeMA, de Antonio P, Munoz J, Lario R. Thalassemia and anesthesia. A case report. Rev Esp Anestesiol Reaim 1982; 29: 95–8

8 Olive M, Mora A, Ballve M, Cortes C, Cabarrocas E. Thalassemic syndromes and anesthesia. Rev Esp Anestesiol Reanim 1992; 39: 166–9[Medline]

9 Weatherall DJ. The thalassaemias. BMJ 1997; 314: 1675–8[Free Full Text]

10 Hershko C, Konijn AM, Link G. Iron chelators for thalassaemia. Br J Haematol 1998; 101: 399–406[ISI][Medline]

11 Olivieri NF, Brittenham GM. Iron-chelating therapy and the treatment of thalassemia. Blood 1997; 89: 739–61[Free Full Text]





This Article
Abstract
Full Text (PDF)
E-Letters: Submit a response to the article
Alert me when this article is cited
Alert me when E-letters are posted
Alert me if a correction is posted
Services
Email this article to a friend
Similar articles in this journal
Similar articles in ISI Web of Science
Similar articles in PubMed
Alert me to new issues of the journal
Add to My Personal Archive
Download to citation manager
Search for citing articles in:
ISI Web of Science (2)
Disclaimer
Request Permissions
Google Scholar
Articles by Mak, P. H. K.
Articles by Ooi, R. G. B.
PubMed
PubMed Citation
Articles by Mak, P. H. K.
Articles by Ooi, R. G. B.