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Year : 2022  |  Volume : 11  |  Issue : 2  |  Page : 146-148

Unusual and rare complication during submental intubation – Pilot cuff fracture, localization by CT and retrieval- A case report

1 Department of Oral and Maxillofacial Surgery, Anil Neerukonda Institute of Dental Sciences, Sangivalsa, Visakhaptnam, Andhra Pradesh, India
2 Department of Anesthesiology, NRIIMS, Viskahapatnam, Andhra Pradesh, India

Date of Submission24-May-2021
Date of Decision25-Dec-2021
Date of Acceptance19-Jan-2022
Date of Web Publication3-Aug-2022

Correspondence Address:
Dr. Venkata Ramana Murthy Vasupilli
Department of Oral and Maxillofacial Surgery, Anil Neerukonda Institute of Dental Sciences, Sangivalsa, Visakhaptnam, Andhra Pradesh - 531 162
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdrntruhs.jdrntruhs_63_21

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A secure airway is always a challenging task in the management of facial trauma. Open reduction and Internal fixation in Lefort II and III warrants airway patency during general anesthesia. Unobstructed surgical field provided by submental intubation helps in open reduction internal fixation (ORIF) and achieving intermaxillary fixation (IMF) during the procedure. However, submental intubation poses few complications such as bleeding, flexometallic tube damage, and obstruction of the tube. We report an unusual complication of pilot cuff fracture and retrieval during submental intubation with exact localization by computed tomography. Even though the technique is safer, it carries a number of rare risks depending on the exact techniques used and act as a reminder of unusual complications that might occur and be aware of the unusual risks of this surgery.

Keywords: Complication, localization, pilot cuff fracture, retrieval, submental intubation

How to cite this article:
Vasupilli VR, Suvvari R, Sampatirao SM, Tummalapalli S. Unusual and rare complication during submental intubation – Pilot cuff fracture, localization by CT and retrieval- A case report. J NTR Univ Health Sci 2022;11:146-8

How to cite this URL:
Vasupilli VR, Suvvari R, Sampatirao SM, Tummalapalli S. Unusual and rare complication during submental intubation – Pilot cuff fracture, localization by CT and retrieval- A case report. J NTR Univ Health Sci [serial online] 2022 [cited 2023 Feb 6];11:146-8. Available from: https://www.jdrntruhs.org/text.asp?2022/11/2/146/353220

  Introduction Top

The technique of submental intubation has many advantages in panfacial trauma comparatively pose minor problems related to pilot tubing system during the procedure. Complications such as severed pilot tube,[1] cuff leak, kinking of pilot tube,[2] and malfunction of pilot system[3],[4],[5],[6],[7] have been reported. We report here a new complication with the pilot tube cuff encountered during Lefort II fracture open reduction and internal fixation requiring submental intubation.

  Case Report Top

A 33-year-old male with Lefort II fracture was scheduled for open reduction and internal fixation under general anesthesia with submental intubation. In the operation theatre, an 8.0-mm ID flexometallic tube was selected and the connector was checked for easy detachment and faster transfer of the tube following oral intubation to submental transfer of the tube. After monitoring of electrocardiogram, noninvasive blood pressure, and pulse-oximetry, the patient was premedicated with fentanyl 100 ug, midazolam 3 mg, and glycopyrrolate 0.2 mg/kg after bag-mask ventilation, vecuronium 6 mg was given, and intubated with 8 mm flexometallic tube.

The patient is positioned with head extension and a 1-cm submental incision was made in the midline, blunt dissection with curved hemostat was done along the lingual surface of the mandible to create a tunnel. The tip of the hemostat was visible below the mucosa in the floor of the mouth and a mucosal incision was placed on the tip of the hemostat and passage was created for endotracheal tube. The connector of the tube was detached. The pilot balloon was deflated and the pilot tube grasped with the hemostat was gently withdrawn through the submental tunnel and flexometallic tube also grasped and withdrawn through the same tunnel.

However, during the tube transfer, 1/3 part of the pilot balloon assembly was found to be missing with ragged margins on the pilot tube [Figure 1]. Upon examination, cuff was found to be intact after inflation but missing part was suspected to be in the submental region. The position of the flexometallic tube was rechecked with laryngoscopy, auscultation, and capnography. A throat pack was placed and endotracheal tube secured with 2-0 silk. The missing part was not explored immediately as localization of the missing part was difficult due to the presence of the flexometallic tube in the same tunnel intraopertively without delaying primary treatment of open reduction and fixation. Retrieval of the missing part of the pilot balloon assembly was planned after shifting the flexometallic tube to oral intubation at the end of the primary treatment.
Figure 1: Fractured pilot Balloon fragment

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Localization of the missing part of the tube was tried intraoperatively using portable Doppler but failed to localize, then tried with color Doppler which showed hyper-intense signal at around 18 mm from the skin surface but failed to provide clear outline of the missing part as advocated by Orlinsky et al.[8] So, planned for retrieval after patient recovery after exact localization using computed tomography.[9],[10] On computed tomography [Figure 2], missing part was localized as a radiopaque foreign body near the genioglossus muscle entrapped along the path of the tunnel created during the transfer of the pilot tube from intraoral to extraoral submental intubation [Figure 3].
Figure 2: Axial CT showing localization

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Figure 3: Saggital CT with fragment in genioglossus muscle

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Upon localization, retrieval was done by a 1.5 submental incision extension layer by layer dissection and exploration 48 h post surgery under local anesthesia and closure was done and healed uneventfully. The utility of diagnostic ultrasound in the detection of foreign bodies retained in soft tissues was tried in only 15% of the cases showing localization. A use of computed tomography outweighs and provides accuracy in most of the cases. This case report highlights a rare event of pilot tube fragment retrieval after accurate localization using step by step use of radiological technique to favor easy retrieval instead of prolonging the duration of general anesthesia and recovery after LeFort II open reduction and fixation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Garg M, Rastogi B.Submental intubation in panfacial injuries: Our experience.Dental Traumatol 2010;26:90-3.  Back to cited text no. 1
Agrawal M, Kang L. Midlinesubmentalorotracheal intubation maxillofacial injuries: A substitute to tracheostomy where Postoperative mechanical ventilation is not required. JAnesthesiolClinPharmacol 2011;26:498-502.  Back to cited text no. 2
Gadre KS, Waknis PP. Transmylohyoid/Submental intubation: Review, analysis, and refinements. J CraniofacSurg 2010;21:516-9.  Back to cited text no. 3
Navaneetham A, Thangaswamy VS, Rao N. Sub-mentalinubation: Our experience. J Maxillofac Oral Surg 2010;9:64-7.  Back to cited text no. 4
Sharma Rk, Tuli P, Cyriac C. Submental tracheal intubation in oromaxillofacial surgery. Indian J PlastSurg 2008;41:15-9.  Back to cited text no. 5
Langford R. Complication of submental intubation. AnaesthIntensive Care 2009;37:325-6.  Back to cited text no. 6
Yoon KB, Choi BH, Chang HS, Lim HK. Management of detachment of pilot balloon during intraoral repositioning of the submental endotracheal tube.Yonsei Med J 2004;45:748-50.  Back to cited text no. 7
Orlinsky M, Knittel P, Feit T, Chan L, Mandavia D. The comparative accuracy of radiolucent foreign body detection using ultrasonography. Am J Emerg Med 2000;18:401-3.  Back to cited text no. 8
Oikarinen KS, Nieminen TM, Makarainen H, Pyhtinen J. Visibility of foreign bodies in soft tissue in plain radiographs, computed tomography, magnetic resonance imaging, and ultrasound. An in vitro study.Int J Oral MaxillofacSurg 1993;22:119-24.  Back to cited text no. 9
Lagalla R, Manfre L, Caronia A, Bencivinni F, Duranti C, Ponte F. Plain film, CT and MRI sensibility in the evaluation of intraorbital foreign bodies in an in vitro model of the orbit and in pig eyes. EurRadiol 2000;10:1338-41.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3]


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