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The endotracheal tube is often brought back into the mouth ahead of extubation, even though extubation immediately through the submental incision is described.49,52 Figure 9 Submental intubation. Proponents of submental intubation cite more aesthetic scars, avoidance of morbidity related to tracheostomies, and minimal problems. NVP-AUY922 In a overview by Caron and colleagues of 25 patients with maxillofacial trauma handled with submental intubation, one (4%) patient produced cellulitis with the incision site.53 Meyer and colleagues reported 1 (4%) patient with hypertrophic scarring and two (8%) individuals with floor of mouth abscesses inside their series of 25 patients with maxillofacial trauma.54 Anwer and colleagues reported 2 of 14 (14%) individuals with postoperative superficial skin infections.

48 Other doable disadvantages contain submandibular gland, Wharton's duct, lingual nerve damage, and orocutaneous fistula formation. On top of that, enhanced sedation could be essential due to the oral route of tube placement in patients who need long-term ventilation. Perhaps the simplest and least morbid approach of steering clear of tracheostomy in patients with panfacial fractures is retromolar intubation. After oral intubation in individuals with missing or impacted third molars, a reinforced endotracheal tube may be passed through the retromolar space and secured to an adjacent tooth with dental wire.fifty five Patients who can shut their jaws immediately after introducing an index finger in to the retromolar space very likely have sufficient room for this maneuver.

Some authors have described concurrent third molar extraction56 and bone removal57 to enable retromolar intubation, selleck kinase inhibitor while the latter approach appears to add further morbidity to a strategy intended to avoid it. Young children are very well suited for this strategy; Arora and colleagues reported 79 of 80 (99%) pediatric patients could accommodate a retromolar endotracheal tube although preserving centric occlusion.58 No reports utilizing retromolar intubation indicate difficulty with placement of maxillomandibular fixation. POSTOPERATIVE MANAGEMENT Individuals with substantial maxillofacial trauma that are maintained in maxillomandibular fixation soon after surgical treatment need to be thoroughly monitored while inside the hospital. Research have predictably demonstrated greater respiratory obstruction in sufferers with maxillomandibular fixation59,60 and, therefore, they must be placed on constant pulse oximetry.

Steroids may be regarded to lessen postoperative edema and improve respiratory status. Wire cutters or scissors must be positioned on the bedside and, far more critical, ancillary workers needs to be taught which wires to reduce if considerable dyspnea or significant nausea/vomiting develops. A special indicates of steering clear of hard postoperative reintubations is through placement of a pediatric airway exchange catheter.