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applications. The Combitube SA applied submentally is useful for patients with serious craniomaxillomandibular
fractures, particularly those which disturb the occlusion and cause serious haemorrhage with attendant difculties
for intubation. Combitube SA used via the submental route will facilitate fracture reduction and temporary
maintenance of fractures, so that bleeding, pain and airway problems may be managed more easily until alternative
intubation has been achieved. r 2003 European Association for Cranio-Maxillofacial Surgery.
INTRODUCTION
The Combitube SA (Tyco-Healthcare-Kendall-Sheridan, Manseld, MA) (Beaumont, 1994; Agro et al.,
2001) using the transoral route should have a
recognized role even in severe oral and maxillofacial
trauma (Adamo et al., 1996; Morimoto et al., 2001). In
such cases, the need to protect the airway from a
fractured prosthesis, broken or displaced teeth that
could, either enter the airway (if the conventional
Combitube route was used), or lacerate its latex
balloons is important. In order to avoid this, we can
use, in certain circumstances, the Combitube SA via
the submental route to reach the supraglottic space,
by either making a wide submental incision to
facilitate the passage of the oropharyngeal balloon
and creating such access quickly, or using traumatic
wounds of the mandibular or submandibular regions
to establish the intubation route (Hernandez Altemir,
1984, 1986; Bogi and Ineze, 1996; Hernandez Altemir
and Hernandez Montero, 2000; Mark and Ooi, 2002).
This has the added advantage that the Combitube
does not interfere with the occlusion, so it is useful for
fracture reduction. It also reduces bleeding, pain and
improves ventilation of the patient. The proximal
balloon can also help to support the maxillomandibular structures, acting as a reducer and positioner for
the displaced bone fragments when it expands,
modelling the dental arches. It is also easier to
visualize the oropharyngeal region without the
difculties that occur when the Combitube is used
via the intraoral route.
MATERIAL AND METHODS
The Combitube SA was chosen according to the
patients weight. When deciding to use the submental
route or the modication that proceeded, we acted in
the following way:
Before using the Combitube SA it was necessary to
check that the airway is open. Then the pharyngeal
257
DISCUSSION
It has been shown that the extended submental route
with an endotracheal tube was sometimes enough for
treatment of facial fractures without the need for a
nasotracheal or orotracheal tube (Gordon and Tolstuonow, 1995; Caron et al., 2000).
We have now established that, in selected cases, the
use of the Combitube SA through an extended
submental route can produce results better than its
use transorally as it permits correction of intraoral
structures and the occlusion without the anaesthetic
tubes impeding. In this way, reduction and xation of
maxillomandibular fractures was easier. Fractures
can be stabilized without the interference of tubes
crossing nasal and oral structures.
Acknowledgements
The authors would like to thank the Department of Anaesthesiology and Reanimation and the Intensive Care Unit of the Hospital
Miguel Servet (Zaragoza, Spain) for its collaboration and
support in the conduct of this technique.
References
Mark PH, Ooi RG: Submental intubation in a patient with betathalassaemia major undergoing elective maxillary and
madibular osteotomies. Br J Anaesth 88: 288291, 2002
Morimoto F, Yoshioka T, Ikeuchi H, Inoue Y, Higashi T, Abe Y:
Use of esophageal tracheal combitube to control severe
oronasal bleeding associated with craniofacial injury: case
report. J Trauma 51: 168169, 2001