|Year : 2014 | Volume
| Issue : 2 | Page : 66-70
Alternatives to surgical tracheostomy: A critical review
Sami A Al Kindy
Department of Surgery, College of Medicine, Taif University, Taif, Saudi Arabia
|Date of Web Publication||20-Jun-2014|
Sami A Al Kindy
Department of Surgery, College of Medicine, Taif University, PO Box 888, Taif - 21974
Source of Support: None, Conflict of Interest: None
Surgical tracheostomy (ST) is the oldest life-saving procedure in records, usually done by otolaryngologists and occasionally by general surgeons, thoracic surgeons, and neurosurgeons. It has been an important surgical skill for any given otolaryngology training program. On the contrary, retromolar, submental, submandibular endotracheal intubations, and their modifications are carried out by oral surgeons, maxillofacial surgeons, skull base surgeons, and plastic surgeons and are considered alternative to ST. Despite none are done in an emergency situation, it is suggested to be less invasive, simple, safe, with less surgical time, nearly unknown complications, has unsightly scar and cheaper in comparison to ST. It is thought that these techniques provide free surgical access in cases where oral and nasal intubations are often not suitable and require intermittent intraoperative dental occlusion to check alignment of fractured fragments. In the current report, PubMed has been reviewed for the reasons, indications, complications, techniques, and modifications of the above mentioned ST alternatives. The article critically discusses the surgical part of these innovative procedures and concludes that ST, in spite of its risks, remains the procedure of choice for surgical airway access when long-term intubation is not anticipated, especially in emergencies and difficult airways. A regular workshop of this highly in demand surgical skill is suggested.
Keywords: Retromolar intubationm, submandibular intubation, submental intubation, tracheostomy
|How to cite this article:|
Al Kindy SA. Alternatives to surgical tracheostomy: A critical review. Saudi J Health Sci 2014;3:66-70
| Introduction|| |
Surgical tracheostomy (ST) is one of the most frequently performed surgical procedures either elective or rarely as an emergency in critically ill patients.  It is considered to be the technique of choice for airway control. , ST is commonly performed by otolaryngologists and occasionally by general, thoracic, and neurosurgeons.  Since 30 years, innovative procedures such as retromolar, submental, submandibular endotracheal (ET) intubations, and their modifications have been introduced. Unlike ST, they are done by oral and maxillofacial, skull base, and plastic surgeons. ,,, Albeit, the name sounds to be a formal ET intubation, it does have a surgical part. Moreover, none of these techniques are done in a lifesaving situation. Although it is a blind technique, their advocators, consider them to be very easy, simple, safe, have low or no complications, quicker with acceptable scar, and financially cheaper compared with ST. ,,,
The first person to introduce alternative to ST was Hernandez in 1986,  an oral and maxillofacial surgeon. His aim was to avoid ST complications, in cases where orotracheal or nasotracheal intubation were not feasible, long-term postoperative ventilation or protection of airway is not anticipated, and free surgical access to restore the fragmented bones to its normal anatomy. ,,, Having it done by the same surgeon is probably an additional reason, is the author's opinion.
The selection criteria put were, craniofacial injuries with associated fractures of nasal bone and skull base, orthognathic surgeries, elective esthetic face surgeries, repair of congenital malformations, multiple or complex facial osteotomies, and transfacial oncologic procedures of the cranial base. , The object of this study is to critically discuss the aims, indications, surgical steps, limitations as well as complications of the alternatives and why they are considered by advocators to be superior to ST. A review of related PubMed English publications with correspondences including oral, maxillofacial, dental, skull base, anesthesia as well as otolaryngology journals of the last 30 years is made.
| Surgical anatomy|| |
Submental and submandibular spaces are potential spaces of the anterior triangles of the neck.
The submental space lie below the chin and bounded by the anterior bellies of digastric muscles, midline, and hyoid bone. Its contents include lymph node and submental salivary gland. While the submandibular space lie below the body of the ramus of the mandible, bounded by the inferior margin of the mandible and the anterior and posterior bellies of digastric muscles. Deep to it are the stylohyoid and mylohyoid muscles. It contains the submandibular salivary gland, deep fascia, lymph nodes and anterior facial vein, facial artery and marginal mandibular branch of the facial nerve.
The cervical trachea is covered by skin, superficial facia and deep fascia and by the sternohyoid and sternothyroid muscles, isthmus of thyroid lying over the second to the forth tracheal rings. The anterior relations of the trachea lower in the neck and superior mediastinum include the inferior thyroid veins, thyoid ima artery when present and thymus gland (small and insignificant in adults). 
After selecting a suitable size armoured ET, patient is inducted and ventilated. The fixed universal connector is replaced with a removable one. A 2 cm submental incision is done just medial to the lower border of the mandible, about one-third between the symphysis and the angle of the mandible and parallel to it. Blunt dissection is carried out with artery forceps through the skin incision toward the mouth cavity while pushing the tongue backward, till the tip tents the mucosa of the floor of the mouth anterior to Wharton's duct papillae. The mucous membrane is incised to introduce the tip of the forceps. With a forceps the ET tube end is grasped and pulled through the tract formed to the submental skin and fixed with sutures.
The removable connector is re attached and ventilation continued through the ET.
After the end of the procedure, the tube is either left in situ to be removed later in the intensive care unit or removed in the theater, skin incision is closed, leaving the inner one to heal as a secondary intention. ,
Originally, a subperiosteal passage in the lingual surface of the mandible was suggested.  However, it was abandoned in favor of extraperiosteal passage which was found to be safer, avoids lesions to the floor of the mouth structures, and ensures good mobility of the mandibular segments. 
Modified submental intubation
The steps are the same as in submental intubation; however, the submental lateral incision was substituted for a midline incision this method has been found to be easier in passing the ET, minimized bleeding, and prevented sublingual gland injury. 
Submandibular intubation is a modification of submental intubation to avoid complications of salivary glands by placing the incision in the submandibular region. 
As previously described Induction and intubation with a suitable size armoured ET is done. A 1.5 cm transverse incision is done in the submandibular area, approximately 1 inch below ½ an inch anterior to the angle of the mandible. Blunt dissection is carried out through the skin using a medium-sized curved artery forceps in which the fat, platysma, investing layer of deep cervical fascia, and the mylohyoid muscle close to the inner side of the mandible till the tip of the forceps tents the mucous membrane of the mouth cavity medial to the second molar tooth. Incision is done in the mucous membrane to introduce the tip of the forceps, the ET is grasped and pulled through the tract formed outside skin incision. Finally, it is fixed after reconnection and ventilation continued. 
Martinez-Lage et al.,  in 1998 was the first one to propose it as an alternative to nasotracheal intubation and tracheostomy. The space is assessed by passing the index finger in the retromolar space and closing the jaw. A missing or impacted third molar creates the space required; ,, otherwise, a semilunar osteotomy or the concurrent third molar extracted as originally described.  The later procedures were later abandoned due to its high morbidity.
After orotracheal intubation with a suitable ET, it is passed in the retromolar space and secured to an adjacent tooth with a dental wire to lie below the exclusion plane. The tube is connected and ventilation continued.
Originally, retromolar intubation did not have a surgical part; however, its modification did, in which the ET is passed to the submental area via the mandibulovestibular space on the selected side however, with the risk of mental nerve injury and a submental scar, especially in Asians. 
Ideally, it is done under sterile and controlled condition in the operation theater. Patient is put in supine position, inducted, intubated (in case of difficult intubations it is undertaken under local anesthesia), and neck extended with a sand bag. The surface anatomy is marked to highlight cricoid cartilage lower border and suprasternal notch. After infiltration with adrenaline for haemostasis, a horizontal incision is undertaken between these two landmarks (vertical incision is preferable in emergency situations to access the trachea directly). The skin, subcutaneous tissues are cut and the strap muscles split in midline. After visualizing the isthmus, it is either retracted or divided, this exposes the cricoid ring and upper tracheal rings. The cuff of the selected tube is tested. A vertical incision in the midline is done, avoiding the first tracheal ring. Edges of the tracheal wall are held with either silk stay suture or held with artery forceps. With coordination, the anesthetist pulls the ET and tracheostomy tube inserted simultaneously. After connecting it to the ventilator, flanges of the tube are secured with sutures. 
The general consensus of ST benefits includes reduced risk of laryngeal injury, weaning from intermittent positive pressure ventilation, less sedation, improved patient comfort, communication, and oral hygiene.  Furthermore, it provides improved care for patients in the trauma or critical care setting and reduces the hospital and patient costs. , Nevertheless, ST is not complication free, there are certain reported risks in neonates, morbid obesity, short neck, cervical stiffness, tumors with neck infiltration and thyroid gland masses. , However, it remains the procedure of choice in these cases  and the option of alternative to ST and percutaneous tracheostomy here is questionable for obvious reasons.
The ST complications quoted by adversaries were haemorrhage, surgical emphysema, pneumothorax, pneumomediastinum, recurrent laryngeal nerve palsy, stomal and respiratory tract infection, tube blockage, dysphagia, difficulty with decanulation, tracheal stenosis, and tracheosophageal fistula as well as an ugly scar. ,
For a short anticipated airway access most of these complications are not expected as so as they are late ST complications, furthermore, any resulting ugly scar for the sake of safety is the least concern in these cases, especially in severe maxillofacial traumas.
Though, hemorrhage, surgical emphysema, pneumothorax are documented perioperative or early complications with incidence reports of 2.4-2.6%, 2.4-4.4%, 1.2% ,,, respectively, none were life-threatening. Bedside tracheostomy was found to be a factor in bleeding that is easily controlled by pressure  and cutting thyroid isthmus with electrical cautry was found to reduce its incidence. 
Inappropriate size of the tube is attributed to subcutaneous emphysema and not due to ST per se. While pneumothorax, though uncommon, was reported in emergency and difficult cases,  while patient's age and long-term tracheostomy were linked to infection. , The complication of recurrent laryngeal nerve injury is very rare indeed, not supported by any publications or reports; however, its mention in otolaryngology textbooks is nothing but theoretically a possibility. 
In spite of the figures mentioned above, a meta-analysis of more than 1000 ST cases, from eight different academic institutions, found that perioperative complications were rare.  On the contrary, the reported complications of the alternatives include bleeding, sublingual salivary gland involvement,  hypertrophic scarring, abscess formation in the floor of the mouth,  superficial infection,  mucocele due to inclusion of mucosal fragment,  accidental ET dislodgement,  and extubation;  however, some lack figures as seen in ST for comparison. In addition, urgent airway access may be hampered, especially in cases with maxillomandbular fixation, ,, where a delay in removing the tube is often required when anticipated risk of airway edema or hematoma, a delay in consciousness level recovery or a possibility of early reoperation. 
Practically speaking alternatives to ST is a blind procedure, with a potential risk of injury to the structures and organs in the submandibular and submental spaces, described above.
Though not reported, the alternatives carry certain potential risk including vascular, sublingual, and submandibular ducts, lingual nerves injuries and hypoxia while passing the tube through the incision. 
The American Society of Anesthesiologists describes a difficult airway as "clinical situation in which a conventionally trained anesthesiologist experiences difficulty with face mask ventilation of the upper airway, difficulty with tracheal intubation, or both''. 
Selection of airway access in these cases requires both sound judgment and considerable experience as so as each technique has its own advantages and limitations, depending on the availability of instruments and surgeon's experience. 
ST is as a simple and safe procedure for high-risk patients and difficult airways ,, as well as helpful in removing aspirated teeth complicating maxillofacial trauma.  Moreover, surgeon's experience is not mandatory  and if warranted done under local anesthesia.  In contrast, alternative to ST is done exclusively by named specialities for selected cases only and demanding certain technical skills.  It carries its own morbid and potential complications , and moreover, problems faced when urgent airway access is required postoperatively ,, especially in cases when short term intubation in is not anticipated.  [Comparison [Table 1]].
|Table 1: Comparison between short-term surgical tracheostomy and modifi ed retromolar, submental, and submandibular intubations|
Click here to view
| Conclusion|| |
Innovative procedures that were meant to avoid ST, are for selected cases, require certain surgical skills, and have airway risks in cases when short-term intubation is not anticipated; furthermore, it is done by named surgical specialities. On the contrary, ST remains to be simple, safe, and the procedure of choice for either short- or long-term airway control, especially in emergencies and difficult airway cases. Moreover, it is not limited to any surgical specialty and requires no surgical experience. However, regular workshops are recommended for this highly in demand procedure.
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