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Journal of Cranio-Maxillofacial Surgery (2003) 31, 257259

r 2003 European Association for Cranio-Maxillofacial Surgery.

doi:10.1016/S1010-5182(03)00026-X, available online at

Combitube SA through submental route. A technical innovation

Francisco Herna! ndez Altemir, Sof!a Herna! ndez Montero, Manuel Moros Pena
Department of Oral and Maxillofacial Surgery (Head: F. Hernandez
Altemir), Miguel Servet University
Hospital, Zaragoza, Spain
SUMMARY. Both endotracheal intubation and the laryngeal mask are already established and have their specic

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.

proximal balloon (blue control balloon) was inated

with 100 cm3 of air and the distal balloon (white
control balloon) with 15 cm3 of air.
It was important to lubricate the tube.
A uids bafe bend has to be connected to the
connector as is marked as 2 in the Combitube
Usually the patient was supine or with the head
slightly turned to one side to facilitate the expulsion
of secretions. In the rst stage the anaesthetist placed
himself in front of the patient lifted the tongue and
mandible achieving control with the index and middle
ngers. The intubation route could thus be seen and
Combitube SA guided into the oropharyngeal and
supraglottic spaces. It also permitted control of or
easy removal of broken teeth or dentures to avoid
displacing them into the digestive or respiratory
tracts, and avoided possible rips in the Combitube SA
Once the tube has been installed in the supraglottic/pharyngeal space, the operator placed himself
behind the patients head in order to use the
laryngoscope, and to facilitate the aspiration and
cleaning of the oropharynx. This was also performed
to ensure that the tube was located in the trachea.
When the Combitube SA has been passed from the
extended submental route it followed its caudal
curvature and adapted to the curvature of tongue
and pharynx. Then the big latex balloon was inated
with 100 cm3 and the distal balloon with 15 cm3of air.
However, the quantity of air may be varied according
to our clinical results.
Ventilation begun as usual using the blue connector (the tube labelled as 1), and if auscultation of
respiratory sounds was positive and no gastric
insufation was evident, ventilation was continued,
observing the thoracic movements and the conventional auscultation procedures (Fig. 1). The second
via could be used to remove the gastric uids with a
suction catheter.
When auscultation of respiratory sounds was
negative and gastric insufation positive, a trial of

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.
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

258 Journal of Cranio-Maxillofacial Surgery

ventilation was started via the transparent connector

of the tube labelled as number 2, conrming gastric
ventilation (Fig. 2). If both, respiratory auscultation
and gastric insufation, were negative, the reason
could have been that the Combitube had been too
introduced into the pharynx. It was then necessary to
deate balloon number 1 and to pull out the
Combitube about 2 or 3 cm. This was followed by
inating balloon number 1 again with 100 cm3 of air,
ventilating via the connector of tube number 1. If in
this case, auscultation of respiratory sounds was
positive and auscultation of gastric insufation
negative, ventilation was continued. The tube was
then xed percutaneously with heavy silk to the
submental wound to avoid displacement. Also, if
airway control was satisfactory, the facial fractures
could be stabilized temporarily or denitively.
Later on the Combitube SA was exchanged
preferably for a nasotracheal tube. Another option
was to use the submental route, or even a conventional tracheostomy.
We have operated on two male patients using this
technique, both with severe maxillofacial trauma.
One of them showed a signicant bleeding from the
oral cavity with mandibular fractures that required
reduction and the other one was a patient with
unstable cervical fractures who had to undergo
orofacial surgery. No complications with either the
surgical procedure, anaesthesia or postoperative
recovery period were encountered.

Fig. 2 Combitube in trachea. Ventilation through the shorter

tube. Trachea is ventilated.

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.
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.


Fig. 1 Combitube SA via submental route in oesophagus. Test

ventilation started via the longer tube. If auscultation over the
lungs is positive and epigastric insufation negative, ventilation
may be continued.

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Francisco Hern!andez Altemir MD

C/Fray Luis Amigo! no. 8
0-B 50006
Tel: +34976270719
Fax: +34976387553

Paper received 23 July 2002

Accepted 6 February 2003