Airway obstruction due to a reinforced tracheal tube obstruction during submental intubation

Submental intubation is an alternative to nasotracheal intubation or tracheostomy in maxillofacial surgery when unobstructed access to the oral cavity is required. Reinforced tracheal tubes are considered the standard for this technique to avoid kinking during the procedure. Removal of the fixed standard 15 mm connector is required to perform the original Altemir's technique, which is the most used technique of submental intubation. Disconnecting the glued connector is a modification developed by clinicians, not endorsed by manufacturers and may expose patients to unforeseen risks. We report the management of a patient undergoing surgical repair of complex facial fractures with planned submental intubation. After repeated disconnections during tube repositioning, mechanical ventilation became difficult due to an intraluminal obstruction. Obstruction was caused by a polyvinyl chloride flap originating from the reinforced tracheal tube at the level of the forcibly removed connector. Removal of the flap restored normal ventilation and the remainder of the procedure was uneventful. To our knowledge, this is the first report of such a complication during submental intubation. It highlights material-related risk and underscores the importance of careful handling and inspection of the tracheal tube after removing the connector. Preventive strategies and alternative airway devices should be considered to enhance airway safety during submental intubation.