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Int. J. Oral Maxillofac. Surg. 2014; xxx: xxx–xxx http://dx.doi.org/10.1016/j.ijom.2014.05.006, available online at http://www.sciencedirect.com

Case Report Trauma

Intermaxillary fixation screw for endotracheal tube fixation in the edentulous patient with facial burns

Y. Fleissig, H. Rushinek, E. Regev Department of Oral and Maxillofacial Surgery, Hadassah-Hebrew University Medical Centre, Jerusalem, Israel

Y. Fleissig, H. Rushinek, E. Regev: Intermaxillary fixation screw for endotracheal tube fixation in the edentulous patient with facial burns. Int. J. Oral Maxillofac. Surg. 2014; xxx: xxx–xxx. # 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. Endotracheal tube fixation in patients with severe facial burns and edentulism is a challenge. We describe a simple and elegant method to secure the endotracheal tube in such patients by means of an intermaxillary fixation screw.

Facial burns are often accompanied by smoke inhalation, which may eventually lead to upper airway oedema and obstruction. In such cases, prophylactic early endotracheal intubation is indicated as a protective and perhaps life-saving measure.1 Standard methods to fixate the endotracheal tube, such as adhesive or non-adhesive tape and commercial tube holders,2 rely on extraoral fixation to the facial skin. Patients with facial burns and blisters present a particular challenge because intact skin is not available3 (Fig. 1a). The routine in our institution is to secure the endotracheal tube to one of the maxillary teeth using bridle wire around the cervix of the tooth.4,5 However, this technique is not possible in the edentulous patient. We describe a simple technique to fixate the endotracheal tube in edentulous patients with facial burns. 0901-5027/000001+02

This work was approved by the ethics committee of the study medical centre. Technique

Local anaesthesia (lidocaine 2% with adrenaline 1:100,000) is infiltrated in

Key words: IMF screw; facial burns; endotracheal tube fixation. Accepted for publication 14 May 2014

the upper vestibule to minimize pain and bleeding during the procedure. An intermaxillary fixation (IMF) screw is inserted in the maxillary bone, preferably in the anterior region in order to avoid critical anatomic structures such as the floor of the nose and the maxillary sinus

Fig. 1. (a) Facial burns demonstrating the absence of intact skin for extraoral tube fixation. (b) An IMF screw in the anterior nasal spine area serves as an anchor for endotracheal tube fixation using bridle wire that passes through one of the cross-holes of the screw.

# 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Fleissig Y, et al. Intermaxillary fixation screw for endotracheal tube fixation in the edentulous patient with facial burns, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.05.006

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Fig. 2. (a and b) 3D model of an edentulous patient demonstrating the safe region in the anterior maxilla for IMF screw insertion. (c) A selfdrilling, self-tapping IMF screw; four cross-holes serve for bridle wire passage.

(Figs. 1b and 2) and to utilize the thick bone of the anterior nasal spine region. Existing imaging, such as computed tomography, can be an adjunct in planning the optimal location for IMF screw insertion. The procedure is completed bedside and does not require cumbersome drilling equipment. Following confirmation of intubation depth, the tube is fixated to the IMF screw using bridle wire that passes through one of the cross-holes of the screw (Fig. 1b). Discussion

Fixation of the endotracheal tube is a top priority in the intensive care unit, especially in patients with smoke inhalation injury. Accidental extubation may be catastrophic, and any attempt at reintubation may simply be impossible due to significant dynamic upper airway swelling. The IMF screw is a self drilling, self tapping fastener made of stainless steel, and it possesses two cross-holes for wire passage (Fig. 2c). Application and removal are done transgingivally and no incision is required. Oral hygiene can be maintained easily and soft tissue trauma is minimal. The IMF screw is contraindicated in unstable or comminuted fractures and also in children, because of potential harm to tooth germ. Some authors have reported inserting a screw in the midline of the maxilla in children.3 In the case of edentulism, the IMF screw is a quick, elegant, minimally invasive, and long-lasting method to fixate the endotracheal tube. Other methods such as circum-mandibular wire6 and transalveolar bridle wire are either more invasive or

require additional drilling equipment. Furthermore, fixation of the endotracheal tube to local mobile and unstable soft tissue is not safe because of potential accidental extubation. Suturing of the tube to the gingiva has been reported in the literature for short surgical procedures, however it appears to be inadequate for extended periods of intubation7. Tracheostomy is always the ultimate alternative for prolonged intubation, but at the cost of increased morbidity. Complications of the IMF screw technique are rare3 and include screw loosening, local infection, and soft tissue irritation. In conclusion, the endotracheal tube can be secured easily in edentulous facial burn patients by using an IMF screw. Its advantages over other methods make it a highly attractive option for endotracheal tube fixation and may defer a tracheostomy. Funding

None. Competing interests

None. Ethical approval

Ethical approval was given by the Hadassah Medical Centre Ethics Committee.

References 1. American College of Surgeons. Advanced trauma life support for doctors. 8th ed. Chicago, IL: American College of Surgeons; 2008: 212. 2. Janakiraman C, Rassam SS. How do you fix reinforced tracheal tubes? Anaesthesia 2008;63:561–2. 3. Davis C. Endotracheal tube fixation to the maxilla in patients with facial burns. Plast Reconstr Surg 2004;113:982–4. 4. Xue FS, Luo MP, Liao X. Intra-oral stabilisation of the reinforced tracheal tubes using the surgical suture. Anaesthesia 2008;63:1017–9. 5. Jensen NF, Kealey GP. Securing an endotracheal tube in the presence of facial burns or instability. Anesth Analg 1992;75:641–2. 6. Furnas DW, Allison GR. Circummandibular or nasomaxillary suture with pullout loop for secure placement of endotracheal tube. Am J Surg 1980;139:887–8. 7. Xue FS, Luo MP, Liao X, Zhang YM. Intraoral fixation of endotracheal tubes using a suture in edentulous patients undergoing maxillofacial surgery. Cleft Palate Craniofac J 2010;47:322–3.

Address: Yoram Fleissig Department of Oral and Maxillofacial Surgery Hebrew University-Hadassah School of Dental Medicine Jerusalem 91129 Israel Tel: +972 50 8946643; Fax: +972 2 6413658 E-mail: [email protected]

Patient consent

Not required.

Please cite this article in press as: Fleissig Y, et al. Intermaxillary fixation screw for endotracheal tube fixation in the edentulous patient with facial burns, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.05.006

Intermaxillary fixation screw for endotracheal tube fixation in the edentulous patient with facial burns.

Endotracheal tube fixation in patients with severe facial burns and edentulism is a challenge. We describe a simple and elegant method to secure the e...
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