Annals of Burns and Fire Disasters - vol. X1 - n. 3 - September 1998

INTERDENTAL WIRE FIXATION OF ENDOTRACHEAL TUBE FOR SURGERY OF SEVERE FACIAL BURNS

Botts J., Srivastava K.A., Matsuda T, Hanumadass M.L.

Sumner L. Koch Burn Center, Cook County Hospital and University of Illinois College of Medicine, Chicago, Illinois, USA

SUMMARY. Complex facial burns requiring complete exposure of the face for initial skin grafting and secondary reconstructive surgery prompted our improvising a wire fixation method of securing the oral endotracheal tube. Utilizing this method, we have experienced no accidental extubations or trauma to the patient's dentition. A small amount of gingival bleeding is possible both during and after insertion and removal of the wire. Alternative methods must be utilized for both edentulous patients and those with prosthetic dental devices located in the anterior portion of the mouth. We have found this method to be superior to the external cranial fixation device of Hansen, the lip fixation method, and various taping techniques when diffuse severe facial burns require reconstructive surgery. Not only does the wire fixation method appear applicable to a wider range of facial surgery such as diffuse burns or severe trauma but the fact that the tube can be safely secured in 5-10 minutes gives an advantage over other previously described methods.

Introduction

Diffuse burns of the face have long been a challenge to the burn surgeon, both in surgical technique and in exposure for the surgical procedure. Facial surgery of any type usually presents a problem with securing of the endotracheal tube: the securing tape impinges on the operative field.` Many methods and devices have been constructed for fixation of the endotracheal tube for various types of surgical procedures on the face. Two of the previously utilized methods are external cranial frame fixation' and the securing of the endotracheal tube to the lower lip with nonabsorbable sutures. None of these procedures is satisfactory in every case. We have devised a method using dental wire to secure the endotracheal tube for acute and reconstructive facial surgery of patients with severe burn injuries.

Material and methods

After oral intubation with a standard endotracheal tube, the tube is connected to a corrugated metal connection extension (gooseneck adapter) to allow better accessibility and exposure of the entire operative field. An eight-to-ten inch segment of number twenty-five dental wire is used, held by one end with a standard needle holder. The wire is first positioned by an anterior approach between the interdental spaces of the first and second incisors on one side of the upper teeth. Next, through a posterior approach, the interdental space of the first and second incisors on the opposite side of the upper teeth is entered, resulting in the two ends of the wire exiting anteriorly. It is imperative to include two teeth in the wire loop, either central incisors or the first and second incisors, on either side of the upper dentition.
The wire is first fixed to the teeth by serially twisting the wire ends in a clockwise fashion. After five to ten loops are made with the wire ends the next step involves securing, the tube to the teeth This is done bv encircling, the wire ends around the tube twice as it exits the mouth near the upper teeth. The ends are then twisted clockwise as previously described, with the final twists being applied with the needle holder until an indentation is noted in the tube (Figs. 1-3).

Fig. 1 - Patient with severe facial keloids, one year post-burn. Interdental wires affixed to bilateral central upper incisors. Note indentation into endotracheal tube from wire securing tube to teeth Fig. 2 - After excision of diffuse facial keloids. Attachment of tube to teeth obscured by oral packing. Fig. 3 - Immediately after application of unmeshed split-thickness skin grafts to excised facial units.

It is necessary to ensure that the tube is unable to be moved anteriorly or posteriorly with moderate traction once secured. The excess wire is then cut and the ends bent upon themselves to avoid lacerations or punctures of the oral mucosa. If the upper teeth are loose or missing, the endotracheal tube can be positioned in a similar manner to the lower teeth. Since the normal mobility of the mandible allows for exaggerated movement of the secured tube in both an anterior and a posterior direction despite proper wire fixation, this method should be used secondarily (Fig. 4).

Fig. 4 - Interdental wires affixed to bilateral central lower incisors when upper teeth are missing. This is our second choice of fixation, as mandibular motion may result in slight telescoping of the endotracheal tube.

Discussion

The method of securing an endotracheal tube with dental wire to the upper incisors is a dated, simple, yet not wellknown procedure which can be performed in approximately five to ten minutes in the operating room. With the wire fixation method, the wire can be easily removed prior to reversal of anaesthesia. Removal may be accomplished utilizing either plain wire-cutters or unravelling the ends simultaneously with two needle holders. Following wire removal and application of facial dressings, extubation can proceed as planned.
The external cranial fixation device of Hansen,' adapted from the apparatus devised by Georgiade for external fixation of facial fractures, is more complex and cumbersome, involving insertion and removal of multiple cranial bone screws. This is a more time-consuming and invasive procedure. It appears applicable only for extensive facial burns requiring long-postoperative intubation. The technique introduced by Galvis' is one where a thin-walled polyvinyl endotracheal tube is split down the middle after insertion, and an endotracheal tube adapter placed where the tube was split. Utilizing the flanged ends of the cut tube, they are then tied around the neck with twill tape to secure the tube. This method only secures the endotracheal tube prior to surgery and is not applicable intraoperatively or postoperatively for severe facial burns.
Another method consists of securing the tube to the lower lip after intubation by passing a 2-0 nonabsorbable suture through the lower lip mucosa anteriorly and tying the suture. This method can induce soft tissue damage as well as bleeding, with the possibility of the suture pulling through the mucosal tissue and dislodging the tube, resulting in a possible accidental extubation.
Jensen' proposes tying a 0 silk suture circurnferentially around the lingual base of the tooth and securing the endotracheal tube to a knot tied 2 cm above the initial knot. The endotracheal tube is further secured with an inferiorly-based 0 silk. A suture secured in this fashion may break with intraoral manipulation, as well as slide down the silastic ET tube, predisposing to unplanned extubation.
Satterfield' proposes endotracheal tube stabilization with the aid of a hose stabilizer specifically for use with the Bain breathing circuit, single hose nasal inhalers, and Magill insufflation anaesthesia. A headband is formulated to secure the nasotracheal tube, limiting forehead exposure. Ward' uses a nasotracheal support splint, attached to the frontal, orbital and nasal regions. This device also limits facial exposure and is poorly suited to secure orally placed endotracheal tubes.
Edelstein' uses a rubber-dam clamp to secure his ET tube. Again, there is the potential of the clamp slipping from the teeth, resulting in unwanted tube movement.
Perrotta' utilizes wires connected to arch bars to secure his ET tube. The arch bars may be difficult t stabilize in children and in persons with limited dentition. Our interdental wire fixation only necessitates two potentially healthy teeth of any age. The interdental wiring technique is simple and accessible to virtually all operating surgeons.
So far, we have used the wire fixation method on seventeen patients with extensive surgery for facial burns and scars. Our results have been gratifying, with no displacement or dislodging of the endotracheal tube. We recommend the use of this inexpensive, easy technique to any surgeon contemplating a complex facial grafting procedure on a dentulous patient.

RESUME. Les brûlures complexes faciales qui nécessitent l'exposition complète du visage pour la greffe initiale de la peau et pour la chirurgie reconstructive secondaire ont stimulé l'intérêt des Auteurs à créer une méthode où la fixation du tube oral endotrachéal est obtenue moyennant l'emploi d'un fil métallique. Avec cette méthode ils n'ont pas rencontré aucune extubation accidentelle ou traumatisme pour la dentition du patient. Il est possible d'avoir une hémorragie gingivale modérée pendant et après l'introduction et l'enlèvement du fil. Il faut suivre des méthodes alternatives pour les patients édentés et ceux qui ont des prothèses dentaires insérées dans la portion antérieure de la bouche. Les Auteurs ont trouvé que la méthode décrite est supérieure à l'appareil de fixation crânienne externe de Hansen, à la méthode de la fixation à la lèvre et à plusieurs techniques d'attachement avec du ruban, dans les cas des graves brûlures diffuses qui nécessitent la chirurgie corrective. Non seulement la méthode de la fixation moyennant un fil est utilisable dans une gamme plus vaste de la chirurgie faciale mais la possibilité de fixer le tube sans risque en 5-10 minutes présente des avantages par rapport aux autres méthodes décrites.

BIBLIOGRAPHY

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