Introduction

Airway management is fundamental to the practice of anesthesia, and its integrity must be maintained throughout the perioperative period. In maxillofacial procedures, the close proximity of the surgical site to the airway places the endotracheal tube (ETT) at risk of accidental damage. Although rare, ETT compromise caused by surgical instruments has been reported during procedures involving the mandible, maxilla, and chin region and can lead to sudden airway emergencies if not promptly recognized [1,2].

Genioplasty is frequently performed as an adjunct to orthognathic surgery for both aesthetic and functional correction. The osteotomy is carried out in close relation to the oral cavity and lower anterior facial structures, where the ETT, particularly during oral intubation converted to submental intubation, may lie vulnerable.

Airway management for orthognathic surgery may be achieved by nasotracheal intubation, by oral intubation with submental conversion, or, in prolonged or complex reconstructions, by tracheostomy. Nasotracheal intubation is conventional but becomes unsuitable when the tube would obstruct the operative field or interfere with the maxilla during a Le Fort osteotomy. Submental intubation, first described by Hernández Altemir in 1986 as an alternative to tracheostomy in maxillofacial trauma, exteriorizes an oral ETT through the floor of the mouth and submental triangle, affording an unobstructed field and free intraoperative access to the dental occlusion [3,4]. Although developed for panfacial trauma, it has since been applied to selected orthognathic procedures in which repeated occlusal assessment is required [5]. Instrument-related ETT injury during such shared-airway surgery is rare but well documented, with partial and complete transection reported during orthognathic and maxillary osteotomies [6-8].

The use of powered saws, osteotomes, and rotary instruments further increases the risk of inadvertent ETT injury during this procedure [9].

Accidental damage to the ETT during genioplasty is particularly hazardous because it may result in air leak, inadequate ventilation, aspiration of blood, and rapid deterioration in oxygenation. Partial tube damage may initially preserve ventilation, thereby delaying diagnosis until significant airway compromise develops.

We report a case of accidental ETT compromise during genioplasty in a patient undergoing combined Le Fort I advancement, bilateral sagittal split osteotomy (BSSO) setback, and genioplasty. To our knowledge, few reports specifically address instrument-related injury to a submentally routed tube during genioplasty; we highlight the anesthetic implications, intraoperative management, and preventive strategies relevant to this shared-airway setting.