Optimal Airway Management in Severe Maxillofacial Trauma: A Case Report on Submental Intubation.

BACKGROUND Submental intubation, a technique often considered a good alternative for managing the airway in challenging maxillofacial surgical scenarios, plays a pivotal role in providing accessibility to the surgical site and ensuring airway safety, particularly in cases involving facial fractures. This innovative approach not only grants surgeons adequate access to the operative field but also mitigates potential complications associated with traditional intubation methods, making it a valuable tool in dealing with complex facial trauma cases. CASE REPORT A 37-year-old man arrived at the Emergency Department (ED) with a severe facial injury caused from a traumatic incident involving a falling concrete wall, resulting in severe facial injuries that included multiple lacerations and abrasions on his face and body. The patient presented with multiple facial and body lacerations and abrasions, necessitating prompt medical intervention. The ED team swiftly treated the facial lacerations, controlled the bleeding, stabilized the patient, and proceeded to secure the airway through orotracheal intubation. Following stabilization, the patient was transferred to the operation theater (OT) for further management of his extensive pan-facial fractures under general anesthesia, utilizing the submental intubation technique for airway management. CONCLUSIONS Despite its limited use, submental intubation is a good option for some maxillofacial surgeries, offering a less intrusive approach to airway management and presenting an alternative pathway to the conventional endotracheal intubation technique. Its ability to streamline procedures, enhance patient outcomes, and reduce complications underscores the importance of considering submental intubation as a valuable tool in dealing with complex maxillofacial cases.

What are the incidence and costs associated with interfacility emergency department transfer patients treated by oral and maxillofacial surgeons?

OBJECTIVE: Interfacility emergency department transfers (IETs) for maxillofacial trauma and infections are prevalent in the United States, with significant implications for health care costs. Limited availability of oral and maxillofacial surgeons (OMS) exacerbates unnecessary transfers and associated expenses. This study aimed to determine the incidence and costs of OMS IET. STUDY DESIGN: A retrospective cohort study was performed for maxillofacial trauma and infection IET at the University of Illinois Health main hospital via electronic medical record query for terms "infection [or] trauma [and] transfer." Inclusion criteria required presentation from January 1, 2022 to June 30, 2022; emergency department (ED)-ED transfer; and or consultation by OMS. Distance transferred, insurance type, location of treatment, weekend presentation, and associated costs were collected. RESULTS: One thousand ninety-nine records were identified, including 46 trauma IET and 122 infection IET. Costs ranged from $2,683,918.90 to $7,984,912.89, indicating ∼$1.5 billion annual expenditure across US OMS programs. Three trauma IET required urgent treatment; no infection IETs were "emergent." Trauma IET averaged 20.7 + 17.1 miles and infection IET 22.0 + 17.4 miles for transfer distance. Among trauma IET, 28 were treated in the operating room (OR), 10 had outpatient follow-up, and 8 had ED treatment. Among infection IETs, 57 received ED treatment, 56 received OR treatment, and 9 received antibiotics/no treatment. CONCLUSIONS: Maxillofacial trauma and infection IET impose significant health care costs. Increased funding for OMS training may mitigate the shortage and improve patient care. Further research is needed for better triaging and reimbursement strategies.

Does a Submental Airway Compared to a Tracheostomy Reduce Length of Stay in Craniomaxillofacial Trauma?

BACKGROUND: Patients with craniomaxillofacial trauma (CMT) are at increased risk of airway compromise and may necessitate airway stabilization via a tracheostomy (TO) or cricothyroidotomy. The submental airway (SMA) is an alternative airway and can avoid complications related to TO. PURPOSE: The purpose of this study was to compare the SMA to the TO with respect to hospital length of stay (LOS) and number of days with an advanced airway, termed airway days (ADs). STUDY DESIGN, SETTING, SAMPLE: This single-center retrospective cohort study included subjects with isolated CMT who required operative treatment with either a TO or SMA at Harborview Medical Center. Subjects were excluded if they required a TO for reasons other than treating their CMT. PREDICTOR VARIABLE: The predictor variable was airway type. MAIN OUTCOME VARIABLE: Primary outcome variables were LOS and ADs measured as number of days between admission and discharge dates, and days between establishment of airway and extubation or decannulation dates, respectively. COVARIATES: Covariates included age, sex, American Society of Anesthesiology classification, weight, body mass index, substance use, hospital status, facial injury severity scale scores, and airway placement location. ANALYSES: Bivariate analysis using independent t test, Mann-Whitney U test, and multiple linear regression analyses were used. P value of <.05 was considered significant. RESULTS: Of the 14 subjects identified, 6 underwent a TO and 8 a SMA. The mean LOS in the TO group was 20.3 ± 15.8 days versus 3.9 ± 4.7 days in the SMA group (P = .02). Mean AD in the TO group was 13.2 ± 8.4 versus 0.6 ± 0.7 in the SMA group (P = .01). The TO group had a higher number of operations at 2.0 ± 0.6 versus 1.1 ± 0.4 with a SMA (P = .02). After linear regression analysis adjusting for sex, age, weight, and facial injury severity scale, there were no statistically significant differences between the groups. CONCLUSIONS AND RELEVANCE: Compared to, SMA has a 5-fold decrease in LOS and 22-fold decrease in ADs on bivariate analysis. An SMA is a viable airway management option for operative treatment of isolated CMT. Further studies are warranted with a larger sample size.

A serial case study of the combined use of intraoperative CT and surgical navigation system for the removal of small foreign bodies in the maxillofacial region.

PURPOSE: The removal of small foreign bodies embedded within the deep soft tissues of the maxillofacial region is a complex and challenging task for maxillofacial surgeons. The purpose of this study was to explore the efficacy of the combination of intraoperative CT and surgical navigation for the removal of small foreign objects in the maxillofacial region. METHODS: A serial case study was conducted involving all consecutive patients who underwent surgical removal of small foreign bodies in the maxillofacial region. The combination of intraoperative CT and a surgical navigation system was used at a single medical institution from January 2018 to December 2022. Comprehensive data, including patient demographics, characteristics of the foreign bodies, previous surgical interventions, duration of the surgical procedure, and removal success rate were collected for this study. Relevant data were recorded into Microsoft Excel sheet and analyzed using SPSS version 22.0. RESULTS: Nine patients (6 males and 3 females) were included in this study, with an average age of 37 years. Each patient had previously undergone an unsuccessful removal attempt utilizing conventional surgical methods based on preoperative CT imaging or C-arm guidance at a local healthcare facility. Four patients also experienced unsuccessful attempts with preoperative CT image-based navigation systems. However, by employing the combined approach of intraoperative CT and surgical navigation, the foreign bodies were successfully removed in all 9 patients. The mean duration of the surgical procedure was 59 min, and the average size of the foreign bodies was approximately 26 mm³. Postoperative follow-up exceeding 6 months revealed no complications. CONCLUSION: The combined use of a surgical navigation system and intraoperative CT represents a potent and effective strategy for the precise localization and subsequent removal of small foreign bodies from the soft tissue structures of the maxillofacial region. This integrative approach appears to increase the success rate of surgical interventions in such cases.

Policy of fourteen maxillofacial divisions towards titanium plates removal after internal fixation of paediatric maxillofacial fractures: A World Oral Maxillofacial Trauma (WORMAT) project.

INTRODUCTION: The aim of this 11-year retrospective multicentric study is to evaluate the policy of 14 maxillofacial surgery divisions in terms of titanium plate removal from paediatric patients who had undergone open reduction and internal fixation (ORIF) to treat maxillofacial fractures. MATERIAL AND METHODS: Patients ≤ 16 years undergoing surgical treatment for fractures of middle and lower third of the face between January 2011 and December 2022, with a minimum follow-up of 6 months, were included. Age (group A: ≤ 6 years, B: 7-12 years, C: 13-16 years), sex, fracture location and type, surgical approach, number, and location of positioned and removed plates, timing and indications for removal were recorded. RESULTS: 191/383 (50 %) patients (median age, 10 years; M:F ratio 2.1:1) underwent removal of 319/708 (45 %) plates. Maxillary dentoalveolar process (91 %), angle/ramus (63 %) and mandibular body (61 %) had a significantly higher removal rate than other fracture sites (p < 0.001). A significant decreasing trend in removal with increasing age was observed, from 83 % in Group A to 24 % in Group C (p < 0.001). On the total of positioned plates, 11 % were removed for symptomatic reasons (5 % infections, 6 % discomfort/pain) and 34 % for other reasons (28 % scheduled removal). DISCUSSION: This multicentric study showed that plate removal was not performed routinely in the paediatric population. The incidence and causes of symptomatic plates removal were consistent with the literature, while the plate removal rate from asymptomatic patients was lower. A correlation was found between increasing age and a reduction in the frequency of plate removal procedures.

Retromolar intubation for the general anesthesia of maxillofacial fracture patients.

BACKGROUND: Evaluate the possibility of retromolar intubation for general anesthesia in patients with maxillofacial fractures. METHODS: The medical records of 54 patients with maxillofacial fractures who visited the Oral and Maxillofacial Surgery Department of Nantong First People's Hospital from January 2020 to August 2022 were collected. The retromolar areas of each patient were measured from the coronal CT images, and correlated with the patient's age, sex, type of fracture (i.e., maxillary fracture, mandibular fracture, or complex fracture of multiple maxillofacial bones), and the presence of the third molar (verified from 3D CT). The dimensions of the retromolar areas were finally compared with the outer diameter (OD) of standard endotracheal tubes (ETTs), most importantly the size 7.5 ETT (OD 10.3 mm) for male and the size 7.0 ETT (OD 9.8 mm) for female. RESULTS: The survey included 38 male and 16 female patients, with an average age of 44.1 and 54.3 years, respectively. The dimensions of the retromolar area (height × width) were as follows: male, (9.39 ± 1.77) mm × (12.08 ± 0.98) mm on the left and (9.81 ± 2.23) mm × (11.77 ± 1.08) mm on the right; female, (8.82 ± 1.53) mm × (10.51 ± 1.00) mm on the left and (9.73 ± 1.60) mm × (10.63 ± 1.58) mm on the right. The width was always larger than the OD of the routinely used ETT, but the height could be smaller by less than 1 mm. However, the oral mucosa can be compressed to allow the ETT to fit in the retromolar area. CONCLUSIONS: The retromolar area provided appropriate space to place a reinforced ETT for patients with maxillofacial fractures needing general anesthesia that must not interfere with intermaxillary ligation. Retromolar intubation can help maxillofacial fracture surgeries that focus on occlusal restoration.

Advances in Three-Dimensional Printing for Craniomaxillofacial Trauma Reconstruction: A Systematic Review.

Craniomaxillofacial (CMF) fractures present significant challenges for plastic surgeons due to their intricate nature. Conventional methods such as autologous bone grafts have limitations, necessitating advancements in reconstructive surgery techniques. This study reviewed the use of three-dimensional printing for CMF trauma reconstruction using human studies. A systematic search of PubMed, EMBASE, and Google Scholar was conducted in February 2024 for case reports, case series, and clinical trials related to CMF trauma reconstruction using three-dimensional printing technology. The authors' systematic review included 20 studies and a total of 170 participants with CMF bone defects. In general, the authors observed low bias risk in analyzed case reports and series, serious bias risk in nonrandomized controlled trials, and moderate bias risk in randomized controlled trials. The printed objects included CMF structure model prototypes, patient-specific implants, and other custom surgical devices. Studies reveal successful outcomes, including restored facial symmetry and function, restored orbital occlusion, resolved enophthalmos and diplopia, achieved cosmetically symmetrical lower face reconstruction, and precise fitting of surgical devices, enhancing patient and surgeon comfort. However, complications such as local infection, implant exposure, and persistent diplopia were reported. Three-dimensional printed devices reduced surgery time but increased preparation time and production costs. In-house production options could mitigate these time and cost expenditures. Three-dimensional printing holds potential in CMF trauma reconstruction, addressing both functional and esthetic restoration. Nevertheless, challenges persist in implementing this advanced technology in resource-limited environments.

Maxillofacial trauma in geriatric patients in an aging country.

Similar to other developing countries, the elderly population has increased in Türkiye in the last 30 years. Due to this increase, there has been a rise in the number of elderly patients suffering from maxillofacial injuries. This retrospective study aimed to evaluate the data of patients with geriatric facial trauma treated in our trauma center between 2010 and 2022 and the leading types of injuries, their causes, accompanying findings, and preferred treatment methods according to sex and age. In the study, the demographic characteristics, including age, sex, comorbidities, causes and sites of injury, treatment options, accompanying injuries, and facial injury severity scores of 292 patients were analyzed. Among more than 4000 patients undergoing treatment for maxillofacial injuries screened from January 2010 to August 2022, 292 (166 males, 56%; age range, 65-98 years) fulfilled the eligibility criteria for the study, of whom 60 had a surgical operation. Falls were the most typical cause of injury (70.20%), followed by motor vehicle accidents (18.15%) and assaults (7.87%). Zygomaticomaxillary complex fractures were the most frequently encountered fracture type (n=126, 29.92%), followed by nose fractures (n=122), orbital fractures (n=85), and mandible fractures (n=72). It was observed that the fractures were managed by surgical intervention or conservative measures and that conservative treatment was mostly preferred at an increasing rate with advancing age. As the elderly population increases, so does the incidence of geriatric facial trauma. Due to increased age, deterioration of health, and increase in the number of comorbidities, surgical interventions are less preferred.

Role of procalcitonin, interleukin-6 and interleukin-10 as a predictive marker for the use of perioperative steroid in maxillofacial trauma patients.

Maxillofacial trauma often brings significant challenges for surgeons in terms of preoperative oedema. Steroids offer oedema reduction, yet potentially increase the risks of postoperative infection. This study explores procalcitonin (PCT), as a marker for bacterial infection risk, and interleukins IL-6 and IL-10, which respectively signify pro-inflammatory and anti-inflammatory responses, as potential indicators of infection and inflammation in these trauma cases and thereby aid in refining perioperative guidelines for the use of steroids. A prospective study was conducted at a tertiary public hospital in India from 2019 to 2022 on patients >18 years with facial trauma. After specific exclusions, patients were randomised into steroid (Group A) and non-steroid (Group B) groups. Various parameters including oedema, PCT, IL-6, and IL-10 levels were measured and analysed using SPSS software. Out of 80 patients, 44 were in Group A and 36 in Group B. Post-24 hours, Group A showed significant oedema reduction, with 25 patients displaying a decline to mild oedema, versus 10 patients in Group B (p = 0.034). However, Group A witnessed a higher infection risk, with 20 patients showing positive wound cultures versus three in Group B. Subgroup analysis revealed a link between higher PCT levels and infections (p = 0.039). Additionally, Group A showed less intraoperative bleeding and reduced operating time. While perioperative steroids mitigate swelling, they might increase postoperative infection risk. Elevated PCT levels indicate potential wound infections, suggesting those patients should avoid perioperative steroids. IL-6 and IL-10 trends during perioperative phases can predict pronounced oedema outcomes.

Peculiarities of treatment of maxillofacial polytrauma during wartime.

OBJECTIVE: Aim: Analyzing of the last-time papers in this subject in organizing, diagnostic and surgery tactic is the aim of this work. PATIENTS AND METHODS: Materials and Methods: The study analyzed the experience of treating patients with maxillofacial polytrauma before and after February 24, 2022. Research methods: bibliographic, systematic, comparative, general clinical, radiological and retrospective analysis. CONCLUSION: Conclusions: Tactic of the multidisciplinal team should based on the principles of damage control, which involves the initial performance of manipulations and surgical interventions that ensure the patient's survival. Modern strategies for infusion-transfusion therapy play a significant role in severe trauma cases. Choosing the rational management of this therapy for severe trauma remains an important issue. Reconstructive surgeries are recommended to be performer deferred, after surgical wound management, neurosurgical interventions and stabilization of the patient common status. Patients with maxillofacial polytrauma needs in specialized medical care at all the levels. Active wound management aimed at creating favorable conditions for healing, comprehensive medical treatment, prevention, early detection and timely treatment of complications.

Simple Method for Re-tightening IMF Wires without Breakage.

AIM: This clinical technique aims to retighten intermaxillary fixation (IMF) wires when loosened intra/postoperatively. BACKGROUND: Intermaxillary fixation is one of the most important steps to obtain stable and functional occlusion in maxillofacial trauma. However, IMF wires tend to loosen over time. This loosened wire is generally removed and a new wire is used for IMF. Removal and refixation is time-consuming for surgeon and unconformable for the patient. TECHNIQUE: We recommend a simple technique for re-tightening IMF wires without breakage, with the use of shepherd's crook explorer by making a small circular loop. CONCLUSION: This technique of re-tightening by looping further stretches and tightens the wire to regain stabilized occlusion with maximal intercuspation. CLINICAL SIGNIFICANCE: This technique eliminates the need for removal and refixation of IMF wires, thereby improving patient comfort, yet obtaining stable occlusion over a long period of time. How to cite this article: Madhu SK, Dominic S, Baptist J, et al. Simple Method for Re-tightening IMF Wires without Breakage. J Contemp Dent Pract 2024;25(3):289-291.

Impact of the COVID-19 pandemic on maxillofacial trauma surgery in Germany - implications from the national DRG database.

PURPOSE: The COVID-19 pandemic has affected the personal and social lives of millions of people and also impacted the etiological factors of midfacial trauma such as falls, interpersonal violence or traffic accidents. The aim of this study was to analyze the influence of the COVID-19 pandemic on maxillofacial trauma surgery in the German healthcare system. METHODS: Nationwide data regarding the national diagnosis-related-group (DRG) inpatient billing system used in all German hospitals was received from the German Federal Statistical Office. Various trauma-associated procedures of the Operation and Procedure Classification System (OPS), a German modification of the International Classification of Medical Procedures (ICPM), were statistically associated with different epidemiological factors between 2012 and 2021. RESULTS: A statistically significant decrease (p < 0.05) in surgeries regarding maxillofacial fractures was registered during the years 2020 and 2021. Young male patients had the largest decline in maxillofacial trauma surgeries during this period (p < 0.05). In contrast. elderly patients 80 years and older showed a dramatic increase in the frequency of fractures in both the midface and the mandible (p < 0.05). CONCLUSIONS: During the COVID 19 pandemic there has been a shift in the number, composition and etiology of maxillofacial fracture surgeries. Measures of social distancing and personal risk avoidance had a societal positive effect on the frequency of facial injuries. This stands in contrast to the drastic increase in fractures of elderly people who should be protected primarily by the measures taken. These results can help to understand these influences better in future pandemics. TRIAL REGISTRATION: German Clinical Trials Register No: DRKS00032778.

Maxillofacial trauma and its management presenting at a tertiary care hospital in Lahore during Covid-19 pandemic.

Objectives: The objective of this study was to assess the patterns of maxillofacial injuries, aetiology and their management during the pandemic of Covid-19 in a tertiary care hospital in Lahore, Pakistan. METHODS: This is a single center, prospective cross-sectional study. Patients from all age groups who presented at the Emergency room of Jinnah Hospital Lahore and managed by the Oral and Maxillofacial Surgery Department during 1st December 2020 till 31st January 2021 were included. Data were analyzed using IBM SPSS for Windows, Version 20.0. RESULTS: Total 202 patient were analyzed, 161 (79.7%) were male and 41 (20.3%) were females. Male to female ratio was 4:1. About fifty three percent of patients belonged to the age group 15-35 years. The most common cause was road traffic accidents (RTA), followed by fall. Eighty-three (41.1%) had only soft tissue injuries without any bony fracture and 119 (58.9%) had facial bones fractures. Zygomatic bone fracture was most common (53.8%) followed by mandible fracture (31.1%). Sixty-one out of 119 patients with fractures were treated with Open Reduction Internal Fixation (ORIF). Three patients had complete loss of vision because of facial trauma. Only 56 (28%) patients were managed under General Anaesthesia. CONCLUSIONS: During the initial pandemic era, a large majority of patients presenting with maxillofacial injuries were young male adults. The most common cause of maxillofacial trauma was RTAs. Soft tissue injuries were predominant followed by facial bone fractures and zygomatic bone was more frequent among the fracture cases. Covid-19 pandemic increased the difficulties faced in the management of maxillofacial trauma patients.

Minimal clinically important difference in maxillofacial trauma patients: a prospective cohort study.

The present study estimated the minimal clinically important difference (MCID) for pain on a visual analogue scale - numerical rating scale (VAS-NRS) and mean bite force (MBF) in patients treated for maxillofacial trauma (MFT). This cohort study included 120 MFT patients treated according to AO principles. Preoperative and four-week postoperative pain on the VAS-NRS, and MBF were measured to calculate MCIDs as indicators of functional rehabilitation. The patient's perspective of the treatment was assessed using a four-item anchor question. The MCID was determined by two anchor-based approaches, namely, the change difference (CD) method and receiver operating characteristic (ROC) curve method. According to the CD method, the MCID for pain was 2.4 and the MBF was 147.9 N. Based on the ROC curve, the MCID for pain was 2.5 (sensitivity 91.7%, specificity 47.2%) and MBF was 159.1 N (sensitivity 71.4%, specificity 61.1%). This study demonstrated a high sensitivity (>70%) for MCID, which implies that pain reduction of 2.4-2.5 points on the VAS-NRS and a gain in MBF of 147.9-159.1N are clinically relevant for patients treated for MFT.

Maxillofacial Surgery in Ukraine During a War: Challenges and Perspectives-A National Survey.

INTRODUCTION: The invasion of Ukraine by Russian troops on February 24, 2022, and the beginning of the full-scale war had huge humanitarian consequences. The major challenges facing the Ukrainian health care system included the disruption of medical infrastructure and logistics, the termination of the supply of expendable materials, significant migration, and a dramatic increase in high-velocity blast and gunshot injuries among combatants and civilians.The aim of the present study was to analyze the challenges and solutions in patient care faced by the Ukrainian system of maxillofacial surgery during the war in different regions of the country. MATERIALS AND METHODS: A cross-sectional study was designed and implemented as an online survey to collect national data concerning maxillofacial surgeons' experiences and professional activities. The study was initiated and supported by Bogomolets National Medical University (Kyiv, Ukraine), the Ukrainian representative of AO CMF (Arbeitsgemeinschaft für Osteosynthesefragen Craniomaxillofacial Surgery) and the University of Helsinki (Finland).The questionnaire was developed by specialists in maxillofacial surgery and sociologists and contained 65 close-ended questions. Surgeons who had not worked in this specialty in inpatient departments of hospitals since at least the beginning of the full-scale war were excluded from the study. We received and analyzed 97 responses that met the abovementioned criteria. The geography of respondents covered all the regions and the main cities of Ukraine, expect for the occupied territories. RESULTS: After a year of warfare, the percentage of surgeons who treated patients with blast and gunshot injuries increased from 43.4% to 86.6%. This percentage was higher in military hospitals and in regions located in the vicinity of the front line. We found that, during the war, 78.6% of respondents performed osteosynthesis in cases of high-velocity multifragmented facial bone fractures (in such cases, 58.3% of them strictly followed AO CMF recommendations, while 41.7% performed the fixation based on available hardware, existing technical possibilities and their own preferences). We found that 70.2% of respondents had the opportunity to apply Computer-Aided Design/Computer-Aided Manufacture technology and patient-specific implants for the treatment of gunshot injuries, 38.1% reported that their hospitals were able to perform microsurgical reconstructions for facial defects, 79.4% of respondents reported that their departments received humanitarian aid and support from volunteer organizations (either Ukrainian or international), which significantly facilitated the treatment process. CONCLUSIONS: According to this nationwide survey of Ukrainian maxillofacial surgeons during a year of the full-scale war, 86.6% of respondents were involved in the treatment of gunshot and ballistic injuries in civilians and combatants. The main problems reported by the respondents were (1) a lack of experience and knowledge related to the treatment of severe wounds, especially by secondary reconstruction, and (2) a deficit of resources (equipment, materials, and medications) under conditions of disrupted logistics and changes in the numbers and nosological distribution of patients. There were the opportunity to transfer the patients to European clinics (29.9%), online consultations (45.4%), collaboration with foreign surgeons who come to Ukraine asvolunteers (32%).

Submental intubation in complex maxillofacial trauma: Pilot balloon protection.

AIMS: This study aims to describe our refined technique of submental intubation to avoid the recorded intraoperative complications related to tube passage and pilot balloon rupture. CASE SERIES: This is a retrospective case series of 21 patients with complex maxillofacial trauma who underwent submental intubation from January 2019 to January 2023. All the patients underwent to the same procedure with a new technique of pilot balloon protection: the pilot balloon was not deflated because, once the connector was removed, only the tube was curved and passed through the incision extraorally while the cuff remained inflated. The wire of the pilot balloon was passed behind the last tooth so as not to interfere with the maxillary-mandibular fixation, remaining extraorally under the anesthetist's view. DISCUSSION: Only 2 patients (9.5%) reported complications related to submental intubation: in particular a patient (4.8%) reported oral floor infection, and in another patient (4.8%) an unesthetic skin scar was observed. No patients reported intraoperative complications related to the procedure. CONCLUSION: The technique of pilot balloon protection that we have proposed seems to be effective in reducing the intraoperative complications related to the passage of the pilot balloon, such as rupture, damage or early extubation.