Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 8  |  Issue : 4  |  Page : 678-680

Difficult airway management in a patient with bilateral bony temporo-mandibular joint ankylosis by awake fiberoptic bronchoscopy


Department of Anaesthesiology, ESIC PGIMSR, Bangalore, Karnataka, India

Date of Submission30-May-2014
Date of Acceptance06-Sep-2015
Date of Web Publication29-Dec-2015

Correspondence Address:
Govindswamy Suresh
Anaesthesiology, #130, 4th Cross, Milk Colony, Malleswaram West Post, Bangalore - 560 055, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1687-7934.172768

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  Abstract 

Here, we present a case of difficult airway after patient consent. A young male patient presented with painless difficult mouth opening of 0.5 cm for 2 years, restricting him to only liquid diet. He was diagnosed as having bilateral temporomandibular joint ankylosis and was posted for release. The patient was classified as difficult for intubation with Mallampathi IV grade; systemic examination was within normal limits. Computed tomography (CT) of the temporomandibular joint showed gross bilateral osteoarthritic changes. He was planned for awake fiberoptic nasal intubation. The patient was given a detailed explanation about the procedure. The airway was prepared with topical and nebulized lignocaine. The fiberoptic bronchoscope was mounted with a 7.0 mm cuffed armored tube and inserted through the nostrils, proceeding until the vocal cords were visualized. After confirming with auscultation and by Capnography, patient was paralysed. Surgery was performed and the patient was extubated awake. Mouth opening improved to 2 cm. The use of the fiberoptic intubating bronchoscope in case of bilateral temporomandibular joint ankylosis with a high risk of airway control due to restricted mouth opening, a gift of modern technology, circumvents this difficulty without compromising on patient safety, with the patient being awake too, and should be considered a safe procedure.

Keywords: Awake intubation, difficulty airway, fiberoptic bronchoscopy, temporomandibular joint ankylosis


How to cite this article:
Suresh G, Lakshmi NK, Kodandaram N S. Difficult airway management in a patient with bilateral bony temporo-mandibular joint ankylosis by awake fiberoptic bronchoscopy . Ain-Shams J Anaesthesiol 2015;8:678-80

How to cite this URL:
Suresh G, Lakshmi NK, Kodandaram N S. Difficult airway management in a patient with bilateral bony temporo-mandibular joint ankylosis by awake fiberoptic bronchoscopy . Ain-Shams J Anaesthesiol [serial online] 2015 [cited 2019 Jun 19];8:678-80. Available from: http://www.asja.eg.net/text.asp?2015/8/4/678/172768


  Background Top


Temporomandibular joint ankylosis implies stiffness of temporomandibular joint resulting from injury or disease process leading to pain and decreased ability to open mouth, thus rendering conventional laryngoscopy difficult or impossible at surgery. The use of the fiberoptic intubating bronchoscope, a gift of modern technology, circumvents this difficulty without compromising on patient safety, with the patient being awake too.


  Case report Top


A 23-year-old male patient presenting with painless difficulty in mouth opening of 2-year duration was posted for release of bilateral temporomandibular joint ankylosis. The patient could not tolerate a solid diet, but only a liquid diet. There was no history of trauma or other comorbidities. The case was studied in ESIC PGIMSR (Employees State Insurance Corporation) Medical College, Bangalore.

Preanesthetic examination

The patient was of ASA grade 1 with normal vital parameters. The patient weighed 55 kg and was 160 cm in height. The patient showed normal neck movements and normal thyromental distance. On airway assessment, Mallampati class IV and mouth opening of 0.5 cm with restricted temporomandibular joint movement were reported. The patient was classified as difficult for intubation. Systemic examination was within normal limits [Figure 1].
Figure 1: Restricted mouth opening

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Investigations

Routine hematological investigations were within normal limits. Chest radiograph was normal and CT of the temporomandibular joint showed gross bilateral osteoarthritic changes [Figure 2] and [Figure 3].
Figure 2: CT image of left temporomandibular joint arthritis

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Figure 3: CT image of right temporomandibular joint arthritis

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Fiberoptic nasal intubation under sedation was planned for the patient because of difficult airway due to restricted mouth opening and restricted jaw movement at the temporomandibular joint.

Anesthesia and surgical procedures

An intravenous line was secured, and vital parameters such as heart rate, arterial blood pressure, arterial oxygen saturation, and ECG were monitored. The patient was given a clear explanation about the forthcoming airway intervention. Anxiolysis was achieved with incremental doses of intravenous midazolam. Topical airway anesthesia was induced nasally (pledgets soaked in 4% xylocaine) along with a vasoconstrictor, as well as orally (10 ml of 4% viscous gargle). The fiberoptic bronchoscope was mounted with a 7.0 mm cuffed armored tube and inserted through the nostrils, proceeding until the vocal cords were visualized. The fiberoptic bronchoscope was advanced beyond the vocal cords until the carina was visualized, at which point the endotracheal tube (ETT) was advanced along with ligocaine using the spray-as-you-go technique. Under vision, the scope was withdrawn and placement confirmed with capnography and auscultation. Anesthesia was induced with propofol 100 mg, fentanyl 70 mg, and sevoflurane 1%, and was maintained with vecuronium 6 mg as an inhalational and intravenous agent. Intraoperatively, vital parameters were maintained. Bilateral condylectomy and coronoidectomy with cartilage interposition on the left side were performed. The procedure lasted for 6 h with minimum blood loss. Awake extubation was performed at the end of the procedure after adequate reversal of muscle relaxant effect 1.


  Results Top


Mouth opening achieved was 2.5 cm. On questioning about airway intervention, the patient did not complain of any discomfort or distress during or after procedure. The patient was happy with the desired results [Figure 4].
Figure 4: Mouth opening before and after surgery

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  Discussion Top


Temporomandibular joint dysfunction is frequently associated with unilateral or bilateral arthritis, thus producing limitations in mouth opening. The incidence of difficult airway is 1-3% [2] . In a patient with nil or limited mouth opening, intubating choices are as follows: blind nasal intubation; retrograde intubation technique through cricothyroid puncture; elective tracheostomy; capnography-mediated awake blind nasal intubation; and awake fiberoptic bronchoscopy [3] .

The awake fiberoptic intubation of a spontaneously breathing patient is the gold standard and technique of choice for elective management of an expected difficult airway. Proper planning and ascertain with attention to details are keys to patient compliance and high success rate. The awake fiberoptic intubation requires time and needs a profound preparation of the patient, including proper oxygenation and well-titrated sedation upon patient's needs. The maintenance of oxygenation is the primary goal while having patient spontaneously breathing and always responding to commands [4],[5] . Nasotracheal approach of fiberoptic intubation is often simpler than that of oral approach because the instruments aimed directly at glottis because of the natural anatomical airway. It is applicable to all age groups and has an excellent patient acceptance [6] .


  Conclusion Top


In case of bilateral temporomandibular joint ankylosis with a high risk of airway control due to restricted mouth opening, skillful fiberoptic bronchoscopic nasotracheal intubation under conditions of awareness should be considered a safe procedure.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Savva D. Prediction of difficult tracheal intubation. Br J Anaesth 1994; 73:149-153.  Back to cited text no. 1
    
2.
Vieria EM, Goodman S, Tanaka PP. Anesthesia and rheumatoid arthritis. Rev Bras Anesthesiol 2011; 61:367-375.  Back to cited text no. 2
    
3.
Benumof JL. Management of the difficult adult airway. With special emphasis on awake tracheal intubation. Anesthesiology 1991; 75: 1087-1110.  Back to cited text no. 3
    
4.
Punchner W, Puhringer FK, Rex C. Awake fiberoptic intubation. AJA 2011; 12:34-39.  Back to cited text no. 4
    
5.
Dave N, Sharma RK. Temporomandibular joint ankylosis in a case of ankylosing spondylitis - anesthetic management. Indian J Anaesth 2004; 48:54-56.  Back to cited text no. 5
  Medknow Journal  
6.
Batra YK, Pretty Mathew PJ. Airway management with endotracheal intubation (including awake intubation and blind intubation). Indian J Anaesth 2005; 49:263-268.  Back to cited text no. 6
  Medknow Journal  


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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