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Case: TMJ Ankylosis

Dr. Lokesh Kashyap

Acknowledgement: Dr. Ganga Prasad, Dr. Umakanth, Dr. Abhijit

Patient Particulars

Name: Sunita
Age: 21yrs
Sex: female
Occupation: none
Residence: Bihar
Date of admission:24/08/08
Date of examination: 03/09/08
Proposed date of surgery: 04/09/08


Chief Complain:

deformity since last 8yrs

Snoring and repeated spontaneous arousal
during sleep for last 2-3yrs

History of Present Illness


B/L TMJ ankylosis; post traumatic

Gap arthroplasty in Aug98
Progressively receding chin following 2yrs of
Bothersome facial deformity
No associated difficulty in feeding, speech
Snoring during sleep for last 2-3yrs


increasing snoring, recurrent

spontaneous sleep arousal.
Disturbed sleep at night
Often resorts to prone, couched decubitus
Excessive day time sleepiness
C/o headache during day
No h/o DOE, Effort tolerance > 4METS


history of pedal swelling

No h/o any other joint pain or swelling
No diificulty in speech, feeding
No h/s/o hypothyroidism like constipation,
cold intolerance, dry skin.

Past History

H/o fall from roof in 96 and hit on chin.

No h/o LOC
H/o bleeding from ears
Progressively increasing difficulty in mouth opening
following 6mo of trauma.
Gap arthroplasty done at AIIMS in 1998

Medical or Surgical History

h/s/o OSA
No other comorbid illness
Previous exposure to GA U/E

Personal History

No addiction
Bowel & bladder habit: normal
Sleep: disturbed
Appetite: poor
Brushing teeth: Once a day

Menstrual History:
Menarche at 13yrs, normal cycle, duration and flow.

Family History

Living with mother and siblings

Father died in interpersonal violence; rest of the family
members are in good health
No similar disease in the family

Treatment History

Not on any treatment

History of Allergy

NKDA, no other allergies

Physical examination
General survey:

Alert, conscious, co-operative

Thin built, poor nutrition
Bird faciessevere growth retardation of mandible.
Pallor -, cyanosis -, clubbing -, icterus -edema -, NV -, NG
PR- 88 bpm, regular, normal volume, all peripheral pulses are
palpable, no radio-radial or radio-femoral delay, no special
BP- 110/70mmHg in left upper limb at supine position
IV access: good
Weight:31.6 kg
Height: 151cm

Airway Examination-11parameters

gap: 3.5cm
Buck teeth: present
Length of incisor: <1.5cm
Upper lip Bite: Class III
MMP: Class IV
Palate: no arching / not narrow
TMD: 1.5cm
RHTMD: 100


compliance: Hardly any

appreciable space
Neck length: sufficient
Neck diameter: thin neck
Neck movement: poor head extension


of TMJ: good movement could be

appreciated on both the sides
B/L glenoid fossa empty
No scar mark
No tenderness
Right nasal cavity appeared to be more

Respiratory system


NVBS all over, no added sounds

Cardiovascular System

S2- normally audible

No murmur

Central Nervous System


functions normal
No sensory/ motor deficit


non tender, non distended.

No palpable lump


Hb: 11.7g%
TLC: 4500/cc
Platelet: 252 thousand/cc
BU/Cr: 22/0.6
Na/K : 147meq/l; 4.4meq/l
LFT: wnl
ABG: pH: 7.39; pO2: 93.6 mmHg; pCO2: 43.3 mmHg;
HCO3: 25.9 mmol/l; Sat: 97%

Severe OSA
Average minimum oxygen saturation:94.46%
Min oxygen saturation: 57.4%
224 times oxygen saturation < 90%
AHI: 54.61 events/hr


normal pulmonary and cardiac shadow.

No prominence of pulmonary arteries.
Lateral XR of head and neck
CT scan: retrognathia
Orthopantomogram: B/L condyles not seen,
B/L impacted tooth

Surgery Planned

Distraction Osteogenesis

Clinical Diagnosis

TMJ ankylosis growth disturbance

leading to retrognathia with severe OSA.


Blind nasotracheal; movie

Shortcut to DIFFICULTY AIRWAY 009.avi.lnk


Latin :articulatio temporomandibularis

Artery: superficial temporal artery
Nerve: auriculotemporal , masseteric

Movements of TMJ

-Hinge like/ rotatory

Side to side movement

Complications of TMJ ankylosis

Limited MO with trismus

Facial asymmetry: bird facies
Micrognathia with receding mandible
Shorter length of mandibular rami: narrow
Occlusion defect
Dentition defect
Poor nutrition
Poor oral hygiene

Management of TMJ Ankylosis

Jaw opening exercise
Management of OSA
-TMJ arthroscopy
-TMJ arthroplasty
-TMJ implants

Airway Management
Fiber optic intubation:
- awake
- following induction of anesthesia with spontaneous breathing
- following induction & respiratory paralysis
Blind nasal intubation:
- following induction of anesthesia with spontaneous breathing
- following induction & respiratory paralysis
Retrograde intubation



Difficulty in threading tube:

For orally inserted fibrebrescope, the tube tends to

move posterior to the glottis, such as onto the
arytenoid cartilage or into the oesophageal inlet.
Right arytenoid cartilage is more likely than the left
arytenoid cartilage to obstruct the passage of a tube.
For nasal ntubation, anterior commissure obstructs.
Size of scopes and tracheal tubes.
Airway intubator
Murphy eye of a tube

Murphy eye of a tube

Oesophageal intubation after correct

insertion of a fibrescope into the trachea.


Use a thick fibrescope and a thin tracheal reduction strategy.

A flexible tracheal tube (or Parker Flex-Tip tube) should be used.

The tube should be loaded over the scope to prevent inadvertently passing
through the Murphy eye of the tube.

The LMA or the ILMA may be inserted to facilitate fibreoptic intubation.

Once the scope has been inserted into the trachea, airway intubator should
be removed.

When there is difficulty in advancing a tube, withdraw the tube for a few
centimetres, rotate it 90 anticlockwise.

If it is still difficult to advance the tube it may be rotated by 180, and the
position of the head and neck adjusted.

A laryngoscope may be inserted before another attempt

(A) The Parker Flex-Tip tracheal tube

(B) The ILMA tube.

Insertion of a thinner tracheal tube

between a larger tracheal tube and a

Some definitions:

Apnea: Decrease in the peak thermal airflow sensor by

90% or greater of baseline for 10 seconds or longer.

Hypopnea:Decrease in a nasal pressure airflow sensor

excursion by 30% or greater of baseline for 10 seconds
or longer with a 4% or more O2 desaturation

A 50% or more decrease in nasal pressure excursion
for 10 seconds or longer with either a 3% or more O2
desaturation or an arousal


AHI or RDI greater than or equal to 15 events per hour


AHI or RDI greater than or equal to 5 and less than or equal to 14

events per hour with documented symptoms of excessive daytime
sleepiness, impaired cognition, mood disorders or insomnia, or
documented hypertension, ischemic heart disease, or history of


Respiratory Effort-Related Arousal (RERA) as " a

sequence of breaths lasting at least 10 seconds
characterized by increasing respiratory effort or
flattening of the nasal pressure waveform leading to
an arousal from sleep when the sequence of breaths
does not meet criteria for an apnea or hypopnea."

In practice, RDI is the number of RERAs per hour

plus the number of apneas and hypopneas

Severity of OSA
Gas exchange abnormalities:
Mild: Mean oxygen saturation remains greater than or equal to 90% and
minimum remains greater than or equal to 85%.
Moderate: Mean oxygen saturation remains greater than or equal to 90%
and minimum oxygen saturation remains greater than or equal to 70.
Severe: Mean oxygen saturation remains less than 90% or minimum
oxygen saturation remains less than 70%.
Respiratory disturbance:
Mild: AHI 5-15
Moderate: AHI 16-30
Severe: AHI greater than 30

Management of OSA

Lifestyle modification

Oral appliances:

-Mandibular repositioning device

-Tongue retaining device


-Radiofrequency ablation of the soft palate and tongue base
-Uvulopalatopharyngoplasty (UPPP)
-Hyoid suspension
-Mandibular advancement, genioglossus advancement, and/or maxillary

Monitoring improvement

sleepiness, either subjective or

measured by ESS


AHI. Target <20 ( >20 HTN)

of life improvement.

The Epworth Sleepiness Scale ( ESS )

Today's Date:
Your Age (Years):
How likely are you to doze off or fall asleep in the following situations, in contrast to
feeling just tired? This refers to your usual way of life in recent times. Even if you have
not done some of these things recently, try to work out how they would have affected
you. Use the following scale to choose the most appropriate number for each situation:
0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing

Chance of Situation: Dozing

Sitting and reading

Watching TV
Sitting, inactive in a public place (e.g., a theater or a meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in traffic

Key: < 10 points = probably normal 10-12 points = mild sleepiness 13-17 points =
moderate sleepiness 18-24 points = severe sleepiness


Blind Nasal Intubation Facilitated by Gum Elastic

Bougie--- M.K. Arora et al: Anesthesia 2006, 61;291

Retrieval of Retrograde Catheter Using Suction--P.Bhattacharya et al: BJA,2004; 92 (6):888

Retrograde Intubation: Utility of Pharyngeal Loop--Virendra et al:Anesth-Analg; 2002,94:470

Fluoroscope-aided Retrograde Intubation---B.K.

Biswas et al: BJA; 2005, 94 (1):281

Facilitated Blind Nasal Intubation in Patients with

TMJ Ankylosis--- Masood et al:J Coll Physician
Surg Pak, 2005;15(1): 4

TMJ Ankylosis with OSA--- Shah et al: J Indian Soc

Pedo Prev Dent; March 2002

Predictors of difficult mask ventilation

Age > 55 years

BMI > 26 kg/m2

History of snoring


Langeron et al, Anesthesiology, November 2006

Neck movement
Patient is asked to hold the head erect, facing
directly to the front maximal head extension
angle traversed by the occlusal surface of
upper teeth
Grade I
> 35
Grade II :
Grade III :
Grade IV :
< 12

Sensitivity & Specificity

Diagnostic test



MMP class









Mouth opening



Wilson risk score






TMD not sensitive


of height to thyromental distance

Useful bedside screening test
RHTMD >25 or 23.5 very sensitive
predictor of difficult laryngoscopy
Anesthesiology, May 2005

Combination Score
Wilson Score
5 factors

Weight, upper cervical spine mobility,

movement, receding mandible, buck teeth



factor: score 0-2

Total score > 2 predicts 75% of difficult

Demerits of ASA
Demerits of ASA Algorithm:
Open ended, wide
choice of techniques
Emphasis on prediction
of difficult airway
No stratification of
available a/w devices
No expression of
strength of

Extubation strategy

Cuff leak test Performed in a spontaneously ventilating patient

at risk of obstruction after extubation

Circuit disconnected occlusion of ETT end and deflation of

cuff ability to breath around the ETT
Ref.: Fisher et al, Anaesthesia, 1992

Conventional awake extubation

Extubation in a deep plane of anaesthesia followed by
placement of LMA to decrease the risk of laryngospasm

Ref.: Brimacombe et al, Anaesthesiology, 1996

Extubation over a fibreoptic bronchoscope

Ref.: Cooper et al, Anesth Clin North America, 1995

Endotracheal ventilation and exchange catheters e.g.

Cooks airway exchange catheter

Tracheal tube exchanger

Thank you