Case: TMJ Ankylosis

Moderator:
Dr. Lokesh Kashyap
Acknowledgement: Dr. Ganga Prasad, Dr. Umakanth, Dr. Abhijit
www.anaesthesia.co.in

anaesthesia.co.in@gmail.com
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

SUNITA, 21 F
Chief Complain:
Facial deformity since last 8yrs
Snoring and repeated spontaneous arousal
during sleep for last 2-3yrs
History of Present Illness
k/c/o B/L TMJ ankylosis; post traumatic
Gap arthroplasty in Aug98
Progressively receding chin following 2yrs of
surgery
Bothersome facial deformity
No associated difficulty in feeding, speech
Snoring during sleep for last 2-3yrs

.HOPI
Progressively 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
.HOPI
No 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
Vegetarian
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
character
BP- 110/70mmHg in left upper limb at supine position
IV access: good
Weight:31.6 kg
Height: 151cm
Airway Examination-11parameters
Inter-incisor 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
Mandibular compliance: Hardly any
appreciable space
Neck length: sufficient
Neck diameter: thin neck
Neck movement: poor head extension
Movement 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
patent
Respiratory system

R.R.-18/min
B/l NVBS all over, no added sounds
Cardiovascular System
S1, S2- normally audible
No murmur

Central Nervous System
Higher functions normal
No sensory/ motor deficit


Abdomen
Soft, non tender, non distended.
No palpable lump

Investigations:
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; pO
2
: 93.6 mmHg; pCO
2
: 43.3 mmHg;
HCO
3
: 25.9 mmol/l; Sat: 97%


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

CXR: 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
Post TMJ ankylosis growth disturbance
leading to retrognathia with severe OSA.
Questions?

Blind nasotracheal; movie
Latin :articulatio temporomandibularis
Artery: superficial temporal artery
Nerve: auriculotemporal , masseteric
TEMPORO
MANDIBULAR
JOINT
Movements of TMJ
Depression:
-Hinge like/ rotatory
-Sliding
Elevation
Protrusion
Retraction
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
oropharynx
OSA
Occlusion defect
Dentition defect
Poor nutrition
Poor oral hygiene

Management of TMJ Ankylosis
Jaw opening exercise
Management of OSA
Surgery:
-TMJ arthroscopy
-TMJ arthroplasty
-TMJ implants
-Condylectomy
-Gap-arthroplasty
Airway Management
Fiber optic intubation:
- awake
- following induction of anesthesia with spontaneous breathing
- following induction & respiratory paralysis
Blind nasal intubation:
-awake
- following induction of anesthesia with spontaneous breathing
- following induction & respiratory paralysis
Retrograde intubation
Tracheostomy

BERMAN
WILLIAMS
OVASSAPIAN

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.
Solutions:
Use a thick fibrescope and a thin tracheal tube.gap 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
Insertion of a thinner tracheal tube
between a larger tracheal tube and a
fibrescope
(A) The Parker Flex-Tip tracheal tube
(B) The ILMA tube.
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
Or
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
OSA:

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

Or

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
stroke
RERA:
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
Sleepiness
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
Surgery
-Septoplasty
-Polypectomy
-Turbinoplasty
-Radiofrequency ablation of the soft palate and tongue base
-Uvulopalatopharyngoplasty (UPPP)
-Hyoid suspension
-Mandibular advancement, genioglossus advancement, and/or maxillary
advancement
Monitoring improvement
Diminished sleepiness, either subjective or
measured by ESS

Diminished AHI. Target <20 ( >20 HTN)

Quality of life improvement.

The Epworth Sleepiness Scale ( ESS )
Name:
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
Literature:
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/m
2

History of snoring
Beard
Edentulous
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 : 22-34
Grade III : 12-21
Grade IV : < 12
Sensitivity & Specificity
Diagnostic test Sensitivity Specificity
MMP class 49% 86%
TMD 20% 94%
Sternomental
distance
62% 82%
Mouth opening 22% 97%
Wilson risk score 46% 89%
MMP + TMD 56% 97%
TMD not sensitive
Ratio of height to thyromental distance
(RHTMD)
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, jaw
movement, receding mandible, buck teeth
Each factor: score 0-2
Total score > 2 predicts 75% of difficult
intubations

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
recommendation

Demerits of ASA Algorithm:
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
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anaesthesia.co.in@gmail.com