Anaesthesia for TMJ Ankylosis with the Use of TIVA, Followed by Endotracheal Intubation

TMJ ankylosis, though it is not common, is an anaesthetic challenge, as it is a difficult airway situation with a moderate to a severely limited mouth opening. Fiber-optic intubation is the gold standard for such cases, but it may not be readily available at all centres. Blind nasal intubation, retro-grade intubation and tracheostomy are the other alternatives, but they require patient co-operation and are associated with considerable morbidity. We are presenting a case of unilateral TMJ ankylosis in a 12 years old boy who was posted for condylectomy and interpositional arthroplasty. He was maintained on TIVA for condylectomy and was then intubated for the remaining procedure. The procedure and the recovery were uneventful.

TMJ Ankylosis,TIVA,Difficult intubation,Ketamine

The Temporomandibular Joint (TMJ) is a synovial joint which is formed between the mandibular condyle and the articular fossa of the temporal bone, whose function is mastication and speech. TMJ Ankylosis is defined as the loss of joint movement which results from the fusion of the bones which are within the joint or from the calcification of the ligaments around it [1].

The bony fusion is painful and it limits the jaw movement than the ligament calcification. The causes are maxillary-mandibular fixation, infection, trauma, degenerative joint disease and prior gap arthroplasty [2,3]. Thus, TMJ ankylosis may occur post-trauma or postsurgery. The more unusual causes include rheumatoid arthritis,[4] sickle cell anaemia [5] and fibrodysplasia ossificans progressiva [6]. The treatment is stretching exercises in the early stages of the cartilagous calcification and later, surgery, to restore the jaw movement [7].

The surgical corrections include gap arthroplasty and interpositional surgery [8]. An anaesthetic management is challenging because of the difficult airway. It could be a difficult airway to ventilate as well as to intubate. Fibreoptic intubation [9,10] is considered as a gold standard in a difficult airway. Here, we are presenting the case report of a 12 year boy with unilateral TMJ ankyosis, wherein total intravenous anaesthesia [11] was used safely and successfully for the endotracheal intubation.

A 12 year boy presented with inability to open the mouth, which was there since 2 years. There was a past history of swelling of the left jaw two and a half years back, from which pus was drained. Since then, the mouth opening had decreased more on the left side. His condition was diagnosed as TMJ ankylosis of the left side.

The airway assessment showed Mallampatti class IV, an atlantooccipital angle of >350 and an interincissor distance of 5mm. It was a case of a difficult intubation. As a small size fibreoptic bronchoscope was not available in our hospital, an alternative technique was planned. He was posted for condylectomy and interpositional arthoplasty. As condylectomy was an extra oral approach which would take 20 minutes, we decided to maintain him on Total Intravenous Anaesthesia (TIVA) with spontaneous breathing till the condylectomy was done. Later, an intubation would be carried out with direct laryngoscopy. The tracheostomy was kept ready in case of an emergency.

On the day of the surgery, an informed written consent was taken from him. An intravenous cannula of 20 G was secured. He was premedicated with glycopyrolate 0.005mg/kg(0.1mg) and midazolam 0.05mg/kg(1.5mg) . He was shifted to the OT and monitors (pulse oximetry, NIBP, ECG and capnography ) were attached. He was induced with Fentanyl 1mcg/kg(25mcg) and propofol 0.5mg/kg(10mg). He was maintained with an infusion of propofol 50mcg/kg/min(1.2ml/min).

He was kept on spontaneous breathing with nasal prongs. The local infiltration of the surgical site was done with 25ml of 1% Xylocaine and 0.25% Bupivacaine (50:50). The condylectomy was completed in 20mins and the interincissor distance was 25mm. He was induced with propofol 2mg/kg(50mg).

He was intubated with a 5.0 cuffed endotracheal tube under direct laryngoscopy with bougie. The endotracheal placement confirmation was done with auscultation and capnography. Muscle relaxation was done with Vecuronium bromide 0.1mg/kg(2.5mg).

Anaesthesia was maintained with Oxygen:

Nitrous oxide (50:50) Halothane 1MAC and Vecuronium bromide 1/4th the loading dose(0.5mg)]. The intraoperative period was uneventful. The neuromuscular blockade was reversed with Glycopyrollate 0.005mg/kg(0.1mg) and Neostigmine 0.05mg/kg(1.5mg). The patient was extubated awake after through suctioning. He was shifted to the PACU. His further hospital stay was uneventful and he was discharged on the 10th postoperative day.

The TMJ ankylosis surgery falls in the category of difficult intubation9, as a direct vocal cord visualization is difficult, due to an inability in opening the mouth. There is associated retrognathia with a relatively large tongue, and a pseudomacroglossia in a confined space that narrows the pharyngeal passage [12,13]. All of these factors make a laryngoscopic intubation much more difficult or impossible.

The other options for securing the airway include a fibre optic assisted intubation [9], semi blind technique of nasal intubation [14] binasopharyngeal airway [15,16], a fluoroscope-aided retrograde placement of the guide wire for the tracheal intubation [17], retrograde endotracheal intubation with the use of a pharyngeal loop [18], and a tracheostomy [20].

Fibreoptic intubation is the gold standard for a difficult airway [19,20,21]. At many centres, a small sized fibreoptic scope may not be available, as in our institute. In such situations, a blind nasal intubation [13] or a retrograde intubation [17,18] are recommended. A blind nasal intubation can lead to bleeding, oedema and further airway complications on repeated attempts [22]. Any airway compromise would be detrimental in a paediatric patient. The retrograde intubation was originally described in 1960, with several modifications which have been since then.

The basic principal behind this is an adequate regional airway blockade with the patient’s co-operation. A retrograde transtracheal puncture and guidewire, can be difficult [23] and it has its own complications like tracheal bleeding, which could become occasionally fatal [23,24]. These complications can be minimized with the co-operation of the patient. Patient co-operation is difficult in paediatric patients.

Tracheostomy [25] is an invasive procedure with a post operative morbidity and so it was reserved for emergency [25] in our case. As external gap arthoplasty [26] approach was used in our case. We planned to give TIVA with adjuvant local anaesthesia till the condylectomy was done. TIVA was given with a propofol [27] infusion 50mcg/kg/min.

Once the mouth opening was adequate, the patient was induced and intubated. Other combinations which can be used are ketamine [28], propofol [27], propofol with fentanyl ,propofol with remifentanyl [29],etc. Each has its own positive and negative points. We chose propofol alone to avoid a respiratory depression which could be caused by opioid and hallicination and arousal which could be caused by ketamine. So, TIVA can be used as an alternative technique in paediatric patients safely.

In case of paediatric unilateral temporo mandibular joint ankylosis, an extra oral approach condylectomy can be maintained initially, with total intravenous anaesthesia. Later, an intubation can be done under direct laryngoscopy and the operation can be continued with interpositional arthoplasty intraorally. This is a safe and an effective technique which can be used when a fibreoptic bronchoscope is not available.

[1]. The Merck Manual-Home Edition, Sec 8, Ch 96 Disorders of the Temporomandibular Joint.html   [Google Scholar]

[2]. Manganello-Souza LC, Mariani PB, Temporomandibular joint ankylosis: report of 14 cases Int J Oral Maxillofac Surg 2003 32(1):24-29.  [Google Scholar]

[3]. Garcia-Aparicio L, Parri FJ, Sancho MA, Sarget R, Morales L, Temporomandibular joint ankylosis (TMA) in children Cir Pediatr. 2000 13(2):62-63.  [Google Scholar]

[4]. Kobayashi R, Utsunomiya T, Yamamoto H, Nagura H, Ankylosis of the temporomandibular joint caused by rheumatoid arthritis: a pathological study and review J Oral Sci. 2001 43(2):97-101.  [Google Scholar]

[5]. Baykul T, Aydin MA, Nasir S, Avascular necrosis of the mandibular condyle causing fibrous ankylosis of the temporomandibular joint in sickle cell anemia J Craniofac Surg. 2004 15(6):1052-56.  [Google Scholar]

[6]. Herford AS, Boyne PJ, Ankylosis of the jaw in a patient with fibrodysplasia ossificans progressiva Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003 96(6):680-84.  [Google Scholar]

[7]. Devgan A, Siwach RC, Sangwan SS, Functional restoration by excision arthroplasty in temporomandibular joint ankylosis--a report of 35 cases Indian J Med Sci. 2002 56(2):61-64.  [Google Scholar]

[8]. Saeed NR, Kent JN, A retrospective study of the costochondral graft in TMJ reconstruction Int J Oral Maxillofac Surg. 2003 32(6):606-09.  [Google Scholar]

[9]. Dasgupta D, Endotracheal intubation in bilateral temporomandibular joint ankylosis Indian J Anesth. 1987 35:367-73.  [Google Scholar]

[10]. Kulkarni DK, Prasad AD, Rao SM, Experience in fibreoptic nasal intubation for temporomandibular joint ankylosis Indian J Anaesth. 1999 43:26-29.  [Google Scholar]

[11]. Absalom ASM, An Overview of TCI and TIVA 2005 Gent, BelgiumAcademic Press  [Google Scholar]

[12]. El-Sheikh Medra AM, Management of unilateral temporomandibular ankylosis associated with facial asymmetry J Craniomaxillofac Surg 1997 25:109-15.  [Google Scholar]

[13]. Colmenero C, Esteban R, Albarino AR, Colmenero B, Sleep apnoea syndrome associated with maxillofacial abnormalities J Laryngol Otol 1991 105:94-100.  [Google Scholar]

[14]. Naveed M, Syed A, Facilitated blind nasotracheal intubation inparalysed patients with temporomandibular joint ankylosis J Coll Physicians. Surg Pak. 2005 15:4-6.  [Google Scholar]

[15]. Gopinath R, Rajender Y, Kumar D, Rao SM, Anaesthesia for temporomandibular joint surgery: A revived technique Indian J Anaesth 1991 39:105-08.  [Google Scholar]

[16]. Weisman H, Wes TW, Elam JO, Use of double nasopharyngeal airways in anaesthesia Anaesth Analg 1969 48:356-58.  [Google Scholar]

[17]. Biswas BK, Bhattacharyya P, Joshi S, Tuladhar UR, Baniwal S, Fluoroscope-aided retrograde placement of guide wire for tracheal intubation in patients with limited mouth opening Br J Anaesth 2005 94:128-31.  [Google Scholar]

[18]. Arya VK, Dutta A, Chari P, Sharma RK, Difficult retrograde endotracheal intubation: The utility of a pharyngeal loop Anesth Analg 2002 94:470-73.  [Google Scholar]

[19]. Vas L, Sawant P, A review of anaesthetic technique in 15paediatric patients with temporomandibular joint ankylosis Paediatr Anaesth 2001 11:237-44.  [Google Scholar]

[20]. Ugboko VI, Aod A, Ho O, Ndukwe KC, Temporomandibular joint ankylosis: A multicenter nigerian study J Dent Oral Med 2002 4  [Google Scholar]

[21]. Vas L, Sawant P, A review of anaesthetic technique in 15paediatric patients with temporomandibular joint ankylosis Paediatr Anaesth 2001 11:237-44.  [Google Scholar]

[22]. Waters DJ, Guided blind endotracheal intubation Anaesthesia 1963 18:158-62.  [Google Scholar]

[23]. Poon YK, Case history number 89: A life-threatening complication of cricothyroid membrane puncture Anesth Analg 1976 55:298-301.  [Google Scholar]

[24]. Schillaci RF, Iacovoni VE, Conti RS, Transtracheal aspiration complicated by fatal endotracheal hemorrhage N Engl J Med 1976 295:488-90.  [Google Scholar]

[25]. Stauffer JL, Complications of endotracheal intubation and trachcostomy Respir Care 1999 44:828  [Google Scholar]

[26]. Roychoudhury A, Parkash H, Trikha A, Functional restoration by gap arthroplasty in temporomandibular joint ankylosis: A report of 50 cases Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999 87:166-69.  [Google Scholar]

[27]. McFarlan CS, Anderson BJ, Short TG, The use of propofol infusions in paediatric anaesthesia: a practical guide Pediatr Anesth 1999 9(3):209-16.  [Google Scholar]

[28]. Dallimore D, Anderson BJ, Short TG, Ketamine anesthesia in children – exploring infusion regimens PediatrAnesth 2008 18(8):708-14.  [Google Scholar]

[29]. Bouillon TW, Bruhn J, Radulescu L, Pharmacodynamic interaction between propofol and remifentanil regarding hypnosis, tolerance of laryngoscopy, bispectral index, and electroencephalographic approximate entropy Anesthesiology 2004 100(6):1353-72.  [Google Scholar]