Masticatory muscle tendon-aponeurosis hyperplasia (MMTAH) is a new disease entity characterized by limited mouth opening due to contracture of the masticatory muscles resulting from hyperplasia of tendons and aponeuroses. The other clinical feature is that the face of the patient with this disease displays a square mandible configuration. Muscle relaxants provide no relief for the limited mouth-opening ability. Anesthesiologists need to suspect difficult airway when patients have limited mouth opening with square mandible configuration. MMTAH can therefore be a possible cause of difficult intubation.

Masticatory muscle tendon-aponeurosis hyperplasia (MMTAH) is a new disease entity characterized by limited mouth opening due to contracture of the masticatory muscles, resulting from hyperplasia of tendons and aponeuroses. In this case series, we report what methods of airway establishment were conclusively chosen after rapid induction of anesthesia. We had 24 consecutive patients with MMTAH who underwent surgical release of its contracture under general anesthesia. Rapid induction of anesthesia with propofol and rocuronium was chosen for all the cases. In 7 cases, intubation using the Macintosh laryngoscopy was attempted; however, 2 of those cases failed to be intubated on the first attempt. Finally, intubation using the McCoy laryngoscopy or fiber-optic intubation was alternatively used in these 2 cases. In 7 cases, the Trachlight was used. In the remaining 10 cases, fiber-optic intubation was used. Limited mouth opening in patients with MMTAH did not improve with muscular relaxation. "Square mandible" has been reported to be one of the clinical features in this disease; however, half of these 24 patients lacked this characteristic, which might affect a definitive diagnosis of this disease for anesthesiologists. An airway problem in patients with MMTAH should not be underestimated, which means that other intubation methods rather than direct laryngoscopy had better be considered.

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Here, we report a case of synovial chondromatosis of the temporomandibular joint (TMJ) with numerous loose bodies. A 56-year-old woman was examined in the oral surgery department for trismus and pain in the left TMJ when opening the mouth. Imaging indicated TMJ synovial chondromatosis, and the patient was referred to our department for further examination. Her facial features were symmetrical, and no occlusal abnormalities were found. The maximum mouth opening was 30 mm, and movement of the left mandibular condyle was restricted and accompanied by pain and joint sounds. Panoramic radiography showed deformation of the left mandibular condyle and radiopaque lesions surrounding it. Computed tomography showed numerous small granules around the left mandibular condyle, some of which were calcified. Magnetic resonance imaging showed anterior disc displacement without reduction in the left TMJ and hypointense lesions on T2-weighted images. Bone scintigraphy showed an accumulation in the area of the left TMJ. Based on the diagnosis of the left TMJ synovial chondromatosis, the lesions were removed, and plastic surgery on the mandibular condyle was performed under general anesthesia. We removed 386 white loose bodies. Histopathologically, the loose bodies were consistent with synovial chondromatosis lesions. The postoperative course was uneventful, with no recurrence or TMJ dysfunction approximately 5 years after the surgery, indicating that open surgery is the best course of intervention in such cases.

A case of a ferromagnetic foreign body in a medically compromised patient was reported. The patient was a 45-year-old male who consulted our department complaining of a foreign body accidentally impacted in the right cheek. X-ray examination revealed a foreign body at the lateral aspect of the right mandibular ramus. The removal of the foreign body was scheduled, but the patient did not return for the procedure. After 8 years he revisited our department for the removal of the foreign body, because it had been found to be ferromagnetic and a barrier to MRI examination. X-ray examination confirmed the foreign body was located at the same site as 8 years prior. Although the patient was suffering from liver cirrhosis with thrombocytopenia and leukopenia, the foreign body was successfully removed under general anesthesia. The foreign body was 12 × 5 × 1 mm, weighed 0.48 g, and was ferromagnetic. The patient’s postoperative course was uneventful. X-ray examination confirmed the removal of the foreign body. Since the surgery, the patient has been in generally stable condition with no complications. This case was a rare example of a foreign body that needed to be removed for medical examination.