Airway challenges in bilateral temporomandibular joint ankylosis with adenoid hypertrophy: a case report

Abstract

Temporomandibular joint ankylosis is one of the most challenging airway disorders associated with varying anatomical abnormalities like adenotonsillar hypertrophy, craniofacial malformations, macroglossia, etc. This case highlights the intubation difficulties confronted during the airway management of a 10-year-old girl presenting lately with bilateral temporomandibular joint ankylosis, hypoplastic mandible, and adenoid hypertrophy. This patient was intubated successfully by using a suction catheter assembly to negotiate the endotracheal tube across the adenoid, and an unmatched-size flexible intubation fiberscope through a "separate insertion" technique and external laryngeal manipulation. This case emphasises the significance of a comprehensive preoperative evaluation in preparing the anaesthetic plan of an anticipated difficult airway in a paediatric population, having diverse anatomical hurdles presenting concurrently.

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“…In this case suction catheter assembly was used to negotiate the endotracheal tube across the adenoid where the endotracheal tube (ET) was introduced through one nostril and an unmatched-size flexible intubation fiberscope (FIF) was introduced through other nostril and the intubation of the ET tube was done under direct endoscopic view of FIF through external laryngeal manipulation under conscious sedation. [1] Vitkovik et al in 2020 presented a case of 8 year old male child with temporomandibular joint ankylosis. Authors managed the case with rigid fiberoptic intubation using a 5mm diameter Bonfils retromolar intubation fiberscope and suggested it to be an alternative method in difficult airway management in paediatric patients.…”

“…Intubation of temporomandibular joint (TMJ) ankylosis patient with limited mouth opening is one of the most challenging situation faced by an anaesthesiologist. [1] TMJ ankylosis patients have limited or nil mouth opening making intubation by direct laryngoscopy impossible as there is no direct visualization of vocal cords. [2] As TMJ ankylosis presents with diverse anatomical hurdles, a thorough meticulous pre operative anaesthetic plan is of paramount importance in view of anticipated difficult airway.…”

“…Concerning anaesthesiologist should have due expertise and ability to deal with any unexpected difficulties. [1] Dependable anaesthetic intubation techniques are most desired by anaesthetists in managing such difficult airway situations. [2] Use of techniques like orotracheal intubation, laryngeal mask airway, combitube and cuffed oropharyngeal airway is not possible due to limited mouth opening.…”

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“…The majority of anesthesiologists focus on the TMJ function evaluation as it relates to optimal intubating conditions [ 7 ]. Difficulties with intubation are especially common in patients with limited mouth opening such as those with TMJ ankyloses [ 8 , 9 , 10 , 11 ]. However, proper TMJ assessment is required both before and after anesthesia in order to avoid or minimize temporomandibular complications [ 6 , 12 ].…”