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 Aug’98 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 facies”—severe 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; pO2: 93.6 mmHg; pCO2: 43.3 mmHg;

HCO3: 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

Shortcut to DIFFICULTY AIRWAY 009.avi.lnk

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 correctinsertion 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 α 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/m2

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 laryngoscopyAnesthesiology, 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 laryngospasmRef.: Brimacombe et al, Anaesthesiology, 1996

Extubation over a fibreoptic bronchoscopeRef.: Cooper et al, Anesth Clin North America, 1995

Endotracheal ventilation and exchange catheters e.g. – Cook’s airway exchange catheter– Tracheal tube exchanger

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