TMJ Ankylosis Case Presentation
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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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anaesthesia.co.in@gmail.com
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