Case: TMJ Ankylosis Moderator: Dr. Lokesh Kashyap Acknowledgement: Dr. Ganga Prasad, Dr. Umakanth, Dr. Abhijit www.anaesthesia.co.in email@example.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
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.
TEMPORO MANDIBULAR JOINT • Latin :articulatio temporomandibularis • Artery: superficial temporal artery • Nerve: auriculotemporal , masseteric
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 correct insertion 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
(A) The Parker Flex-Tip tracheal tube (B) The ILMA tube. Insertion of a thinner tracheal tube between a larger tracheal tube and a fibrescope
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 withdocumented 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