Anesth Analg 2006;102:1294
© 2006 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000199217.90585.B5
LETTER TO THE EDITOR
Prolonged Temporomandibular Joint Dislocation in an Unconscious Patient After Airway Manipulation
Vidya Rattan, MDS, and
Suman Arora, MD
Unit of Oral & Maxillofacial Surgery, Oral Health Sciences Center, drvidyarattan{at}sancharnet.in (Rattan)
Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India (Arora)
To the Editor:
Temporomandibular joint (TMJ) dislocation can occur during airway manipulation. The diagnosis of TMJ dislocation particularly with oral tracheal tube in situ can be difficult and may be easily missed. Cases have been reported in which diagnosis of TMJ dislocation was missed intraoperatively, and could only be made after the patient regained consciousness and complained of preauricular pain and inability to close the mouth (1,2). Prolonged unconsciousness, such as that after a head injury or critical illness, might considerably delay the diagnosis of TMJ dislocation after airway manipulation. Delayed reduction of TMJ dislocation leads to fibrosis and adhesions in the joint, which makes manual reduction more difficult and may require surgical reduction. We report a case involving a 3-mo delay in diagnosis of TMJ dislocation, eventually requiring surgical reduction.
A 22-yr-old male reported to the oral and maxillofacial unit with a chief complaint of pain in the temporal region and the inability to chew or close his mouth. There was a history of head injury with a Glasgow Coma Scale score of 7/15 3 mo previously. The emergency room registrar performed emergent orotracheal intubation. On computerized tomography scan, the patient had been diagnosed with multiple contusions of the brain, managed conservatively by neurosurgeons in intensive care unit on ventilatory support. Two days later a tracheostomy was performed and a feeding tube was placed. The patient's Glasgow Coma Scale Score improved to 15/15 over a period of 3 mo, after which he had been decannulated and discharged.
When the patient presented to the oral and maxillofacial outpatient unit 3 mo after his primary injury, he had a prognathic appearance with a long face, anterior open bite, and inability to close his mouth or speak. Mandibular movements were painful, and lateral and protrusive movements were restricted. A computerized tomographic scan showed anterior dislocation of both mandibular condyles. It was planned to reduce the dislocation under general anesthesia with an option of surgical reduction. Manual manipulation of the condyles could not reduce the dislocation. Surgical reduction was carried out with some difficulty by applying downward force with the help of interosseous wire placed at the angle of mandible bilaterally.
In this case, TMJ dislocation most likely occurred during airway manipulation. Retrospectively, the computerized tomographic scan of the brain taken immediately after intubation revealed anterior dislocation of condyles. There was no evidence of trauma to the chin, thus excluding posttraumatic TMJ dislocation. There was no history of previous TMJ disorder and the patient was not on any drugs causing extrapyramidal side effects, thus excluding other causes of dislocation.
In certain hypermobile joints, mandibular condyle during mouth opening can crossover the articular eminence. The movement of condyle crossing over the articular eminence can be felt, and such hypermobile joints can be more prone to TMJ dislocation. When such a movement is felt, the anesthetist should make sure that condyles have moved back to their resting position after airway manipulation. This can be checked by occluding the teeth in maximum intercuspation. Apart from taking proper history and physical examination for TMJ pathology, the anesthetist should also check the occlusion just before inducing the patient. This would help in comparing the occlusion to preintubation status in case of any doubt regarding TMJ dislocation. Oral tracheal tubes can hinder in occluding the teeth; in such cases shifting the tube to the retromolar space may assist in occluding the teeth. The anesthetist should be particularly careful to avoid this complication in an unconscious patient requiring indeterminate ventilatory support.
References
- Rastogi NK, Vakharia N, Hung OR. Perioperative anterior dislocation of the temporomandibular joint. Anesth Analg 1997;84:924–6.[Medline]
- Gambling DR, Ross PLE. Temporomandibular joint subluxation on induction of anesthesia. Anesth Analg 1988;67:91–2.[Free Full Text]
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