Anesth Analg 2004;99:383-385
© 2004 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000132999.57989.FA
AMBULATORY ANESTHESIA
Unsuspected Temporomandibular Joint Pathology Leading to a Difficult Endotracheal Intubation
Robert H. Small, MD,
Steven I. Ganzberg, DMD, and
Andreas W. Schuster, MD
Department of Anesthesiology, The Ohio State University, Columbus, Ohio
Address correspondence to Robert H. Small, MD, Department of Anesthesiology, The Ohio State University, 410 W. 10th Ave., Columbus, OH 43210. Address e-mail to small.12{at}osu.edu The authors will not provide reprints.
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Abstract
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A 40-yr-old woman with an unremarkable medical history and no prior surgeries presented for ambulatory surgery. Physical examination revealed normal jaw opening. On induction of general anesthesia, her jaw was found to be locked in a nearly closed position. We discuss anesthetic considerations and the pathology of temporomandibular joint anterior disk dislocation without reduction. A simple maneuver to reduce the dislocation is described.
IMPLICATIONS: The result of failing to secure the airway of a patient undergoing general anesthesia can be catastrophic. It is ominous when there is a condition that makes airway management difficult and that is not easily diagnosed in advance. This report discusses one such condition and describes a technique to overcome the difficulty.
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Introduction
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Knowledge of temporomandibular joint (TMJ) anatomy, function, and pathology is an important part of the anesthesiologist’s knowledge base. Several TMJ pathologic conditions result in decreased oral opening and difficult laryngoscopy (1). TMJ anterior disk dislocation can cause the mouth to lock in a nearly closed position in the anesthetized patient (1–4), even though the preoperative range of motion is normal. We report such a case in this article.
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Case Report
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A 40-yr-old woman presented for ambulatory surgery. Her medical history was unremarkable, with no prior operations. Physical examination was unremarkable and revealed a Mallampati Class I airway with normal oral opening and normal thyromental distance. The preoperative medication was midazolam 2 mg IV. General anesthesia was induced with propofol 2 mg/kg and fentanyl 1 µg/kg IV. After a patent airway was established via a mask, rocuronium 0.6 mg/kg was administered. In 2 min, neuromuscular blockade was demonstrated by no twitches in a train-of-four stimulation of the ulnar nerve. When endotracheal intubation was attempted, maximum oral opening was approximately 15 mm. The masseter muscles were soft, eliminating the possibility of masseter muscle spasm (5). Jaw movement within a 15-mm range was easy, but oral opening was limited by a hard obstruction. With lateral manipulation of the mandible, an approximately 30-mm oral opening was obtained, and the trachea was successfully intubated with a No. 6 endotracheal tube by using a Macintosh 3 blade. After surgery, the patient was fully awakened with the endotracheal tube in place, and voluntary oral opening was normal. Tracheal extubation was uneventful. After surgery, the patient reported that she often heard a click when opening her mouth widely. She denied any history of TMJ pain or restriction of mouth opening. Physical examination of the TMJ, performed by the anesthesiologist, was unremarkable.
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Discussion
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This case report illustrates a potential hazard in airway management during general anesthesia and is similar to cases reported by Redick (2), Patane et al. (3), and Lim and Andrews (4). These authors describe the importance of anterior translation of the TMJ in mouth opening and recommend using a jaw-thrust maneuver to overcome the obstruction. This report reviews the anatomy and pathology of TMJ anterior disk dislocation and reviews a reduction maneuver (6).
The patient in this report had a history and operative course consistent with intermittent TMJ anterior disk dislocation with reduction. Jaw clicking was not reported before surgery by the patient or discovered on examination by the anesthesiologist. In normal TMJ movement, the initial 15 to 20 mm of opening is associated with rotation of the TMJ. Further opening results in anterior translation of the mandibular condyle/disk assembly in the TMJ fossa. When anterior disk dislocation is present, the disk is located anterior to the mandibular condyle. This can interfere with the anterior translation necessary for full mouth opening. TMJ anterior disk dislocation takes two forms: with reduction and without reduction (Fig. 1). Reduction refers to the reestablishment of a normal disk/condyle relationship upon anterior translation of the mandibular condyle. This reduction often produces a painless click. Anterior disk dislocation without reduction leads to jaw locking when translation of the mandibular condyle is blocked by the displaced disk, resulting in limited oral opening (9). The incidence of TMJ disk dislocation is 8%–41% in adults and 8%–29% in children and adolescents aged 7 to 18 years (9). Prolonged impairment of oral opening in the conscious patient is uncommon because patients learn mandibular movements to unlock the jaw. In cases in which mouth opening remains restricted, adaptive changes often allow for gradually progressive increased opening. The loss of muscle tone under anesthesia and neuromuscular blockade can lead to anterior disk dislocation without reduction when the patient is supine, allowing posterior mandibular displacement and consequent anterior disk dislocation.
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Figure 1. Anterior dislocation with reduction (a) and without reduction (b). Anterior translation of the mandibular condyle is blocked when the dislocation is not reduced (arrows). Adapted from Pertes and Gross (7) and Okeson (8) (used with permission from Quintessence Publishing Co., Inc.).
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A simple maneuver is often effective in reducing anterior disk dislocation (6). In anterior disk dislocation without reduction, the jaw will be deflected ipsilateral to the locked joint when the mouth is opened (Fig. 2). The thumb is placed over the lower molar teeth on the locked side, and gentle inferior pressure is applied. The jaw is then moved gently in the contralateral direction, upon which a pop may be felt or heard, indicating disk reduction. Figure 3 illustrates the maneuver. The jaw can frequently be opened after this maneuver and should not be allowed to close until endotracheal intubation has been confirmed. Extubation should be performed with the patient fully awake and with protective reflexes intact.
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Figure 2. Left-side anterior dislocation without reduction. Note the limited oral opening and ipsilateral displacement of the mandible. Adapted from Pertes and Gross (7) (used with permission from Quintessence Publishing Co., Inc.).
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Figure 3. Reduction maneuver for left anterior dislocation without reduction. First, inferior pressure is applied to the joint (A). Second, gentle movement of the mandible in the contralateral direction will reduce the dislocation (B). Adapted from Friedman and Weisberg (6) (used with permission from Quintessence Publishing Co., Inc.).
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It is recommended that preanesthetic assessment include TMJ evaluation (10–12). For patients with a history of jaw clicking, it may be advisable to ask the patient to open the mouth past 25 mm or until the jaw clicks. Then, place a soft bite block to hold the mouth open before the induction of anesthesia. This will open the jaw to the point where joint reduction has occurred and avoid the locking problem altogether.
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References
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- Aiello G, Metcalf I. Anaesthetic implications of temporomandibular joint disease. Can J Anaesth 1992; 39: 610–6.[Web of Science][Medline]
- Redick LF. The temporomandibular joint and tracheal intubation. Anesth Analg 1987; 66: 675–6.[Free Full Text]
- Patane PS, Ragno JRJ, Mahla ME. Temporomandibular joint disease and difficult tracheal intubation. Anesth Analg 1988; 67: 482–3.
- Lim BSL, Andrews R. Unexpectred difficult intubation in a patient with normal airway on assessment. Anaesth Intensive Care 2001; 29: 642–3.[Web of Science][Medline]
- Yemen TA. Are we obsessed with masseter muscle rigidity? Temporomandibular joint disease mistakenly diagnosed as masseter muscle rigidity on two separate occasions in one patient. Anesth Analg 1993; 77: 848–50.[Free Full Text]
- Friedman MH, Weisberg J. Temporomandibular joint disorders: diagnosis and treatment. Chicago: Quintessence, 1985.
- Pertes R, Gross S. Clinical management of temporomandibular disorders and orofacial pain. Chicago: Quintessence, 1995.
- Okeson JP. Management of temporomandibular disorders and occlusion. 3rd ed. St. Louis: Mosby-Year Book, 1993.
- Schiffman E, Fricton JR. Epidemiology of TMJ and craniofacial pain: an unrecognized societal problem. In: Fricton JR, Kroening RJ, Hathaway KM, eds. TMJ and craniofacial pain: diagnosis and management. St. Louis: Ishiyaku EuroAmerica, 1988: 1–10.
- Benumof JL. TMJ assessment before anaesthesia. Br J Anaesth 2003; 91: 757.[Free Full Text]
- Agro F, Salvinelli F, Casale M, Antonelli S. Temporomandibular joint assessment in anaesthetic practice. Br J Anaesth 2003; 90: 707–8.[Free Full Text]
- Caplan RA, Benumof JL, Berry FA, et al. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2003; 98: 1269–77.[Web of Science][Medline]
Accepted for publication March 5, 2004.
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Abstract
Introduction
