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LETTERS TO EDITOR
Year : 2017  |  Volume : 18  |  Issue : 1  |  Page : 27-28
 

Airway management of a child with temporomandibular joint ankylosis and obstructive sleep apnea


Department of Anesthesiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India

Date of Web Publication27-Jun-2017

Correspondence Address:
Bharat Paliwal
Sector-23, House-14, Chopasni Housing Board Colony, Pal Road, Jodhpur - 342 008, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_1_17

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How to cite this article:
Paliwal B, Bhatia P, Bihani P, Saran A. Airway management of a child with temporomandibular joint ankylosis and obstructive sleep apnea. Indian Anaesth Forum 2017;18:27-8

How to cite this URL:
Paliwal B, Bhatia P, Bihani P, Saran A. Airway management of a child with temporomandibular joint ankylosis and obstructive sleep apnea. Indian Anaesth Forum [serial online] 2017 [cited 2019 Oct 22];18:27-8. Available from: http://www.theiaforum.org/text.asp?2017/18/1/27/208962


Sir,

Temporomandibular joint (TMJ) ankylosis in children results in severe restriction of mouth opening and abnormal facial skeletal growth. Obstructive sleep apnea (OSA) develops in longstanding cases as the size of oral and pharyngeal space also decreases secondarily. Such patients present difficulty in airway management.[1],[2] Managing difficult intubation with limited available resources can be challenging. We report airway management of such a child.

An 8-year-old male child weighing 18 kg scheduled for TMJ ankylosis release had inter-incisor gap of 2 mm only on mouth opening. Other features included presence of micrognathia, missing lower incisor, receding chin, and nasal septum deviation toward the right [Figure 1]a. Computed tomography scan confirmed TMJ involvement [Figure 1]b.
Figure 1: (a) The child having facial asymmetry. (b) Computed tomography scan showing left and right temporomandibular joints

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Endotracheal intubation was planned using flexible fiberoptic laryngoscope (FOL), through left nostril after inhalational induction, preserving the spontaneous respiration. After attaching routine monitoring, glycopyrrolate 0.2 mg was given intravenously. Xylometazoline nasal drops were instilled. Since the child was not accepting face mask or allowing nebulization with 4% lignocaine, we had to give intravenous midazolam 0.5 mg, fentanyl 20 mcg, and ketamine 10 mg. Following sedation, oxygen saturation (SpO2) dropped from 99% to 89%. A 5.0 mm uncuffed endotracheal tube (ETT) was introduced as a nasopharyngeal airway, through the left nostril and connected to the bains circuit, which normalized SpO2. Inhalational induction with sevoflurane 6% was initiated, but the patient developed intercostal retraction. Mask ventilation was also not effective, so sevoflurane was stopped. Meanwhile, superior laryngeal nerve block and transtracheal injection of 2% lignocaine were given. ETT modified as nasopharyngeal airway was removed from the left nostril and flexible FOL (3.7 mm, 30 cm; Karl Storz, Germany), with an another cuffed ETT of 5.0 mm mounted over it, was introduced. Intubation was achieved after some external manipulations. Oxygen insufflation during the procedure was done through a 3.0 mm ETT introduced into the oral cavity through a gap present due to missing lower incisor. The same space was also utilized for intermittent oropharyngeal suction. After intubation, the position of ETT was confirmed by auscultation and capnography. Once the airway was secured, the plane of anesthesia was deepened with sevoflurane. Anesthesia was maintained using N2O, isoflurane, and intermittent doses of fentanyl and atracurium intravenous. At the end of the surgery, residual neuromuscular blockade was reversed, and the patient was extubated after complete recovery. Postoperatively, the patient was monitored in high dependency unit for 24 h where he maintained SpO2 on room air.

The airway management in this patient was difficult because of several reasons. The child was noncooperative; hence, awake intubation and airway blocks were not possible. Sedation, though generally avoided in difficult airway, may be required in noncooperative patient. On sedation, hypoxia developed as the child also had obstructed sleep apnea. His mouth opening was negligible. Since pediatric nasopharyngeal airway was not available, ETT was used which only partly relieved the obstruction and mask ventilation was not effective. Inhalational induction preserved spontaneous ventilation and allowed rapid recovery on discontinuation but increased the obstruction in this patient. Hence, sevoflurane had to be stopped and airway blocks were quickly given before recovery from sedation. Besides, pediatric fiberoptic bronchoscope was also not available. Blind nasal technique is usually adopted to secure airway in this situation.[3],[4] We could manage difficult intubation with flexible FOL. Patency of single nostril due to deviated nasal septum precluded simultaneous use of flexible FOL and nasopharyngeal airway. The flexible FOL, though handy due to shorter length (30 cm), is devoid of channels for oxygenation and suction-like bronchoscope. Hence, oxygen supplementation was given orally during fiberoptic intubation, using a 3 mm ETT.


  Conclusion Top


Airway of a noncooperative child with OSA, difficult intubation, oxygenation, and ventilation, in the absence of FOB, was managed with flexible FOL and airway blocks. ETTs were used as airways to oxygenate patient while securing airway.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

We would like to thank Dr. Anamika Purohit for her contribution in preparing the manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Schwengel DA, Sterni LM, Tunkel DE, Heitmiller ES. Perioperative management of children with obstructive sleep apnea. Anesth Analg 2009;109:60-75.  Back to cited text no. 1
[PUBMED]    
2.
Shah FR, Sharma KR, Hilloowalla RN, Karandikar AD. Anaesthetic considerations of temporomandibular joint ankylosis with obstructive sleep apnoea: A case report. J Indian Soc Pedod Prev Dent 2002;20:16-20.  Back to cited text no. 2
[PUBMED]    
3.
Shetty SR, Bhandary A, Roy A, Shetty V. Anaesthetic management of temporomandibular joint ankylosis in paediatrics: A 5 year audit in a university hospital. Sch J Appl Med Sci 2015;3:333-7.  Back to cited text no. 3
    
4.
Sankar D, Krishnan R, Veerabahu M, Vikraman BP, Nathan JA. Retrospective evaluation of airway management with blind awake intubation in temporomandibular joint ankylosis patients: A review of 48 cases. Ann Maxillofac Surg 2016;6:54-7.  Back to cited text no. 4
[PUBMED]  [Full text]  


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