Airway management of patient with TMJ ankylosis , fiberoptic intubation

1. ANAESTHETIC MANAGEMENT OF
PATIENT POSTED FOR
CORONOIDOTOMY OF TMJ
DEPARTMENT OF ANAESTHSIOLOGY
ST STEPHENS HOSPITAL
TEES HAZARI ,DELHI
HOD – DR SHOBHA SIKARWAR

2. A 28 years old male presented to PAC room for preanaesthetic evaluation for
coronoidotomy of temporomandibular joint .He had a road traffic accident 1 year back and
sustained TMJ injury and was operated for the same 1 year back but he started developing
difficulty in mouth opening within 8 months of surgery due to trismus ,presently he can
take only liquid and semisolid food orally .On detailed history patient is not having any co
morbidity and belongs to ASA 1 class with METS >4.
On examination,patient was cooperative ,consious oriented to time place and person with
HR-74Bpm,Bp:-120/70 mmHg,SPO2:-98% on room air,weight 62kg, height 168cm .
On systemic examination
Cardiovascular system - S1 ,S2 normal , no murmur was present
Respiratory system –bilateral air entry was equal , vesicular breath sound.
Central Nervous system :no focal neurological deficiet ,GCS-15/15

3. EXTRA ORAL EXAMINATION : No Facial asymmetry
No hypoplastic mandible
Upper lip bite class 3
No receding mandible
AIRWAY EXAMINATION
Patient is having restricted mouth opening (1 and half finger )
MPC IV ,Interincisor distance -2.2 cm
Thyromental distance-7cm
Mentohyoid distance was 3 finger breadth (7cm)
TMJ joint movement was restricted
Neck flexion and extension was normal
Dentition was normal

4. PREOPERATIVE INVESTIGATION
Hb :13g/dl ,platelets-2 lakh 40,000, TLC -6400
INR-0.98
BUN -17, creatinine -0.94, Serum Na+ 138,Serum K+ 4.4
Serum bilirubin(total) – 0.7, direct -0.2, indirect -0.7 , Serum AST -32,Serum ALT 28
albumin -4.2.
Chest xray-Normal , ECG –rate , rhythm normal
Patient was accepted for anaesthesia and written informed consent was taken from
patient and patient’s father .
Method of securing airway with fiberoptic intubation was explained to the patient
and his father and Consent for tracheostomy(if needed) was also taken

6. Following are the screening test to assess the difficult airway .
1) Mallampati classification— . Examiner sits opposite the patient at eye level and the
patient opens the mouth as wide as possible and protrudes the tongue without phonating.
Grade 1—Soft palate, uvula, tonsillar fauces and posterior pharyngeal wall visible
Grade 2—Soft palate, uvula and tonsillar fauces visible
Grade 3—Soft palate and base of uvula seen
Grade 4—Only hard palate visualized
Grade 0—Epiglottis seen.
2) Thyromental distance—Normal > 6.5 cm (4 fingers)
3) Mentohyoid distance—Normal > 6 cm (3 fingers) [2.80+0.15xage]

7. Assessment of TMJ function
a.Interincisor gap/mouth opening—> 5 cm or normally >3 fingers
b. Jaw protrusion
c.Upper lip bite test: -
Class I lower incisors can bite upper lip above the vermilion line
Class II lower incisors can bite upper lip below vermilion line
Class III lower incisors cannot bite upper lip.
d. Movement of condyle of mandible in front of the tragus

8. Assessment of cervical and atlanto occipital joint function: Optimal position for
direct laryngoscopy involves flexion of cervical spine and extension of
AtlantoOccipital(AO) joint (Sniffing position aligns oropharyngeal and laryngeal
axes to a favorable line of sight).
If the patient can touch his manubrium sterni with his chin this assures neck flexion
of 25–30 degrees. The patient is now asked to open his mouth wide such that the
occlusal surface of the upper incisor teeth is parallel to the ground. On extending
AO joint the angle created by movement of the occlusal surfaces is estimated. It
should be at least 80–85 degrees.

9. Thyroid to floor of mouth distance: It indicates the position of the larynx in the
neck. It is normally placed if the patient can place 2 fingers between the top of the
thyroid cartilage and the floor of the mouth.
Sternomental distance: This is measured with the head in full extension and the
mouth closed. Normal distance is > 12.5 cm.
Quality of glottic view during laryngoscopy:
a.Indirect mirror laryngoscopy or Hopkins examination.
b.Direct laryngoscopy
Radiological Assessment X-ray neck cervical spine (AP/Lat)
Atlanto-occipital gap < 5 mm
C1-C2 gap < 5 mm
Airway compression/Deviation

12. Group Indices: (Multiple Parameter)
Wilsons scoring system: Based on weight of patient, Head and neck movement, inter-
incisor gap presence of buck teeth and receding mandible. It has a total score of 10. Score
< 5 = Easy laryngoscopy, 6–7 moderate difficulty, 8–10 severe difficulty.
Benumof ’s 11 parameter analysis:
(first 4 parameters for teeth) Length of upper incisors, Inter-inscisor gap, involuntary
buck teeth override, voluntary protrusion of mandibular teeth in relation to maxillary
teeth,
(next 2 parameters for intraoral structures) MPC, Palatal configuration and narrowness.
(next 2 for mandibular space) Thyromental distance, compliance of mandibular space.
(last 3 parameters for neck) neck length, neck thickness, Head and neck movement

13. Assessment for difficult bag mask ventilation:
1. Bearded individuals
2. Obese individuals
3. No teeth
4. Elderly
5. Snorers

14. WHAT IS DIFFICULT AIRWAY
Defined as a condition in which a trained anaesthesiologist
experiences
difficulty with mask ventilation or difficulty with endotracheal
Intubation or both

15. SINCE THIS PATIENT IS HAVING LIMITED MOUTH OPENING ,MPC IV , RESTRICTED
TMJ MOVEMENT , WE ANTICIPATED DIFFICULT AIRWAY IN THIS PTIENT .
Following methods can be adopted in the patient with Anticipated Difficult airway .
1) Fibre Optic Intubation
2)Blind nasal intubation
3)Video laryngoscopy
4) Intubated LMA (fastrach LMA)
5) Light wand (lighted stylet )
6) Retrograde intubation
We preferred awake intubation (fiberoptic intubation ) in this patient (High
success rate )

16. Preanaesthetic optimization was done and patient was kept nil per oral night
before surgery 0.5mg alprazolam was given a night before surgery ,injection
pantoprazole 40mg and injection perinorm 10mg was given on the day of surgery
as an aspiration prophylaxis before sending to OT complex.
On the morning of the surgery patient shifted to OT complex and brief history and
preanaesthetic evaluation was done again in preanaesthesia holding area,patient
was nebulized with 4% lignocaine in the pre anaesthesia holding room . Difficult
airway cart was kept ready in the OT.
Patient was shifted to operating room , monitors were attached and monitoring
was done according to standard ASA monitoring .An intravenous line with 18G
cannula was secured and iv fluid Ringer lactate was connected , two drops of 0.1%
xylometazoline instilled in both nostrils to prevent nasal bleeding while performing
fiberoptic intubation via nasal route .

17. The patient was premedicated with injection glycopyrrolate 0.2mg IV, inj. midazolam
1mg IV, inj fentanyl 100mcg. 10% lidocaine was sprayed in the pharyngeal area to
blunt to gag reflex
Inj propofol 20mg stat was given to patient .patient was kept in spontaneous
ventilation with light sedation and 100% oxygen was provided with JR circuit through
left nostril.
Transtracheal block for recurrent laryngeal nerve was also carried out after the
cricothyroid membrane was located in the midline of the neck. Using 22 G needle on
a 10 ml syringe with 4 ml of 2% lignocaine was passed perpendicular to the axis of
the trachea and pierces the cricothyroid membrane.
After the aspiration of air freely into the syringe, instillation of local anaesthetic was
performed. This was followed by violent cough which facilitates the spread of local
anaesthetic.
Bilateral superior laryngeal nerve block was given using 2-3 ml of 1% lignocaine via 24
g needle attached to 5 ml syringe .

18. The fiberoptic bronchoscope was preloaded with a 7.0-ID ETT, is advanced into the
hypopharynx.The vocal cords are visualized and 4 mL of 4% lidocaine solution is
injected toward the laryngeal and sub laryngeal structures through the accessory
lumen of the fiberoptic scope through the right nostril.
The distal end of the fiberscope is then advanced into the larynx and trachea until
the carina is identified. The ETT is advanced and the fiberscope removed, leaving
behind the ETT, which is observed to remain above the carina.
The anesthesia circuit is attached to the tracheal tube,ET tube placement was then
checked by auscultation ,bilateral chest movement and Confirmed by using
capnograph.bolus dose of vecuronium (0.08-0.1 mg /kg ) was given to the patient.
Patient was connected to ventilator ( Volume controlled ventilation with tidal
volume -6-8ml/kg, Respiratory rate – 14 breaths /minute ,peak airway pressure -
30cmH2O,PEEP-5cm H2O,fio2-50%)

20. Plane of anaesthesia was maintained by oxygen (2l/min)+nitrous oxide
(2l/min)+isoflurane (0.8-1%). Intermittent doses of vecuronium was given to the
patient during the surgery .
During the surgical procedure.Adequate hydration was maintained with balanced
salt solution according to fluid calculation using holliday segar formula .
Vitals (Heart rate , Blood pressure , SPo2,Capanography )were monitored during
the surgery
Analgesia was maintained by giving injection diclofenac 75mg and intermittent
bolus of injection fentanyl (25 microgram )
Hourly urine output was monitored ,blood loss and temperature monitoring was
done.
After the completion of surgery which lasted for 2 hours . Incision site was
infilterated with 10ml of 0.25 % bupivacaine for analgesia .

22. After the completion of surgery , all inhalational anaesthetic agents were cut off
and 100% oxygen was delievered to the patient oropharyngeal suctioning was
done.
The neuromuscular blockade was reversed with inj neostigmine (2.5mg) and inj
glycopyrrolate (0.4mg)i.v and after gaining complete consciousness ,swallow and
cough reflexes ,adequate ventilator parameters for extubation, patient was
extubated, after extubation oral suctioning was done and oxygen oxygen at 6L/min
via face mask was given , patient was observed for 10 mintutes in the OT for airway
patency .
Then the patient was shifted to the post anaesthesia recovery room. Where
patient’s vitals were monitored, iv fluids were given and the patient maintained a
patent airway

23. RECOMMENDATIONS FOR ANTICIPATED
DIFFICULT AIRWAY MANAGEMENT
When appropriate, perform awake intubation if the patient is suspected to be a difficult
intubation and one or more of the following apply:
(1) difficult ventilation (face mask/supraglottic airway)
(2) increased risk of aspiration
(3) the patient is likely incapable of tolerating a brief apneic episode
(4) there is expected difficulty with emergency invasive airway rescue.

24. The uncooperative or pediatric patient may restrict the options for difficult airway
management, particularly options that involve awake intubation.
Airway management in the uncooperative or pediatric patient may require an approach
(e.g., intubation attempts after induction of general anesthesia) that might not be
regarded as a primary approach in a cooperative patient.
Proceed with airway management after induction of general anesthesia when the
benefits are judged to outweigh the risks. , For either awake or anesthetized intubation,
airway maneuver(s) may be attempted to facilitate intubation.
Be aware of the passage of time, the number of attempts, and oxygen saturation(>95%)

25. Provide mask ventilation after each attempt, when feasible.
Limit the number of attempts at tracheal intubation or supraglottic airway placement
to avoid potential injury and complications.
If an elective invasive approach to the airway is selected, identify a preferred
intervention
Ensure that an invasive airway is performed by an individual trained in invasive airway
techniques, whenever possible.
If the selected approach fails or is not feasible, identify an alternative invasive
intervention.
Initiate ECMO when/if appropriate and available.

27. DIFFICULT AIRWAY CART

30. RETROGRADE INTUBATION
THANK YOU

31. E FONA(EMERGENCY FRONT OF NECK ACCESS
Emergency invasive procedure to secure the airway
Surgical cricothyrotomy
Needle cricothyrotomy with jet ventilation
Tracheostomy

32. THANK YOU