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|Date of Web Publication||11-Feb-2019|
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Saurav, Singh S, Kiran S, Jaiswal A. Anaesthetic management of bilateral temporomandibular joint ankylosis with cervical spine fusion for total alloplastic joint replacement in a patient with ankylosing spondylitis. Indian J Anaesth 2019;63:148-50
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Saurav, Singh S, Kiran S, Jaiswal A. Anaesthetic management of bilateral temporomandibular joint ankylosis with cervical spine fusion for total alloplastic joint replacement in a patient with ankylosing spondylitis. Indian J Anaesth [serial online] 2019 [cited 2019 Feb 12];63:148-50. Available from: http://www.ijaweb.org/text.asp?2019/63/2/148/251972
It is not very common to manage a patient with ankylosing spondylitis (AS) and bilateral 'temporomandibular joint' (TMJ) ankylosis with cervical spine fusion to undergo alloplastic joint replacement. However, anaesthetic management of such patients in the context of difficult airway has been described. AS presents challenges to the anaesthesiologist as a consequence of potential difficult airway, cardiovascular, respiratory complications and increased risk of neurological complications. Incidence of TMJ involvement is 4–24% in AS; however, a case where bilateral TMJ ankylosis associated with cervical spine fusion and AS having undergone total alloplastic joint replacement is rare.
A 39-year-old male patient with complaint of difficulty in mouth opening for the past 18 years presented for bilateral alloplastic TMJ replacement. Airway examination revealed 6 mm of interincisor distance, grade IV Mallampati score with no lateral movement of the mandible, along with rigidity of cervical spine. Computerised tomography scan of both TMJs confirmed severe ankylosis [Figure 1]. X-ray of the cervical spine revealed fusion of the cervical spine [Figure 2]. All routine investigations including haemogram, biochemistry, chest X-ray and ECG were within normal limits. No abnormality was detected in lung function tests and arterial blood gas analysis.
|Figure 1: Three-dimensional CT scan of patient showing bilateral TMJ ankylosis|
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|Figure 2: Lateral view X-ray of neck showing cervical spine fusion|
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He was planned for general anaesthesia with awake fibreoptic nasal intubation which is the gold standard in view of restricted mouth opening and potential loss of airway under muscle relaxant. In the operation theatre, trolley for emergency surgical tracheostomy was kept ready. All standard monitoring devices were attached and the patient was pre-medicated with inj. glycopyrrolate 0.2 mg intravenous (IV) and inj. midazolam 1 mg IV. For nasal decongestion and topical anaesthesia, xylometazoline 0.05% nasal drops (3–5 drops) were instilled and nasal packing by gauze soaked in 2% lignocaine was done. Recurrent laryngeal nerve block was performed by injecting 2 ml of 4% lignocaine after piercing the cricothyroid membrane. Mild sedation for the awake fibreoptic intubation was achieved with inj. dexmedetomidine 20 μg IV and inj. ketamine 20 mg IV. After pre-oxygenation, both nasal passages were lubricated with lubricant jelly and fibreoptic bronchoscope was passed through the left nasal passage. After manipulation, epiglottis was visualised, and with spray-as-you-go technique using 4% topical lignocaine glottis was visualised. The pre-loaded flexo-metallic cuffed endotracheal tube size 7.0 mm was gently advanced over the bronchoscope. The position of the tube was confirmed by ETCO2 and the anaesthesia was induced with inj. propofol 120 mg IV and maintained on O2, N2O, isoflurane and vecuronium. Intraoperative period was uneventful. Operating on each side of his face posed a practical problem because of the rigidity of his cervical spine, which required a bodily tilt of the operating table by 15–25° on each side. Neck support was used during anaesthesia and movements of the neck in the presence of neuromuscular blockade were restricted to avoid neurological injury. Three litres of crystalloid were infused intraoperatively with a total blood loss of 350 ml. The patient was shifted to surgical intensive care unit (SICU) with endotracheal tube in situ and maintained on assisted ventilation support in view of difficult airway and risk of airway oedema. After 12 h, the trachea was extubated uneventfully in SICU over an airway exchange catheter in view of potential difficult extubation. The same precautions regarding patient positioning and neck movement were applied at emergence, as with intubation. The patient was discharged on the seventh postoperative day.
To conclude, we successfully managed a case of AS with bilateral TMJ ankylosis having cervical spine fusion undergoing alloplastic joint replacement. It is emphasised that the prime concerns of the anaesthesiologists are to maintain a patent airway and maintain immobility of cervical spine, apart from the other anaesthetic concerns during perioperative management of such patients.
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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.
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Conflicts of interest
There are no conflicts of interest.
Dave N, Sharma RK. Temporomandibular joint ankylosis in a case of ankylosing spondylitis – Anaesthetic management. Indian J Anaesth 2004;48:54-6.
[Figure 1], [Figure 2]