The temporomandibular joint (TMJ) is a hinged synovial joint formed by the mandibular condyle and glenoid fossa of the temporal bone. TMJ ankylosis is intracapsular bony fusion leading to loss of movement. This dysfunction can manifest as impaired mastication and speech, extensive caries due to inability to perform thorough oral hygiene, and, eventually, complete immobilization of the joint.1,2 The most common etiologies of TMJ ankylosis are trauma and infection, particularly osteomyelitis and otitis media, although other contributing factors include previous TMJ surgery, congenital deformity, or systemic diseases like rheumatoid arthritis and ankylosing spondylitis.2–4 TMJ ankylosis often presents in childhood, but due to improved surgical interventions and early antibiotic treatment of infections, the incidence of TMJ ankylosis in North America is low.2
TMJ ankylosis presents unique challenges for airway management. Most cases are diagnosed preoperatively, allowing for meticulous planning and optimization of patients. However, we describe an unusual case, in which a nonverbal patient with advanced dementia was scheduled for dental rehabilitation, and her presumed TMJ ankylosis remained undiagnosed until the induction of general anesthesia and unanticipated difficult intubation, ultimately leading to intraoperative case cancellation. Written Health Insurance Portability and Accountability Act authorization was obtained from the patient’s son for the publication of this case report.
An 85-year-old female with a history of diabetes, hypertension, stroke, osteoarthritis, and advanced dementia was scheduled for dental rehabilitation. The patient was living in a nursing home for more than 5 years. She was accompanied by her nursing home care provider and family, all of whom endorsed that she was nonverbal for several years and only uttered unintelligible sounds. Whenever anyone approached closely, she grimaced and moaned loudly with lips apart, but her jaws remained closed. It was uncertain if she could open her mouth, as she received her nutritional intake via a percutaneous gastrostomy tube.
Preoperative assessment of the airway, mouth, and dentition by both the surgical and anesthesia teams was unsuccessful due to the patient’s inability to follow commands. Eventually, the teams decided to proceed with the case because it was uncertain if the patient’s inability to open her mouth was due to a lack of cooperation or physical limitation.
In the operating room, after preoxygenation, general anesthesia was induced with fentanyl and etomidate. A fiberoptic bronchoscope was available in the room as a backup plan. A nasal airway was placed atraumatically in the left nare. After ensuring satisfactory mask ventilation, 30 mg rocuronium was administered. Soon after, a 7.0 nasal Ring-Adair-Elwyn endotracheal tube was inserted through the left nare. The anesthesia resident then attempted to open the patient’s mouth, which proved to be impossible. Oxygen saturation remained at 100% with continued mask ventilation. Three more unsuccessful attempts were made to open the jaw by 2 anesthesia attending physicians and the surgeon. Her mouth was firmly shut so that the tip of the laryngoscope blade could not be inserted between the incisors (Figure 1). The oral and maxillofacial surgeons were in the operating room next door, so they were consulted intraoperatively. They recommended a computed tomography scan of the airway to confirm the diagnosis of TMJ ankylosis, but the family declined.
At this juncture, the surgeon decided to cancel the case, as there would be no access to the oral cavity until surgical correction of the presumed TMJ ankylosis occurred. The patient had 2 twitches on train-of-four stimulation, so 140 mg (2 mg/kg) intravenous sugammadex was given 10 minutes after rocuronium administration. The patient’s vital signs remained stable throughout the case, and she emerged uneventfully with spontaneous breathing. She recovered in the postanesthesia care unit with a nasal airway in place and supplemental oxygen via face mask.
The anesthetic management of known TMJ ankylosis has been well documented.1,5–7 This case is an unusual presentation of undiagnosed TMJ ankylosis masked by the patient’s dementia. To our knowledge, this is the first report of presumed TMJ ankylosis discovered only after induction.
TMJ ankylosis is primarily caused by trauma and infection, and less commonly by systemic disorders like rheumatoid arthritis or congenital abnormalities.8 In patients with long-standing diabetes mellitus, glycosylation and accumulation of advanced glycation end-products in joints can lead to limited joint mobility syndrome. This syndrome is characterized by the progressive painless stiffness of hands and fingers, fixed flexion contractures of the small hand and foot joints, and impairment of fine motion and grip strength in the hands. As limited joint mobility syndrome progresses, it can also affect other joints.9 In diabetic patients, if the “prayer sign” is positive (failure to fully oppose the palmar surfaces), TMJ ankylosis should be ruled out during the anesthetic preoperative examination. In addition, our patient’s advanced dementia contributed to her inability to talk or eat. That, in turn, may have led to further disuse of her TMJ, worsening its immobility. In similar scenarios with patients with advanced dementia, stroke, psychiatric or cognitive disabilities that limit oral intake, and patients who cannot comply with a physical examination, further evaluation with a computed tomography scan and orthopantomogram should be considered.3 TMJ ankylosis symptoms include difficulty with mouth opening, speech, and mastication, causing manifestations like widespread caries, gingivitis, periodontal disease, dental calculi, and mandibular asymmetry if the ankylosis occurred in childhood before full mandibular growth. Definitive management of TMJ ankylosis requires surgical reconstruction to increase joint articulation and correct associated facial deformities.3 However, surgical intervention is associated with a risk of recurrence.10
TMJ ankylosis results in a difficult airway due to inadequate interincisor distance. Complete ankylosis is defined as an interincisor opening of <5 mm, which was true for our patient.11 Other manifestations include retrognathia and a relatively large tongue in a confined space, making laryngoscopy nearly impossible. Therefore, when direct laryngoscopy is not possible, there must be a backup plan for intubation. The backup plan can be either awake or asleep fiberoptic intubation (FOI). Topical local anesthesia or sedation can be used when performing awake FOI.5,12 When a fiberoptic bronchoscope is not available, blind nasotracheal intubation under sedation can be attempted in the adult patient.13,14 Although retrograde intubation is an alternative to FOI, it is not recommended due to increased morbidity. When awake FOI is not an option, like in young children, asleep FOI should be pursued.15 In our patient, we were able to pass a fiberoptic bronchoscope easily through the nares and visualize the vocal cords. For a different surgery with our patient, we could have avoided case cancellation by adapting our anesthetic plan to include the use of a fiberoptic bronchoscope.
Mohan et al1 discuss the case of a 12-year-old patient with documented TMJ ankylosis undergoing condylectomy and interpositional arthroplasty. The patient had an interincisor distance of 5 mm, so direct laryngoscopy was not feasible. Furthermore, the surgical team did not possess a small-size fiberoptic bronchoscope. Because condylectomy is performed via an extraoral approach, they maintained the patient on total intravenous anesthesia with spontaneous breathing via nasal cannula until the condylectomy was completed. The tracheostomy kit was ready as a backup in case the airway was lost. Afterward, they intubated the patient via direct laryngoscopy before the interpositional arthroplasty. The condylectomy was completed in 20 minutes, after which the interincisor distance increased to 25 mm, allowing them to intubate the patient with a 5.0 cuffed endotracheal tube under direct laryngoscopy.1 This case demonstrates that with adequate planning, direct laryngoscopy with intubation can be done after condylectomy if the resources to intubate using a fiberoptic bronchoscope are unavailable. However, a tracheostomy kit and otolaryngology backup should always be ready for possible emergencies.
Our case is an example of how an undiagnosed condition can lead to unavoidable intraoperative case cancellation. The dental surgeon was unable to anticipate the difficulty of accessing the surgical field before scheduling the surgery, given the patient’s inability to follow commands due to her advanced dementia. Anesthesiologists should consider possible undiagnosed ankylosis if the patient is nonverbal, has limited communication abilities, has no oral intake, or does not separate the jaws when groaning or crying. If the surgeon is unable to perform a clinical examination before surgery due to a patient’s physical or cognitive limitations, imaging studies or an evaluation ahead of time by the anesthesiology team are indicated to diagnose and treat TMJ ankylosis.
In patients with limited mouth opening scheduled for oral and maxillofacial surgery, nasotracheal intubation with traditional laryngoscopy or video laryngoscopy may be difficult, if not impossible. We present a unique case of undiagnosed TMJ ankylosis, in which the patient’s presentation can be attributed to the consequences of advanced dementia. Our case highlights the need for the anesthesiologist to recognize signs of undiagnosed TMJ ankylosis and prepare for potential FOI in patients with limited mouth opening.
The authors would like to thank Alex Bekker, MD, PhD, Chair of the Department of Anesthesia at Rutgers New Jersey Medical School, for his helpful feedback.
Name: Parisorn Thepmankorn, BS.
Contribution: This author helped revise and rewrite the manuscript.
Name: Mahir A. Sufian, BS.
Contribution: This author helped review the literature and write the manuscript.
Name: Omar Singer, BS.
Contribution: This author helped review the literature and write the manuscript.
Name: Somdatta Gupta, MD.
Contribution: This author helped present a poster at a conference and edit the manuscript, and was the resident anesthesiologist who conducted the case.
Name: Dennis Grech, DO.
Contribution: This author helped review and edit the manuscript, and aided during the case.
Name: Tomas Ballesteros, DDS.
Contribution: This author helped review and edit the manuscript, and was the attending dental surgeon for the case.
Name: Shridevi Pandya Shah, MD, FASA.
Contribution: This author helped submit a poster, edit the manuscript, and create the report, and was the attending anesthesiologist for the case.
This manuscript was handled by: BobbieJean Sweitzer, MD, FACP.
1. Mohan K, Mohana-Rupa L, Gopala Krishna Murthy S, Greeshma P, Bhavana U. Anaesthesia for TMJ ankylosis with the use of TIVA, followed by endotracheal intubation. J Clin Diagn Res. 2012;6:1765–1767.
2. Chidzonga M. Temporomandibular joint ankylosis: review of thirty-two cases. Br J Oral Maxillofac Surg. 1999;37:123–126.
3. Movahed R, Mercuri L. Management of temporomandibular joint ankylosis. Oral Maxillofac Surg Clin North Am. 2015;27:687–692.
4. Izumi Y, Kino K, Ohmura Y, Wake H, Shibuya T, Amagasa T. Clinico-statistical study of temporomandibular joint ankylosis. JSTMJ. 1994;6:346–359.
5. Kang J, Lee K, Kim D, Yi J. Airway management of an ankylosing spondylitis patient with severe temporomandibular joint ankylosis and impossible mouth opening. Korean J Anesthesiol. 2013;64:84–86.
6. Sankar D, Krishnan R, Veerabahu M, Vikraman B, Nathan J. Retrospective evaluation of airway management with blind awake intubation in temporomandibular joint ankylosis patients: a review of 48 cases. Ann Maxillofac Surg. 2016;6:54–57.
7. Vitkovic B, Milic M, Filipan D, Dediol E. Rigid fiber-optic device intubation in a child with temporomandibular joint ankylosis. J Craniofac Surg. 2020;31:e193–e194.
8. Kobayashi R, Utsunomiya T, Yamamoto H, Nagura H. Ankylosis of the temporomandibular joint caused by rheumatoid arthritis: a pathological study and review. J Oral Sci. 2001;43:97–101.
9. Stanaway S, Gill G. Protein glycosylation in diabetes mellitus: biochemical and clinical considerations. Pract Diabetes Int. 2000;17:21–24.
10. Partyka L. Goldenhar syndrome with ankylosis of the temporomandibular joint: a case report. A A Pract. 2021;15:e01461.
11. Arakeri G, Kusanale A, Zaki G, Brennan P. Pathogenesis of post-traumatic ankylosis of the temporomandibular joint: a critical review. Br J Oral Maxillofac Surg. 2012;50:8–12.
12. Tsukamoto M, Hitosugi T, Yokoyama T. Awake fiberoptic nasotracheal intubation for patients with difficult airway. J Dent Anesth Pain Med. 2018;18:301–304.
13. Dhasmana S, Singh V, Pal U. Awake blind nasotracheal intubation in temporomandibular joint ankylosis patients under conscious sedation using fentanyl and midazolam. J Maxillofac Oral Surg. 2010;9:377–381.
14. Zemedkun A, Angasa D, Gobena N, Regasa T. Blind nasal intubation as an alternative airway management modality for bilateral temporomandibular joint ankylosis in a resource constrained set-up: a clinical case report. Int J Surg Open. 2022;42:100467.
15. Goswami D, Singh S, Bhutia O, Baidya D, Sawhney C. Management of young patients with temporomandibular joint ankylosis—a surgical and anesthetic challenge. Review Paper. Indian J Surg. 2016;78:482–489.