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Summary:

Keywords:

Temporomandibular joint ankylosis (TMJ) is always a challenge to intubate. We successfully carried out endotracheal

intubation in a 12 yr oldpatient whowas postedfor corrective surgery using retrograde intubation technique.

retrogradeintubation, TMJ ankylosis, guidewire,difficult intubation

Introduction

Casereport:

Authors& Correspondence

:

The establishment of an airway by orotracheal

intubation in TMJAnkylosis is always a challenge to the

anaesthesiologist. A number of techniques are followed

for intubation like blind nasal intubation, retrograde

intubation using a guide wire, fibreoptic laryngoscopy

and finally tracheostomy. We followed retrograde

intubation using flexible J tippedguidewire.

A 12 yr, ASA grade I, male child, weighing 22 kg was

our patient. Parents gave history of inability to open his

mouth since birth. He was diagnosed as a case of B/L

T MJ a n ky l os i s a n d w as t o u n de rg o B / L

osteoarthrotomy. His neck mobility was normal. We

planned for retrograde intubation technique using

flexible J-tipped guidewire.

The procedure and the possibility of resorting to

tracheostomy was explained in their native language

and consent was taken from parents. IV line secured

using 20G IV cannula in right arm. Monitors used werepulseoximeter, ECG,NIBPand capnography.

Pre-op 45 min prior to the procedure i.m atropine

0.6mg wasgiven. Xylometazoline nasal drops instilled.

Topical 10% xylocaine sprayed into the mouth. Inj

midazolam 0.5mg IV given. Inj propofol (25mg) IV

given initially and then intermittently 10mg IV was

given. B/L superior laryngeal nerves blocked using 1%

lidocaine 2ml on each side was given. Airway reflexes

were additionally blunted by instilling 4% lidocaine

into trachea via 24G needle which was introduced into

trachea through the cricothyroid puncture.Under strict asepsis, 18G Tuohy epidural needle was

used to puncture the trachea around 2-3 cm below the

cricothyroid membrane with the needle directing upwards.

Prof.&Head*

Asst.Prof.

Assoc.Prof

Prof.&Head(DepartmentofPlasticSurgery)

PostGraduatestudent

Departmentof Anaesthesiology,KLE

University'sJ.N.MedicalCollege&KLESDr.

PrabhakarKoreHospital,Belgaum

* Dr.CSSanikop:09448863688

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RetrogradeIntubationinTemperomandibularJointAnkylosisDr.C.S.Sanikop ;Dr.Manjunath.C.Patil ;DrRajesh.S.Mane ;Dr.RajeshPowar ,Dr.TaraNandan

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Through this the flexible J tipped guide wire was

passed whichnegotiated the curved pathway afterthree

attempts and came out of the nostril. The whole

procedurewasvisualizedusing fluoroscope.

The tuohy needle was then removed keeping the

guide wire intact. No.6 COETT was passed through the

guide wire. The guide wire was then removed and tube

passed further down. IPPV was started manually and

tube position confirmed by auscultating the chest and

monitoring EtCO2. We gave vecuronium and propofol.

Anaesthesia maintained with IPPV by O +N O+

Halothane 0.5%- 1%. At the end of surgery mouthopening was two fingers. Residual neuromuscular

block was reversed. Extubation was done when patient

was awake, responding to oral commands and airway

reflexes were present. The subsequent recovery was

uneventful.

In our patient conventional intubation of the trachea

was impossible. In cases of difficult airway, there are a

number of other options like awake intubation, blind

nasal intubation, intubation using a fibreoptic

laryngoscope, using LMA, oesophageal trachealCombi-tube, tracheal jet ventilation, the use of McCoy

laryngoscope, the use of light wand, retrograde

intubation and tracheostomy.

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Discussion:

Fig1:TMJankylosis

inthepatient

Fig2:showing18GTuohyneedle

puncturingthetrachea

Fig3.fluoroscopicimageshowingthe'J'tippedguidewirenegotiatingthenasopharynx

(theimagehasbeenmodifiedtohighlighttheguidewire.).

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In our pediatric patient we opted for retrograde

intubation as awake intubation or blind nasal

intubation would be difficult (pt may not co-operate).

The term retrograde intubation refers to a technique in

which a guide wire is passed into the trachea and then

into the mouth or nose. A tracheal tube is then passed

down over the guide until it enters the trachea. This

technique was first described by Butler and Cirillo in1960.

Blind nasal carries a risk of nasal bleeding and is not

alwayssuccessful, LMAwas notpossible to insert in our

case due to limitation of the mouth opening. Fibreoptic

intubation requires considerable experience before it is

used in difficult cases. Tracheostomy also carries many

risks particularlyin theabsence of a tracheal tube.

The retrograde method has been used successfully in

many patients even in infants and the technique proved

to be straightforward method of tracheal intubation in

our patient. Although there are some complicationsmentioned in the literature like bleeding from the nose

or from the site of cricothyrotomy, minimal

subcutaneous emphysema, infections like pretracheal

abscess, airway trauma,we have not encountered any

complications in our case. Thus, even in an emergency

scenario retrograde nasal intubation could be a suitable

alternative.

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References:

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2. Williamson R. The airway decides the anaesthetic approachbefore trachealintubation.Br.J. Anaesth1993;70: 601.

3. Waters DJ. Guided blind endotracheal intubation: for patientswithdeformitiesof theupper airway. Anaesthesia 1963; 18:158-62.

4. Van Stralen DW, Rogers M, Perkin RM, FeaS. Retrograde intubation

trainingusinga mannequin. Am J Emerg Med1995;13:50-2.5. HarrisonW, BertrandM, AndewegS, Clark J. Retrograde intubation

around an in situ Combitube: A difficult airway managementstrategy. Anesthesiology 2005; 102:1061-2.

6. Gill M, Madden MJ, Green SM. Retrograde endotrachealintubation: An investigation of indications, complications, andpatientoutcomes. Am J Emerg Med2005; 23:123-6.