Airway management of an ankylosing spondylitis patient with severe temporomandibular joint ankylosis and impossible mouth opening

Corresponding author: Jae-Woo Yi, M.D., Ph.D., Department of Anesthesiology and Pain Medicine, Kyung Hee University Hospital at Gangdong, College of Medicine, Kyung Hee University, 149, Sangil-dong, Gangdong-gu, Seoul 134-727, Korea. Tel: 82-2-440-6192, Fax: 82-2440-7808, E-mail: [email protected] This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. CC In most cases of surgery requiring general anesthesia, airway management and endotracheal intubation are important procedures that must take place. However, when a patient has ankylosing spondylitis (AS) involving the cervical spine in addition to a temporomandibular joint ankylosis (TMJA), head manipulation is difficult to perform. Also, when a patient has limited mouth opening or is unable to open the mouth altogether, airway management and endotracheal intubation are significantly difficult. We experienced the case of an AS patient who was completely unable to open the mouth due to TMJA, admitted for osteotomy and osteoplasty under general anesthesia. A 34-year-old man (44.7 kg, 132.7 cm) with TMJA was admitted to the Oral and Maxillofacial Surgery Department to receive surgery for the mouth opening disorder. The patient was scheduled to receive corrective surgery for the secondary spinal transformation due to AS and had severe kyphosis in the thoracic and lumbar spine due to complete AS (Fig. 1A). In 1997, the patient underwent a cervical spine u-bar insertion and temporomandibular joint surgery at Cedars-Sinai Medical Center, US. (Fig. 1B). A tracheostomy was also performed which left the patient with a surgical scar on his left neck. At the time of the surgery in 1997, the mouth opening was about 25 mm but several years following the procedure, abnormal coronoid process hypertrophy and TMJA (Fig. 1C) developed. For more than 10 years following the disease development, the patient could not tolerate a solid diet but only a liquid diet such as milk or soy milk. When the patient was finally assessed during this admission, his ability to open his mouth was completely impossible (Fig. 1D). An anesthetic induction was performed by an anesthesiologist with over 200 awake fiberoptic bronchoscopic intubation experiences. Glycopyrrolate 0.2 mg was given as premedication, and 4% lidocaine was injected trans-tracheally to anaesthetise the trachea. To prevent bleeding from the nasal cavity, gauze soaked with 0.1% epinephrine for 15 minutes was packed in the nasal cavity then, a lubricated 5 mm diameter fiberoptic bronchoscope (LF-TP, Olympus Optical Company, Tokyo, Japan) was passed through the right nostril to confirm the airway. After spraying 4 ml of 4% lidocaine on the vocal cord for 15 seconds, the end of the fiberoptic bronchoscope was passed through the vocal cords, and positioned between the vocal cords and carina. Afterwards, an endotracheal tube was placed. After confirming endotracheal intubation, anesthetic induction was conducted using propofol 90 mg and rocuronium 50 mg. Although the tracheostomy was expected to be difficult due to the limited cervical spine movement and the history of tracheostomy, a tracheostomy set and a jet ventilator were prepared to cope with the emergency situation in airway control during the whole procedure. For anesthesia maintenance, 2% propofol and remifentanil were administered using a computer-controlled infusion pump