Anesthetic considerations for masticatory muscle tendon-aponeurosis hyperplasia: a report of 24 cases

Masticatory muscle tendon-aponeurosis hyperplasia (MMTAH) is a new disease entity characterized by limited mouth opening due to contracture of the masticatory muscles, resulting from hyperplasia of tendons and aponeuroses. In this case series, we report what methods of airway establishment were conclusively chosen after rapid induction of anesthesia. We had 24 consecutive patients with MMTAH who underwent surgical release of its contracture under general anesthesia. Rapid induction of anesthesia with propofol and rocuronium was chosen for all the cases. In 7 cases, intubation using the Macintosh laryngoscopy was attempted; however, 2 of those cases failed to be intubated on the first attempt. Finally, intubation using the McCoy laryngoscopy or fiber-optic intubation was alternatively used in these 2 cases. In 7 cases, the Trachlight was used. In the remaining 10 cases, fiber-optic intubation was used. Limited mouth opening in patients with MMTAH did not improve with muscular relaxation. "Square mandible" has been reported to be one of the clinical features in this disease; however, half of these 24 patients lacked this characteristic, which might affect a definitive diagnosis of this disease for anesthesiologists. An airway problem in patients with MMTAH should not be underestimated, which means that other intubation methods rather than direct laryngoscopy had better be considered.     

Masticatory muscle tendon-aponeurosis hyperplasia diagnosed as temporomandibular joint disorder: A case report and review of literature

IntroductionMasticatory muscle tendon-aponeurosis hyperplasia (MMTAH) is a new clinical entity that presents mainly with trismus due to hyperplasia of the masseter aponeurosis and temporalis muscle tendon. However, the etiological factors of this disease are unknown; it is often mistreated as temporomandibular joint disorder (TMD).Presentation of caseWe report a 32-year-old female patient complaining of bilateral pain in her jaw and difficulty opening her mouth. She was first diagnosed as TMD and treated with a splint; however, her symptoms did not improve. Clinical examination revealed a square mandible, tenderness in the left and right temporalis muscles and masseter muscles, and tenderness along the anterior border of the masseter muscle. Her maximum mouth-opening was 30 mm. Short TI inversion recovery magnetic resonance imaging showed areas of low intensity at the anterior border of the masseter muscle and around the coronoid process where the temporalis muscle tendon attaches. Consequently, the diagnosis made based on the clinical and radiographic findings was MMTAH. Bilateral coronoidectomy was performed, followed by a rehabilitation program for six months. The maximum opening was maintained at 48 mm two years after the operation.DiscussionMMTAH was treated as type 1 TMD until it was recognized as a new disease at the conference for the Japanese Society for Oral and Maxillofacial Surgeons. Since then, many clinicians have become aware of this particular condition, and different treatment modalities have been proposed.ConclusionClinicians should consider MMTAH as a differential diagnosis when the patient’s chief complaint is gradually decreasing mouth-opening.     

Transzygomatic coronoidectomy as a treatment for pseudoankylosis of the mandible after transtemporal surgery

Pseudoankylosis of the mandible after a transtemporal operation is rare. In patients with severely limited mouth opening, a transzygomatic approach is the approach of choice. We report a case of pseudoankylosis of the mandible that was successfully treated by transzygomatic coronoidectomy.     

Anaesthetic management of two paediatric patients with Hecht–Beals syndrome

We undertook the anaesthetic management of two children with Hecht-Beals syndrome for orthopaedic surgery under general anaesthesia. Both patients had arachnodactyly, kyphoscoliosis, and multiple congenital joint contractures, but limited mandible excursion was not obvious preoperatively in either, although mental retardation made it difficult for them to cooperate with mouth examination. They had no apparent difficulties with their mouths in daily activities. The anaesthesia records of one patient showed that intubation had been difficult in an earlier procedure. The other patient also had a history of difficult intubation, with slight tearing of the corners of her mouth during an intubation procedure. During slow induction of general anaesthesia with sevoflurane, face mask ventilation was easily performed. We attempted to visualize the larynx under anaesthesia with muscle relaxation, but we were unsuccessful because of the limited mouth opening. After several trials, blind oral intubations were fortunately successful in both patients. There were no postoperative problems with the airway.     

Surgical correction of trismus in a child with Hecht syndrome

Hecht syndrome is a rare condition that is also known as trismus pseudocamptodactyly syndrome. Short muscle and tendon units limiting the range of motion of upper and lower extremities and mouth characterize this disorder of muscle development. There is no consensus on the optimal treatment of temporomandibular joint (TMJ) ankylosis in this patient population. Endoscopic release in one patient resulted in early postoperative recurrence. The authors present a 28-month old boy who had a limited mouth opening of 6 mm. CT scan showed no bony ankylosis. The range of mouth opening did not to improve with physical therapy. The patient underwent extensive subperiosteal dissection of the mandible, bilateral coronoidectomy, and TMJ exploration. An intraoperative opening of 18 mm was achieved. The patient remained intubated until postoperative swelling resolved. He was extubated in the operating room 6 days later. The patient continued to improve with physical therapy. He had a 25-mm mouth opening at 12 months of follow-up.     

Long-term follow-up after arthroplasty for pediatric temporomandibular joint ankylosis performed before the critical period of mandibular growth: A case report

Introduction and importancePediatric temporomandibular joint (TMJ) ankylosis can lead to significant difficulties in opening the mouth, as well as stunted mandibular growth resulting in a small mandible and facial asymmetry. For pediatric TMJ ankylosis, the ideal time to perform TMJ mobilization in order to achieve standard mandibular growth is unclear.Case presentationAn 11-year-old boy with limited mouth opening was referred to our hospital. The patient had previously sustained a fracture of the left articular process of the mandible. Clinical examination revealed bony ankylosis of the left TMJ, and the condylar head was dislocated anteromedially. The bony ankylosis was removed at the age of 12 years. Mouth-opening exercises were started postoperatively. His mouth opening recovered without the development of severe facial asymmetry, and the dislocated condylar process served as a new joint and provided good jaw function until the most recent follow-up at the age of 21 years.Clinical discussionIt is practical to perform surgical intervention after the child has achieved some growth and at a time when the surgery would not interfere with jaw development because the mouth opening can be improved by postoperative physical therapy. No interpositional implant was used because strict postoperative mouth opening exercises and the displaced condylar process, which was maintained to almost normal TMJ structure, were expected to preserve the gap between the ramus and the zygomatic arch.ConclusionSurgical intervention in the appropriate growth period is important to prevent the sequelae of mandibular growth suppression due to pediatric TMJ ankylosis.     

A rare cause of difficult intratracheal intubation: Langenbeck's disease]

A case of difficult tracheal intubation due to insufficient mouth opening once anaesthesia had been induced is described. At the pre-anaesthetic visit, the 47-year-old female patient had painless restricted mouth opening (two fingers' breadth), dental malpositions, and slight lateral mandibular deviation. Cervical spine movements were normal. She was ranked 3 on the Mallampati scale. The anaesthetic technique preserved spontaneous breathing (induction with propofol 1.5 mg.kg-1 and alfentanil 15 micrograms.kg-1). Manual ventilation was impossible. An oral cannula could not be inserted. As intubation by the normal route was impossible, the retromolar approach had to be used. Several attempts were required for successful intubation by this route. At the end of surgery, the patient was extubated without any difficulties. Postoperative investigations revealed hypertrophic coronoid processes. In this condition, the mandible is jammed by hitting the maxilla, especially when mandibular lifting manoeuvres are used to facilitate manual ventilation and tracheal intubation. Clinical and paraclinical predictors of difficult tracheal intubation seem to be unreliable in such dynamic abnormalities of mouth opening.     

Unexpected difficult intubation in a patient with normal airway on assessment.

Routine preoperative assessment of the patient's airway includes an assessment of mouth opening and a grading of the view according to the Mallampati scale. This is carried out with the patient sitting and actively opening the mouth without phonation. This case report illustrates that the temporomandibular joint is a complex joint and that certain pathologies may prevent passive depression of the mandible after induction of anaesthesia.     

Awake tracheal intubation through the intubating laryngeal mask

PURPOSE: To report successful awake insertion of the intubating laryngeal mask (Fastrach) and subsequent tracheal intubation through it, in a patient with predicted difficult tracheal intubation, due to limited mouth opening, and difficult ventilation through a facemask, due to a large mass at the corner of the mouth. CLINICAL FEATURES: A 53-yr-old woman with a large post-gangrenous mass on the right cheek to the angle of the mouth was scheduled for its resection. The right side of her face was damaged by a bomb attack followed by cancrum oris 50 yr ago. The distance between the incisors during maximum mouth opening was 2 cm and that between the gums on the right side < 1 cm. After preoxygenation and 50 micrograms fentanyl and 30 mg propofol i.v., propofol was infused at 2 mg.kg-1.hr-1. Lidocaine, 8%, was sprayed on the oropharynx. A #4 intubating laryngeal mask was inserted with a little difficulty. A fibrescope was passed through a 7.5-mm ID RAE tracheal tube, and the combination was easily passed through the laryngeal mask into the trachea. General ansthesia was then induced. Finally, the intubating laryngeal mask was removed, while the RAE tube was being stabilized using an uncuffed 6.0-mm ID tracheal tube. CONCLUSION: Awake tracheal intubation through the intubating laryngeal mask is a useful technique in patients with limited mouth opening in whom ventilation via a facemask is expected to be difficult.     

Micrognathia with temporomandibular joint ankylosis and obstructive sleep apnea treated with mandibular distraction osteogenesis using skeletal anchorage: a case report

Background

We describe the case of a 16-year-old female patient with micrognathia, temporomandibular joint (TMJ) ankylosis, and obstructive sleep apnea, who was treated with mandibular distraction osteogenesis (DO) combined with sliding genioplasty, using skeletal anchorage.

Case presentation

We first performed interpositional arthroplasty, in which an interposition of fascia temporalis and surrounding fat tissue was inserted into the defect after bilateral condylectomy, increasing the maximum mouth opening from 5.0 to 32.0 mm. Subsequently, orthodontic treatment and advancement of the mandible were carried out by mandibular DO, using miniscrews and miniplates. Finally, sliding genioplasty was performed to bring the tip of the mandible forward. The total amount of mandibular advancement at the menton was 16.0 mm. An improved facial appearance and good occlusion were eventually achieved, and the apnea-hypopnea index decreased from 37.1 to 8.7. There was no obvious bone resorption or pain in the temporomandibular region, limited mouth opening (maximum mouth opening: 33.0 mm), myofascial pain or headache, downward rotation of the mandible, or lateral shift of mandibular position evident at 5 years and 6 months after mandibular DO.

Conclusion

Mandibular DO using skeletal anchorage with intermaxillary elastics is useful for preventing extrusion of the upper and lower anterior teeth, thereby preventing rotation of the mandible. In addition, mandibular DO combined with sliding genioplasty is effective at improving both dentofacial deformities and impaired respiratory function.

     

Regional anesthesia with a single spinal anesthesia using hyperbaric bupivacaine in a child with arthroglyposis multiplex congenita

Arthrogryposis multiplex congenita (AMC) consists of complex congenital anomalies characterized by multiple contractures. Anesthetic management of these patients requires special care: as this disease often progresses until dysfunction of multiple organ systems occur, it may have an impact on the anesthetic management. Here, we report a case of AMC undergoing urgent surgery for open tibia fracture who had difficult airway management because of limited mouth opening. The anesthetic management of this patient is represented in light of the literature.     

Mouth opening in relation to the craniocervical position during induction of general anesthesia

BACKGROUND: Decreased mouth opening and limited neck mobility sometimes make direct laryngoscopy or tracheal intubation difficult and compromise the safety in establishing the airway during induction of general anesthesia. Recent report indicated that mouth opening was related to the craniocervical position in awake subjects. The query about whether the neck position modulate the mouth opening during anesthetic induction under paralyzed condition is not clarified. We hypothesized that the neck extension and the flexion induce changes in inter-incisor distance (IID) during anesthetic induction. METHODS: Thirty relatively young patients for general anesthesia were (male; 20, female; 10) subjected. IID was measured with his/her neck positioned flexed, neutral and extended in the sagittal plane, each at preanesthetic awake period, and during anesthetic induction period. The effect of sniffing position on the mouth opening was also studied. RESULTS: At preanesthetic period, IID (mean +/- SD in mm) at neck flexion (37.4 +/- 7.8) was significantly shorter than both at neutral (44.1 +/- 7.5) and at extension (47.4 +/- 7.0). During induction, significant increase in IID was observed as patients' neck position changed from flexed (31.8 +/- 5.4) to neutral (36.6 +/- 5.4), and extended, (41.7 +/- 8.3). Sniffing position did not affect the mouth opening both at preanesthetic and during anesthetic induction period. CONCLUSIONS: Craniocervical extension may play a desirable role in the airway management with mouth opening widely during anesthetic induction under neuromuscular blockade.     

Prediction of difficult tracheal intubation in Turkish patients: a multi-center methodological study

BACKGROUND AND OBJECTIVE: Preoperative evaluation is important in the detection of patients at risk for difficult airway management. It is still unclear whether true prediction is possible and which variables should be chosen for evaluation. The aim of this prospective, multi-centre study was to investigate the incidence of difficult intubation, the sensitivity and positive predictive values of clinical screening tests and whether combining two or more of these tests will improve the prediction of difficult intubation in Turkish patients. METHODS: Seven study sites from six regions in Turkey participated in this study. One thousand six hundred and seventy-four ASA physical status I-III patients, scheduled to undergo elective surgery under general anaesthesia, were included. RESULTS: The incidence of difficult intubation was 4.8% and increased with age (P < 0.05). The incidence of difficult intubation was significantly higher in patients who had a Mallampati III or IV score, a decreased average thyromental and sternomental distance, decreased mouth opening, or decreased protrusion of the mandible (P < 0.05). Mouth opening and Mallampati III-IV were found to be the most sensitive criteria when used alone (43% and 35%, respectively). Combination of tests did not improve these results. CONCLUSIONS: There is still no individual test or a combination of tests that predict difficult intubations accurately. Tests with higher specificity despite low positive predictive value are needed.     

Sublingual ultrasound as an assessment method for predicting difficult intubation: a pilot study

Current methods to assess the airway before tracheal intubation are variable in their ability to predict a difficult airway accurately. We hypothesised that sublingual ultrasound could provide additional information to predict a difficult airway with greater success than current methods. We recruited 110 patients to perform sublingual ultrasound on themselves following brief instruction. Ability to view the hyoid bone on sublingual ultrasound, mouth opening distance, thyromental distance, neck mobility, size of mandible and modified Mallampati classification were recorded and assessed for ability to predict a difficult intubation based on the grade of laryngoscope. Visibility of the hyoid using ultrasound was associated with a laryngoscopic grade of 1–2 (p < 0.0001), and (p < 0.0001) had a positive likelihood ratio of 21.6 and a negative likelihood ratio of 0.28. Each of the other methods had considerably lower positive likelihood ratios and lower sensitivity. Our results suggest that sublingual ultrasound is a potential tool for predicting a difficult airway in addition to conventional methods.     

Congenital fusion of the maxilla and mandible: brief case report.

Congenital fusion of the mandible and maxilla is a rare anomaly usually seen in association with various syndromes. Reports of isolated cases of bony fusion of the jaws are sparse. Only 10 reported cases were found in the literature search. Maxillomandibular fusion restricts mouth opening, causing feeding problems and difficulties in swallowing, respiration, growth, and development, and thus must be treated early. We report a case of congenital fusion of the mandible and maxilla in a 1-year-old boy and describe the clinical features of this anomaly to add to the existing literature on the subject. This is our second encounter of such a case.     

Endoscopically assisted removal of unilateral coronoid process hyperplasia

Coronoid process hyperplasia (CPH) is an uncommon disorder characterized by an enlarged coronoid process impinging against the posterior aspect of the zygomatic arch. Young male adults are usually affected, presenting with limited mouth opening, which is typically painless and progressive in nature. The diagnosis of true CPH is established by the findings of (1) uniform coronoid enlargement on radiographic examination and (2) normal bone structure on histopathological examination (i.e., the specimen should be free of any neoplastic growth, such as the previously reported cases of coronoid osteomas, osteochondromas, or exostoses). The treatment is mainly surgical, by means of a coronoidectomy. An intraoral approach is mostly preferred for this procedure to avoid an external scar. However, to avoid the drawbacks of this approach, such as limited exposure and the risk of hematoma and subsequent fibrosis, an extraoral approach may be indicated. This report describes a case of true unilateral CPH in a 17-year-old boy who presented with progressive limited mouth opening in the absence of any pain. Computed tomography (CT) demonstrated a uniformly enlarged right coronoid process. A coronoidectomy was performed with the aid of endoscopic systems, approaching via two short incisions in the temporal scalp. Histopathological examination of the specimen demonstrated essentially a normal bony structure with no evidence of a neoplasm. The authors present the endoscopically assisted technique of coronoid process excision as an alternative method of surgical treatment of CPH and any mass of the coronoid process in general. With this method, the incision is much shorter than a conventional coronal incision and thus morbidity is diminished considerably.     

The Shikani Optical Stylet: a useful adjunct to airway management in a neonate with popliteal pterygium syndrome

The craniofacial abnormalities of popliteal pterygium syndrome present unique challenges to the pediatric anesthetist. Congenital fibrous bands between the maxilla and mandible limit mouth opening and the tongue may be fused to the palate. We describe the use of the Shikani Optical Stylet, a novel fiberoptic endoscope, in the airway management of a neonate with popliteal pterygium syndrome and syngnathia.     

Difficult laryngoscopy: incidence and predictors in patients undergoing coronary artery bypass surgery versus general surgery patients

OBJECTIVE: Cardiac surgery patients might have a higher incidence of difficult laryngoscopy than the general population because of older age, dental problems, and obesity. The authors estimated the incidence and predictors of difficult laryngoscopy in coronary artery bypass surgery patients. DESIGN: Prospective, controlled study. SETTING: University setting. PARTICIPANTS: Patients undergoing coronary artery bypass or general surgery. INTERVENTIONS: Two hundred consecutive patients undergoing coronary artery bypass graft and 444 general surgery patients, all aged >40 years, were compared for the incidence and predictors of difficult laryngoscopy, defined as a grade III or IV view. MEASUREMENTS AND MAIN RESULTS: Predictors of difficult laryngoscopy were considered mouth opening <4 cm, limited cervical mobility, thyromental distance <6 cm, protruding or partially missing upper teeth, and Mallampati classes 3 and 4. More cases of difficult laryngoscopy were recorded in cardiac patients (10% v 5.2%, p <0.023). The cardiac patients were older, mostly men, and belonged to ASA III-IV risk classes. Mallampati classes 3 and 4 were more frequent in the control group. With univariate analysis, difficult laryngoscopy correlated with 7 variables: older age, ASA-IV risk class, protruding or partially missing upper teeth, limited mouth opening, limited neck movement, thyromental distance <6 cm, and diabetes mellitus. Multivariate analysis adjusted for propensity score identified older age (odds ratio = 1.05/yr, 95% confidence interval = 1.005-1.09, p < 0.03) and limited neck movement (odds ratio = 9.5, 95% confidence interval = 2.2-41, p < 0.003), but not cardiac surgery per se, as independent predictors of difficult laryngoscopy. CONCLUSIONS: Difficult laryngoscopy was more frequent in cardiac surgery patients (10% v 5.2%). Older age and limited neck movement, but not cardiac surgery per se, were independent predictors of difficult laryngoscopy.     

Congenital alveolar adhesions.

We report an infant girl with congenital alveolar adhesions and a cleft palate. The mucosal bands were resected the day after birth. Stretching exercises of the mandible improved the range of movement at the temporomandibular joint. Two weeks of therapy were required before full mouth opening was possible. Previously reported patients and theories of embryogenesis are reviewed.     

Difficult tracheal intubation in paediatric: myth or reality?

Difficult tracheal intubation is a rare event according to the airway feature in child. This situation is mostly predictable, occurring in identified malformations and in specific diseases. Pre-operative clinical evaluation must detect facial abnormalities (lip or palate cleft, microtia, facial asymmetry.), micro or retrognathia, limited mouth opening, reduced distance between thyroid cartilage and chin, macroglossia and external ear malformations. According to this clinical evaluation, a strategy for managing difficult tracheal intubation is planned.