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Progressive mandibular midline deviation after difficult tracheal intubation

Progressive mandibular midline deviation after difficult trachealintubation J. Mareque Bueno,1,2 M. Fernandez-Barriales,3 M. A. Morey-Mas4,5 and F. Hernandez-Alfaro6,7 1 Associate Professor, 6 Professor, Department of Oral and Maxillofacial Surgery, Universitat Internacional deCatalunya, Barcelona, Spain2 Staff, 3 Visiting Resident, 7 Director, Institute of Maxillofacial Surgery, Teknon Medical Center, Barcelona, Spain4 Staff, Department of Oral and Maxillofacial Surgery, Hospital Son Dureta, Palma de Mallorca, Illes Balears, Spain5 Associate Professor, Especialidad Universitaria en Implantologıa Oral, Universitat des Illes Balears, Illes Balears,Spain SummaryWe report condylar resorption of the temporomandibular joint after difficult intubation, leading to progressivemidline mandibular deviation, subsequently treated by prosthetic joint replacement.
Correspondence to: M. Fernandez-BarrialesEmail: marcosfbarriales@gmail.comAccepted: 19 March 2013 Forces applied during difficult tracheal intubations can Following induction of anaesthesia and neuromus- cause oedema, bleeding, tracheal and oesophageal per- cular blockade, laryngoscopy with a Macintosh blade foration, pneumothorax or aspiration. Resorption of (size 3) permitted revealed a poor laryngeal view the temporomandibular joint has not been associated (Cormack-Lehane score 2–3) and there were three unsuccessful tracheal intubation attempts. Intubationwith a tube reinforced by a stylet was achieved after changing to a Miller (size 2) laryngoscope blade.
Urgent laparotomy was deemed necessary in a 52- The patient complained of right temporomandibu- year-old woman due to rapid clinical deterioration and lar joint pain from the first postoperative day, followed suspected anastomotic leak of a Roux-en-Y gastric by progressive chin displacement and malocclusion.
bypass. Pre-operative examination demonstrated pain- Four months later, physical examination revealed less interincisal opening of 4.5 cm without mandibu- marked deviation of the mandible to the right with lar deviation, a thyromental distance of 6.5 cm, and severe malocclusion, right cross bite and left scissor′s a Mallampati score of 2. A previous laryngeal view bite (Fig. 1). Magnetic resonance imaging showed (Cormack-Lehane grade 1) and orotracheal intubation extensive condylar resorption and diminished right had been uneventful. She was treated for hypertension, temporomandibular joint space without significant hypothyroidism and anxiety-depressive disorder. She findings on the left. Similar findings without apparent had no record of temporomandibular joint pain or fracture lines were reported on CT scan. No rheuma- tological conditions were reported upon specialised Anaesthesia 2013 The Association of Anaesthetists of Great Britain and Ireland Mareque Bueno et al. | Progressive mandibular midline deviation after intubation and oesophageal perforation, pneumothorax and aspi-ration [1]. The rate of dental injuries following trachealintubation is approximately 1:4500 [2]. To our knowl-edge, there are no previous reports on progressive con-dylar resorption, chin deviation and malocclusion.
‘Idiopathic condylar resorption’ is a progressive decrease in condylar mass and change in shape, whichoccurs most frequently in women between 15 and35 years of age [3, 4]. Factors associated with anincreased incidence of condylar resorption includeinfectious, autoimmune, endocrine and cardiovasculardiseases, nutritional and metabolic disorders, andtrauma [5–10]. Our patient had nutritional and endo- Figure 1 Deviation of the mandible to the right and crine disorders associated with obesity, as well as malocclusion, with right cross bite and left scissor’s trauma during four intubation attempts. Of these three factors, forceful laryngoscopy might best explain theimmediate postoperative pain and progressive mandib-ular deviation.
Idiopathic condylar resorption should be consid- ered in patients suffering severe temporomandibularjoint pain, malocclusion and mandibular midline devi-ation following forced laryngoscopy or other manoeu-vres. Computed tomography or magnetic resonanceimaging can confirm the diagnosis, with consultationand treatment by a maxillofacial specialist. Customisedprosthetic replacement of the joint is a treatmentoption that can restore both function and aesthetics[11].
Figure 2 Postoperative CT scan showing patient-fitted Dr R Ayerdi interpreted anaesthetic charts and notes prosthetic temporomandibular joint replacement with and advised on difficult airway management. This adequate midline dental alignment and cantingreduction.
report was published with the written consent of thepatient. No external funding and no competing inter- consultation. Intra-articular triamcinolone acetonide injection reduced pain a little. After thorough 3D reconstruction and planning, the diseased joint was 1. American Society of Anesthesiologists Task Force on Manage- replaced with a prosthesis (Fig. 2).
ment of the Difficult Airway. Practice guidelines for manage-ment of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Manage-ment of the Difficult Airway. Anesthesiology 2003; 98: 1269– The ASA Task Force defines difficult tracheal intuba- tion as when a conventionally-trained anaesthetist 2. Warner ME, Benenfeld SM, Warner MA, Schroeder DR, Maxson PM. Perianesthetic dental injuries: frequency, outcomes, and experiences difficulty with facemask ventilation of the risk factors. Anesthesiology 1999; 90: 1302–5.
upper airway, difficulty with tracheal intubation, or 3. Papadaki ME, Tayebaty F, Kaban LB, Troulis MJ. Condylar resorption. Oral and Maxillofacial Surgery Clinics of North both [1]. Reported complications following difficult tracheal intubation include oedema, bleeding, tracheal Anaesthesia 2013 The Association of Anaesthetists of Great Britain and Ireland Mareque Bueno et al. | Progressive mandibular midline deviation after intubation 4. Huang YL, Pogrel MA, Kaban LB. Diagnosis and management 8. Arnett GW, Tamborello JA, Rathbone JA. Temporomandibular of condylar resorption. Journal of Oral and Maxillofacial Sur- joint ramifications of orthognathic surgery. In: Bell WH, ed.
Modern Practice in Orthognathic and Reconstructive Surgery.
5. Arnett GW, Milam SB, Gottesman L. Progressive mandibular Philadelphia: WB Saunders, 1992: 523–93.
retrusion - idiopathic condylar resorption. Part I. American 9. Arnett GW. A redefinition of bilateral sagittal osteotomy (BSO) Journal of Orthodontics and Dentofacial Orthopedics 1996; advancement relapse. American Journal of Orthodontics and Dentofacial Orthopedics 1993; 104: 506–15.
6. Arnett GW, Tamborello JA. Progressive class II development – 10. Schellhas KP, Wilkes CH, Fritts HM, Omlie MR, Lagrotteria LB.
female idiopathic condylar resorption. In: West RA, ed. Oral MR of osteochondritis dessicans and avascular necrosis of the and Maxillofacial Clinics of North America. Philadelphia: WB mandibular condyle. American Journal of Roentgenology 7. Susami T, Kuroda T, Yano Y, Nakamura T. Growth changes and 11. Mercuri LG. Patient-fitted (‘‘custom’’) alloplastic temporoman- orthodontic treatment in a patient with condylolysis. Ameri- dibular joint replacement technique. Atlas of the Oral and can Journal of Orthodontics and Dentofacial Orthopedics Maxillofacial Surgery Clinics of North America 2011; 19: 233– Anaesthesia 2013 The Association of Anaesthetists of Great Britain and Ireland


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