ANKYLOSIS OF THE TEMPOROMANDIBULAR JOINT

Introduction: Difficult intubation is a very dreaded situation in anesthesia and is frequently encountered in maxillofacial surgery15.7%(1)particularlyinpatientswithankylosisofthejoint temporomandibular (TMJ) the scarcity of equipment used in the event of difficult intubation (ID) such as that a nasofibroscopy represents a challenge and requires the use of other techniques (2). The interest of our study is to show the importance of capnography and ultrasound guidance during an ID blind nasotracheal. Comment: It concerns the management of the respiratory tract of a patient aged 41 years and 78 kg followed for epilepsy since childhood, substegretol 200mgx2/jet with congenital TMJ ankylosis. On the basis of preoperative clinical and radiological results, we have found the criteria for ID in particular the impossibility of opening the mouth and with the resources available, an intubation nasotracheal surgery under general anesthesia with spontaneous breathing was considered and a written informed consent for an emergency tracheotomy if required has been obtained from the patient. The procedure successively consisted of pre-oxygenation of the facial mask, xylocaine 0.05% a been sprayed into the right nostril, 0.05% xylocaine gargle, blockage of the laryngeal nerves superior by transcutaneous injections of lidocaine 1% and intra-tracheally, then we performed sedation with propofol 50mg. Blind nasotracheal intubation was successful in one uneventful attempt per No. 6.5 mm reinforced probe, the verification was made by visualizing the intra-tracheal probe at through ultrasound and confirmation by capnography. The anesthesia was completed by the administration of fentanyl 250 gamma, propofol 100 mg and rocuronium 40mg. Maintenance of anesthesia was performed by a mixture of isoflurane (1.5%) and oxygen and air (50%:50%). The patient was extubated after the surgical procedure and the operation was a success.

Conclusion: The anesthesia of patients with TMJ ankylosis represents a situation where the difficulties tracheal intubation should be considered in principle, and where an anticipatory strategy should be developed. Due to the absence of anasofibroscopy, the anesthetic treatment must be carried out by a team experienced and trained in blind ID.