Difficult Airway Management in a Pediatric Patient with Bilateral Temporomandibular Joint Ankylosis Undergoing Interpositional Arthroplasty

Abstract

Background: Due to severely limited mouth opening and altered airway anatomy, pediatric patients with temporomandibular joint (TMJ) ankylosis present a significant anesthetic challenge. Fiberoptic - guided nasal intubation under general anesthesia is the recommended technique because it frequently precludes the use of traditional intubation techniques. A safe outcome depends on careful planning and preparation of the airway. Case Presentation: We present a case of a 4 - year - old male child diagnosed with bilateral TMJ ankylosis, scheduled for interpositional arthroplasty. The child exhibited severely limited mouth opening and normal neck mobility. Preoperative airway preparation included nebulization with 4% lignocaine and nasal decongestion with xylometazoline drops. In the operating room, standard monitors were applied, and a nasopharyngeal airway was inserted for oxygen insufflation. Anesthesia was induced with incremental doses of sevoflurane while preserving spontaneous ventilation. A 4.5 mm endotracheal tube was successfully placed via fibreoptic bronchoscopy through the contralateral nostril. Anesthesia was maintained with sevoflurane in oxygen - air mixture, and atracurium was used for muscle relaxation. Intravenous paracetamol provided intraoperative analgesia. The surgical procedure was completed without complications. The patient was successfully extubated and transferred to the pediatric intensive care unit (PICU) for observation, with an uneventful postoperative course. Conclusion: A safe and efficient method for managing airways in children with TMJ ankylosis is fiberoptic - guided nasal intubation performed under general anesthesia while maintaining spontaneous ventilation. Safety and procedural success are improved using nasopharyngeal oxygenation, preoperative topical anesthesia, and carefully selecting pediatric airway equipment. The significance of tailored planning and a methodical approach in handling challenging pediatric airways is emphasized in this case.