Case Report

Triple trouble – anaesthetic management of a child with TMJ ankylosis with retrognathia and OSA

K. Senthil Kumar,*, P. Sasi Kumar, S. Khaja Mohideen, S. Nirmal Kumar

Department of Anaesthesiology, Kauvery Hospital, Trichy, Tamil Nadu



Bilateral temporomandibular joint (TMJ) ankylosis with retrognathia and obstructive sleep apnoea (OSA) is relatively uncommon in children. The present case describes the anaesthetic management of a similar toddler who was posted for TMJ release and Interposition Arthroplasty.

Case Presentation

A 2-year-old boy weighing 11 kg with bilateral TMJ ankylosis and retrognathia, with restricted mouth opening and OSA was scheduled for TM joint release and Interposition arthroplasty.

Triple-trouble-1Fig 1. Severe Retrognathia.

Triple-trouble-2Fig. 2. Restricted mouth opening.



Triple-trouble-3Fig. 3. Mask Induction.


Fig. 4. ETT through right nostril connected to JR circuit and adjusting to get a good tracing of ETCo2.


Fig. 5a and b. FOB intubation through left nostril with inhalational induction through right nostril.


Fig. 6a and b. After intubation in left nostril the right sided ETT is removed and final ETT in position.


Though much literature mentions the introduction of the supraglottic device (SGD) and then introducing ETT through the SGD for the severely retrognathic child, in our scenario it is not possible as the child had TM joint ankylosis & restricted mouth opening and Nasal intubation is the only option to secure the airway. Oral airway and Laryngoscopic intubation are also not a possibility due to restricted mouth opening. For TMJ release & Inter position arthroplasty nasal intubation gives ultimate comfort to surgical work. For fear of apnea following IV induction agents and difficulty ventilating (as the child is having OSA), inhalational induction with ETT in one nostril and maintaining spontaneous breathing till we secure the ETT intra trachea through the other nostril is the safest choice to secure the airway. Moreover, Inhalational induction with ma ask will not give room for FOB intubation comfortably.


Awake FOB intubation, the safest technique in the difficult airway is not feasible in paediatrics. Hence sedation is necessary for performing FOB. Sedation with an intravenous technique can result in apnea compared to inhalational induction. Hence our technique of using ETT as a nasal airway for inhalational induction helps to achieve adequate oxygenation and depth of anaesthesia as well as allows the anesthesiologist enough time to use FOB.


  1. Shah FR, Sharma KR, Hilloowalla RN, et al. Anaesthetic considerations of temporomandibular joint ankylosis with obstructive sleep apnoea: A case report. J Indian Soc Pedod Prev Dent. 2002;20:16-20.

Dr. K. Senthil Kumar

Head of the Department, Anaesthesiology and Toxicology


Dr. P. Sasi Kumar



Dr. S. Khaja Mohideen