Pediatric temporomandibular joint ankylosis: A case report

Nirmal Kumar. S*, Senthil Kumar K, Ruby Sagayaraj

Department of Anesthesiology, Kauvery Hospital, Cantonment, Trichy

Introduction

Temporomandibular joint (TMJ) ankylosis poses a significant challenge in airway management, particularly in pediatric patients. The condition often results in severely limited mouth opening or near-complete trismus, making access to the airway extremely difficult. In children, the situation is further complicated by the necessity of administering general anesthesia prior to securing the airway.

Case Presentation

An 8-year-old child presented with temporomandibular joint (TMJ) ankylosis. The child appeared malnourished and had significant difficulty chewing solid food, consuming only liquids for nutrition. Anthropometric measurements revealed height and weight below the expected range for age. Boy’s mother reported a history of obstructive breathing during sleep, especially in the supine position, with features suggestive of obstructive sleep apnea (OSA). Preoperative monitoring showed oxygen saturation (SpO₂) dropping to 64% when the child was sleeping supine, accompanied by pronounced chest indrawing and paradoxical breathing during inspiration. Upon repositioning to the lateral position, SpO₂ improved to 86%, with a noticeable reduction in paradoxical breathing.

Preoperative images were attached for reference. The child had initially presented at 2 years of age with similar complaints and had undergone surgical intervention at that time. However, there was a loss to follow-up postoperatively. Airway examination revealed, retrognathia, mandibular hypoplasia, and prominent upper incisors (buck teeth). Mouth opening was restricted to approximately 1 cm. Routine investigations were within normal limits.

Fig (1): Pre-operative Airway Evaluation

Anesthesia-Management

Pre-operative Management

Given the child’s significant history of obstructive sleep apnea (OSA), which was more severe than during early childhood presentation, preoperative sedation was avoided to prevent respiratory compromise.

Preparation

Recognizing the potential for a difficult airway due to severe OSA, retrognathia, and restricted mouth opening, an anxiolytic dose of benzodiazepine was administered cautiously.

A 3.5 size endotracheal tube (ETT), trimmed according to the tragus-to- nose-tip measurement, was inserted through one nostril to function as a nasal airway. Compared to a standard nasal airway, the ETT offered the advantage of allowing connection to both open and closed breathing circuits,

enabling real-time monitoring of spontaneous ventilation through bag movement and EtCO₂ measurement.

Sedation Technique

An antisialogogue was administered prior to sedation. Sedation was achieved using a bolus dose of dexmedetomidine (0.75 mcg/kg) along with an analgesic dose of ketamine. The child was brought to a state of mild-to-moderate sedation and then gradually transitioned to inhalational anesthesia via the nasal circuit.

Fig (2): (ET) Nasal Tube Insertion for oxygenation

Airway Management and Intubation

A size 3.6 AMBU® fiberoptic video bronchoscope was preloaded with a 4.5 mm endotracheal tube. The bronchoscope was introduced through the contralateral nostril, with topical local anesthetic sprayed to anesthetize the nasal and pharyngeal passages. After visualizing the vocal cords and entering the trachea, the endotracheal tube was advanced over the scope. Correct placement was confirmed with EtCO₂ monitoring, following which general anesthesia was administered

Intraoperative Course

Surgery proceeded uneventfully. Following corrective measures, the child’s mouth opening improved to approximately 3–4 cm

Postoperative Management

The child was successfully awakened postoperatively and extubated to a face mask. He was subsequently shifted to the Pediatric Intensive Care Unit (PICU) for observation.

By postoperative Day 5, the child had recovered well and was discharged in stable condition.

Discussion

Temporomandibular joint (TMJ) ankylosis in children results from fibrous or bony fusion between the mandibular condyle and the glenoid fossa. It is typically caused by trauma, infections, or autoimmune diseases. The condition is categorized based on the type of tissue involved (fibrous, bony, or fibro-osseous), its location (intra- or extra- capsular), and the completeness of fusion1.Clinical features include restricted mouth opening, retrognathism, facial asymmetry, feeding difficulties, poor nutrition, and psychosocial challenges. Management ranges from conservative jaw exercises to surgical intervention.

Fig (3): Video bronchoscopy Intubation through other nostril

A large retrospective study involving 372 pediatric patients (including 85 with obstructive sleep apnea, OSA) reported that all OSA cases exhibited retrognathia. Fiberoptic bronchoscope (FOB)-guided intubation was successful in 97.3% of cases. Difficult mask ventilation and intubation were more frequent among OSA patients (18% and 12.9%, respectively). Desaturation occurred in 5.1% during induction and 7.2% during extubation, though no surgical airway was required2.

FOB-guided intubation under anesthesia was the most commonly used airway technique. Idea is to preserve spontaneous ventilation. While awake intubation is generally safer in difficult airways, it is often impractical in children due to poor cooperation. Most cases were managed with inhalational induction while maintaining spontaneous respiration. Sedated awake FOB using dexmedetomidine or ketamine may serve as alternative approaches. Other methods of securing airway include blind nasal intubation, retrograde intubation or surgical airway(tracheostomy) needed in these children3.

In our case, a combination of intravenous and inhalational induction was used while maintaining spontaneous respiration. A modified nasal airway allowed continuous EtCO₂ monitoring and visual assessment of bag movements. Fiberoptic nasal intubation was successfully performed on the first attempt, and general anesthesia was administered thereafter.

Considering the child’s history of OSA, extubation was performed while retaining the nasal airway. The patient received postoperative CPAP support in the ICU on days 1 and 2, followed by gradual weaning. He was discharged in stable condition on postoperative day 5.

Long-term success in TMJ ankylosis treatment depends heavily on aggressive and sustained jaw physiotherapy. Prolonged ankylosis leads to disuse atrophy of the masticatory muscles. Physiotherapy post-surgery is vital to restore muscle strength, increase bulk, and improve mandibular mobility4.

Conclusion

Although blind nasal and retrograde intubation techniques are described in the literature, fiberoptic-guided endotracheal intubation remains the gold standard and most definitive approach in such cases. The primary challenge in pediatric anesthesia with difficult airway lies in maintaining spontaneous ventilation while ensuring effective sedation.

Reference

  • A case report on temporomandibular joint ankylosis (pediatric difficult airway) | International Journal of Current Research [Internet]. Journalcra.com. 2025 [cited 2025 Jul 8]. Available from: http://journalcra.com/article/case-report- temporomandibular-joint-ankylosis-pediatric-difficult-airway
  • Trikha A, Roychoudhury A, Goswami D, Maitra S, Bhutia O, Baidya DK. Perioperative airway management techniques and complications in patients with temporomandibular joint ankylosis: Experience from a tertiary care teaching institute. Saudi Journal of Anaesthesia. 2025 Jan;19(1):8–13.
  • Vas L, Sawant P. A review of anaesthetic technique in 15 paediatric patients with temporomandibular joint ankylosis. Pediatric Anesthesia. 2001 Mar;11(2):237–44.
  • Neelam Noel Andrade, Kapoor P, Mathai P, Gupta V, V.K. Lakshmi, Sharma S. Management of paediatric ankylosis. Journal of Oral Biology and Craniofacial Research. 2023 Mar 1;13(2):191–201.

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