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| LETTER TO THE EDITOR |
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| Year : 2020 | Volume
: 13
| Issue : 4 | Page : 416-417 |
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Lockjaw – An airway nightmare
Karthika Rajan, Nandini M Dave, Harick B Shah, Priyanka P Karnik
Department of Paediatric Anesthesiology, Seth Gordhandas Sunderdas Medical College, King Edward Memorial Hospital, Mumbai, Maharashtra, India
| Date of Submission | 15-May-2019 |
| Date of Decision | 09-Jul-2019 |
| Date of Acceptance | 11-Jul-2019 |
| Date of Web Publication | 20-Jul-2020 |
Correspondence Address:
Harick B Shah
14/Peace Bird Society, T.H. Kataria Marg, Matunga (West), Mumbai - 400 016, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/mjdrdypu.mjdrdypu_130_19
How to cite this article:
Rajan K, Dave NM, Shah HB, Karnik PP. Lockjaw – An airway nightmare. Med J DY Patil Vidyapeeth 2020;13:416-7 |
Sir,
Obligatory active opening of unconscious patients' mouth by anesthesiologists to facilitate laryngoscopy is usually considered a nondestructive maneuver. However, we report a case of unanticipated difficult airway secondary to abrupt onset of inability to open the mouth in a patient in cardiac arrest.
A 45-year-old male, known case of alcoholic liver disease with portal hypertension, presented with cellulitis of the lower limb in early sepsis was scheduled for emergency fasciotomy and wound debridement. In view of deranged coagulation profile, general anesthesia was instituted. Preoperative airway evaluation revealed no restriction of mouth opening. Anesthesia was maintained with air, oxygen, and sevoflurane with bag and mask using two-hand technique and sufficient jaw thrust. Intraoperative vitals were stable, and recovery was uneventful.
Postoperatively, the patient's condition deteriorated and he sustained a cardiac arrest. Immediate cardiopulmonary resuscitation was initiated, and intubation was attempted. However, the mouth could not be opened as the teeth were firmly approximated. Succinylcholine 2 mg/kg intravenous was administered as an attempt to loosen the jaw but was unsuccessful. The second attempt 1 min later by a senior anesthesiologist also failed to open the mouth. A nasopharyngeal airway was inserted, and mask ventilation resumed. A blind nasal intubation was not attempted as it was more appropriate not to interrupt the ventilation. Fiber-optic bronchoscope was unavailable in the intensive care unit. An emergency tracheostomy was called for, but despite all measures, the patient expired.
Inadequate relaxation due to under dosage of succinylcholine could be excluded as the inability to open the mouth persisted even after death. Possibility of masseter spasm due to succinylcholine was ruled out since it preceded scoline administration. Another differential diagnosis like malignant hyperthermia was less likely as there was no raised body temperature. Anterior dislocation of the mandibular condyles producing a fixed open mouth, responsive to immediate manipulative reduction and followed by adequate jaw function, has been described complicating orotracheal intubations.[1],[2] It has been stated that severe anterior disc displacement can cause the mouth to lock in the closed position and has been suggested as a cause of a “locked jaw” in earlier publications.[3] Temporomandibular joint (TMJ) being a ginglymoarthrodial joint is capable of both hinging and gliding movements.[4] [Figure 1] The cartilaginous articular disc present between the mandibular condyle and the mandibular glenoid fossa moves anteriorly and inferiorly down the articular eminence during volitional opening of the mouth. However, forceful opening of the anesthetized patient's jaw can force the condyle against the disc displacing it anteriorly beyond its normal range of motion, avulsing the superior retrodiscal lamina (SLR). Interruption of the SLR gives way for the unopposed action of superior lateral pterygoid muscle to fix the avulsed disc anterior preventing forward motion of the mandibular condyle resulting in a closed lock.[5] In our case, holding the mask with aggressive jaw thrust under general anesthesia could have triggered the event.[6] A radiograph of the joint as well as an autopsy would have been more confirmative but could not be done. | Figure 1: (a) Normal anatomy of the temporomandibular joint, (b) Anteriorly displaced articular disc of the temporomandibular joint
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Little focus is usually given to TMJ diseases as an attributable cause of unsuspected restricted mouth opening. Though rare, lockjaw is a possibility that can prove fatal if not prepared for. Flexible fiber-optic bronchoscope and front of neck access can be most vital in handling such crisis.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Sosis M, Lazar S. Jaw dislocation during general anesthesia. Can J Anaesth 1987;34:407-8.  |
| 2. | Gambling DR, Ross PL. Temporomandibular joint subluxation on induction of anesthesia. Anesth Analg 1988;67:91-2. |
| 3. | Akasapu KR, Wuduru S, Padhy N, Durga P. Unanticipated cannot intubate situation due to difficult mouth opening. J Anaesthesiol Clin Pharmacol 2015;31:123-4. [ PUBMED] [Full text] |
| 4. | Okeson JP. Nonsurgical management of disc-interference disorders. Dent Clin North Am 1991;35:29-51. |
| 5. | Gould DB, Banes CH. Iatrogenic disruptions of right temporomandibular joints during orotracheal intubation causing permanent closed lock of the jaw. Anesth Analg 1995;81:191-4. |
| 6. | Oofuvong M. Bilateral temporomandibular joint dislocations during induction of anesthesia and orotracheal intubation. J Med Assoc Thai 2005;88:695-7. |
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