Ultrasound-assisted awake retrograde nasal intubation for bilateral post-traumatic temporomandibular joint ankylosis with frozen mouth: A case report

Abstract

INTRODUCTION

Temporomandibular joint (TMJ) ankylosis is a condition characterized by temporo-mandibular joint movement restriction resulting from fibrous or bony fusion. Bilateral involvement may lead to complete mouth closure, creating one of the most challenging airway scenarios encountered by anaesthesiologists. Awake airway management techniques are generally preferred in such patients because loss of spontaneous ventilation after induction of anaesthesia may result in a catastrophic cannot-intubate-cannot-oxygenate situation. Although awake fibreoptic intubation is considered the gold standard for anticipated difficult airways, retrograde intubation remains an important alternative, particularly in resource-constrained settings.

CASE PRESENTATION

We report the case of a 20-year-old ASA-I (physical status) male weighing 50 kg with bilateral post-traumatic TMJ ankylosis and complete absence of mouth opening. Airway examination revealed severe mandibular retrusion, inter-incisor distance of 0 mm, sternomental distance less than 12 cm, and adequate neck movements. Ultrasound-guided bilateral superior laryngeal nerve blocks and ultrasound-assisted transtracheal recurrent laryngeal nerve block were performed using lignocaine. Awake retrograde nasal intubation was successfully accomplished using an 18-gauge epidural needle, urology guidewire, and 6.5-mm cuffed flexometallic endotracheal tube. General anaesthesia was subsequently administered for surgical release of ankylosis.

CONCLUSION

Ultrasound-assisted awake retrograde nasal intubation provided safe and effective airway control while maintaining spontaneous ventilation throughout airway instrumentation. This case highlights the continuing relevance of retrograde intubation in modern difficult airway management, especially in low-resource settings.