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LETTER TO EDITOR
Year : 2021  |  Volume : 4  |  Issue : 1  |  Page : 61-62

Jaw dislocation at end of anaesthesia – A distressing complication revisited


Department of Anesthesiology, JSS Academy of Higher Education and Research, Mysore, Karnataka, India

Date of Submission28-Nov-2020
Date of Acceptance02-Jan-2021
Date of Web Publication29-Apr-2021

Correspondence Address:
Dr. S Vyshnavi
#20, Block 11, Madhuvana Layout, Srirampura 2nd Stage, Mysore - 570 034, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/arwy.arwy_56_20

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How to cite this article:
Vyshnavi S, Darshini S, Ashwini N, Chandrashekar P. Jaw dislocation at end of anaesthesia – A distressing complication revisited. Airway 2021;4:61-2

How to cite this URL:
Vyshnavi S, Darshini S, Ashwini N, Chandrashekar P. Jaw dislocation at end of anaesthesia – A distressing complication revisited. Airway [serial online] 2021 [cited 2021 Jul 27];4:61-2. Available from: https://www.arwy.org/text.asp?2021/4/1/61/315166



Temporomandibular joint (TMJ) dislocation is a complication that can be prevented by a well-informed and vigilant anaesthesiologist. Assessment of the TMJ is an integral part of airway examination before administration of general anaesthesia. Considering that airway manipulation can itself result in TMJ dislocation and that its incidence after endotracheal intubation/laryngoscopy is 5%,[1] a sound knowledge of this complication becomes important.

Various risk factors associated with TMJ instability include a poorly developed articular fossa, TMJ capsule/ligament laxity, female gender, increasing age, interincisal distance, previous history of TMJ pain/dislocations, overuse of masticator muscles under psychological stress (bruxism), laughing, vomiting, yawning and seizures.[2],[3],[4],[5] Procedures resulting in TMJ dislocation are laryngoscopy; insertion of oropharyngeal airway, endotracheal tube or laryngeal mask airway; nasogastric tube placement in intubated patients; dental/ENT/endoscopy and transoesophageal ECHO procedures; fibreoptic bronchoscopy and intubation with the lighted stylet. It is interesting to note that even jaw thrust used routinely to ensure a wider mouth opening is an implicated factor.[3] It is more commonly encountered in certain syndromes such as Ehlers-Danlos syndrome, Marfan syndrome and orofacial dystonia.[4] Of note, the duration of the intubation or Mallampati score is not associated with TMJ dislocation.[1]

The pathophysiology involves movement of the condylar process in front of the articular eminence and an inability to move back to normal position. Diagnosis is usually clinical. Inability to close the mouth- ‘open-lock', pain, deviation of the chin to the opposite side (in unilateral dislocations), drooling of saliva, impaired speech, palpable depression in preauricular area and prominent lower jaw are the usual pointers to TMJ dislocation.[1],[4],[5] Although obvious, the diagnosis can still be missed in unconscious, sedated and ventilated patients.

Early recognition and prompt reduction are important to prevent fibrosis and fractures which occur when left untreated for >14 days.[2] Furthermore, reflex spasm of the pterygoid muscles and painful stimuli from the joint capsule can ankylose the jaw complicating manual reduction and necessitating subsequent surgical intervention.[4] The manual intraoral reduction is performed with the operator in front of the patient, placing his thumbs near the rear teeth and other fingers grasping the lower edge of the jaw. The pressure is applied on the teeth with upwards push on the chin along with the posterior displacement of the entire mandible.[6] Auriculotemporal nerve block, local infiltration in joint space or light sedation with benzodiazepines, narcotic or propofol can be considered for a pain-free reduction.[1],[4] The role of muscle relaxants to overcome reflex muscle spasm is debatable.[4] A simple, effective and rapid method of reducing an acute dislocation was described by Awang. He described stimulating a gag reflex by probing the soft palate as a method to induce a reflex neuromuscular action that resulted in reduction.[7]

Following reduction, soft diet and avoidance of extreme mouth opening (yawning, laughing) is advised. Mild analgesics and a brace for stabilising the mandible in the immediate post-reduction period helps to avoid the recurrence of dislocation. Failed reduction, associated fractures or repeated dislocations will warrant an orosurgical consultation.

A quick reference guide to avoid this painful condition is as follows:

Preoperative period:

  1. History of previous TMJ dislocation, jaw ‘clicks’ with yawning/laughing, preauricular pain, previous injury to joint
  2. Determine the range of motion of TMJ and ability to protrude the lower jaw. Note limitations, if any.


Intraoperative period:

  1. Gentle mouth opening and jaw thrust manoeuvre, especially in patients with suggestive history
  2. High index of suspicion if the mouth is persistently open after airway instrumentation, particularly if manipulated repeatedly.


Postoperative period:

  1. Exclude TMJ dislocation/dysfunction by confirming normal mandibular excursion in all patients receiving a general anaesthetic.


A thorough knowledge of the risk factors, gentle airway manipulation, reassessment of the TMJ at the end of an anaesthetic and most importantly, a vigilant anaesthesiologist, play a crucial role in not only avoiding but also in early detection and prompt treatment of this painful complication.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Pillai S, Konia MR. Unrecognized bilateral temporomandibular joint dislocation after general anesthesia with a delay in diagnosis and management: A case report. J Med Case Rep 2013;7:243.  Back to cited text no. 1
    
2.
Han I, Kim TK, Yoo JH, Park JH, Chung EY. Dislocation of the temporomandibular joint following general anesthesia. Korean J Anesthesiol 2014;67:S113-4.  Back to cited text no. 2
    
3.
Prasad G, Agrawal S. Temporomandibular joint (TMJ) dislocation during LMA insertion. Indian J Anaesth 2004;48:151-2.  Back to cited text no. 3
  [Full text]  
4.
Sharma NK, Singh AK, Pandey A, Verma V, Singh S. Temporomandibular joint dislocation. Natl J Maxillofac Surg 2015;6:16-20.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Kaushal A, Kapoor I, Mahajan C, Prabhakar H. Temporomandibular joint dislocation following endotracheal tube manipulation: A near miss! J Neuroanaesthesiol Crit Care 2018;5:206-7.  Back to cited text no. 5
    
6.
Sosis M, Lazar S. Jaw dislocation during general anaesthesia. Can J Anaesth 1987;34:407-8.  Back to cited text no. 6
    
7.
Awang MN. A new approach to the reduction of acute dislocation of the temporomandibular joint: A report of three cases. Br J Oral Maxillofac Surg 1987;25:244-9.  Back to cited text no. 7
    




 

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