Unanticipated cannot intubate situation due to difficult mouth opening

Abstract

We report a case of unanticipated difficult endotracheal intubation secondary to an abrupt onset of difficulty in opening the mouth in an anesthetized adult. A female aged 76 years with American Society of Anesthetists risk Class IV E with an apparently normal preoperative temporomandibular joint was scheduled for emergency laparotomy. Following rapid sequence induction, and muscle relaxation with rocuronium, the anesthesiologist noticed lock-jaw when intubation was attempted. She was ventilated with nasopharyngeal airway, but was progressively desaturating. An emergency tracheostomy was performed. Unfortunately, she sustained cardiac arrest and could not be revived. The complication of the lock-jaw is a nightmare to airway management, especially in an unprepared situation.

‘Locked jaw’ – An unusual unanticipated difficult airway

“…Durga et al . [ 2 ] have reported a case of unanticipated difficult intubation due to displacement of temporomandibular joint which led to difficulty in mouth opening and unfortunately cardiac arrest of the patient. Similar difficult mouth opening because of undiagnosed temporomandibular joint pathology has been reported by Lee et al .…”

Cannot intubate situation arising out of difficult mouth opening due to jaw thrust

“…made for interesting reading. [ 1 ] We congratulate the authors for reporting this case that had a fatal outcome due to failed intubation arising out of temporomandibular joint dislocation during induction of anesthesia. Temporomandibular joint dislocation during mask ventilation, airway manipulation, and laryngoscopy is not unknown and is attributed to loss of protective muscle tone due to general anesthesia or sedation.…”

In response to unanticipated cannot intubate situation due to difficult mouth opening

“…We read with the interest case report “Unanticipated cannot intubate situation due to difficult mouth opening” by Akasapu et al . [ 1 ] published in January-March 2015 issue 1 volume 31. We have some queries regarding the management of this case: The use of 100mg of rocuronium in an ASA grade IV E patient can be confounding.…”