Temporomandibular Joint Ankylosis in an Infant: A Rare Cause of Difficult Airway

1.Pre-assessment data of the patient A 2-year-old boy, weighing 15 kg was admitted with a history of limited mouth opening(inter-incisor distance of 6 mm), hypoplastic and retrognathic mandible (bird face deformity) and facial asymmetry from left temporomandibular joint ankylosis (TMJA). He was born at term, after an uneventful pregnancy, and there was no report of trauma during caesarean section. No other possible aetiologies were identified. He was scheduled for mandibular osteotomy. Preoperative ENT examination revealed adenotonsillar hypertrophy. 2. Anaesthetic Plan A fiberoptic nasal intubation was performed under deep inhalation anaesthesia with sevoflurane, with the patient breathing spontaneously. Midazolam (0.05 mg.kg-1) and alfentanil (0.03 mg.kg-1) were given and anaesthesia was maintained with O2/air and sevoflurane. No neuromuscular blocking agent was administered since the surgical team needed facial nerve monitoring. 3. Description of incident During surgery an accidental extubation occurred and an attempt was made to reintubate the trachea by direct laryngoscopy. Although the osteotomy was nearly completed, the vocal cords could not be visualized (Cormack-Lehane grade IV laryngoscopic view). 4. Solving the problem Re-intubation was finally accomplished with the flexible fiberscope and the procedure was concluded without any more incidents. Extubation was performed 24 hours postoperatively with the patient fully awake. After surgery mouth opening improved to inter-incisor gap of 15 mm. 5. Lessons learned and take home message Two airways issues present in this case can lead to difficultventilation and intubation: TMJA and adenotonsillar hypertrophy. These difficulties were anticipated and managed accordingly. The accidental extubation brought to our attention the fact that, even after surgical correction, this airway remains challenging. Even with intensive jaw stretchingexercises there is a high incidence of re-ankylosis, especially in younger patients. One should bear that in mind when anaesthetizing patients with TMJA.

Validação da Versão Portuguesa da "Activities-specific Balance Confidence Scale"

Introdução: Muitos dos instrumentos disponíveis para a avaliação do equilíbrio, risco de queda e medo de cair medem apenas actividades simples no domicílio e apresentam tendência para um “efeito de tecto” em idosos residentes na comunidade. A “Activities-specific Balance Confidence (ABC) Scale” foi concebida para avaliar o equilíbrio de forma abrangente, num conjunto de actividades de vida diária associadas a um largo espectro de dificuldade. Objectivos: Traduzir para português e adaptar culturalmente para Portugal a “Activities-specific Balance Confidence (ABS) Scale” e avaliar a sua fiabilidade. População e Métodos: Tradução e adaptação cultural do instrumento e subsequente aplicação a uma população idosa portuguesa, para determinação da sua fiabilidade inter-observador, fiabilidade intra-observador e consistência interna. Resultados: Os resultados foram muito homogéneos na grande maioria das comparações realizadas, quer intra-observador, quer inter-observador. A avaliação da consistência interna revelou valores muito elevados. Estes níveis de fiabilidade mantiveram-se mesmo removendo qualquer uma das 16 questões que compõem o questionário, mantendo-se praticamente constantes os valores registados com o questionário completo. Conclusões: A versão portuguesa da escala ABC demonstrou boa fiabilidade intra-observador, fiabilidade inter-observador e consistência interna na avaliação da auto-percepção do equilíbrio para diversas actividades de vida diária numa população idosa portuguesa. Outros trabalhos serão necessários para avaliar a utilidade desta escala na avaliação do risco de queda e do efeito de intervenções terapêuticas nesta população.