Psoriatic arthritis (PsA) affects 15% of psoriasis patients, It also affects the temporomandibular joint (TMJ) at a much lower frequency. TMJ symptoms in PsA patients include positional abnormalities of the condyle, erosion, pain, or restricted movement in the incipient stage and fibrous or osseous ankylosis at an advanced stage. We report the general anesthetic management of a patient with psoriatic arthritis at the TMJ who required surgical treatment for TMJ ankylosis.
A 52-year-old man (weight, 80 kg ; height, 180 cm) was diagnosed as having psoriasis at the age of 23 years. He developed trismus at the age of 45 years and was diagnosed as having PsA 2 years later. He had subsequently undergone rehabilitation therapy for trismus, yet his maximum mouth opening was 7 mm. He had been treated with conservative therapy for an aortic dissection, which occurred at the age of 51 years. He was scheduled to undergo a gap arthroplasty for the release of the ankylosis of the TMJ under general anesthesia.
As a premedication, midazolam and atropine were administered intramuscularly. Nasotracheal fiberoptic intubation was performed under intravenous sedation with fentanyl and midazolam. General anesthesia was maintained with sevoflurane, fentanyl, and remifentanil. The perioperative systolic blood pressure was strictly controlled at less than 130 mmHg to avoid a relapse of the aortic dissection.
When anesthetizing patients with PsA, anesthesiologists should consider the individual-specific comorbidities, including cardiovascular diseases, and the possibility of a difficult airway because of TMJ ankylosis.
