Authors: Uppalapati V et al.
Cureus, Volume 18, Issue 1, Article e101662, January 2026. DOI: 10.7759/cureus.101662.
Summary
This case report describes the perioperative airway assessment and management of a 56-year-old man with long-standing temporomandibular joint (TMJ) ankylosis and a prior history of emergency tracheostomy following a cannot-intubate, cannot-ventilate scenario. The coexistence of severely restricted mouth opening, limited neck mobility, and post-tracheostomy status raised significant concern for an anticipated difficult airway and possible subglottic or tracheal stenosis prior to elective laparoscopic cholecystectomy.
To better characterize the airway, cone-beam computed tomography (CBCT) was used as an adjunctive preoperative imaging modality. Three-dimensional CBCT reconstruction allowed precise measurement of tracheal anteroposterior and transverse diameters at predefined anatomical levels, including the subglottic region and mid-trachea. Imaging demonstrated tracheal dimensions within normal limits and no evidence of stenosis, enabling informed selection of endotracheal tube size and refinement of the airway plan.
Based on CBCT findings and clinical assessment, awake nasal fiberoptic intubation was performed in accordance with contemporary difficult airway guidelines. Airway topicalization and nerve blocks were used to facilitate patient cooperation and minimize physiological stress. A 7.0-mm flexometallic endotracheal tube was successfully railroaded under direct fiberoptic visualization on the first attempt. General anesthesia proceeded uneventfully, and the patient was extubated safely in a controlled postoperative setting.
This report highlights the role of CBCT as a complementary imaging tool for airway evaluation in selected complex cases, particularly in patients with prior airway trauma or surgery. Although CBCT does not replace conventional imaging or clinical examination, it provided actionable, three-dimensional anatomic detail that reduced uncertainty, supported planning, and potentially avoided repeated airway instrumentation in a high-risk patient.
What You Should Know
Patients with TMJ ankylosis and prior tracheostomy represent a high-risk, anticipated difficult airway population.
CBCT can provide rapid, low-radiation, three-dimensional visualization of the airway and facilitate accurate tracheal measurements.
Preoperative confirmation of tracheal patency can inform endotracheal tube selection and reduce repeated intubation attempts.
CBCT should be viewed as an adjunct to, not a replacement for, thorough airway examination and established difficult airway strategies.
Key Points
Risk profile: Severe TMJ ankylosis with prior traumatic airway and post-tracheostomy status.
Intervention: Preoperative CBCT imaging to assess tracheal dimensions and exclude stenosis.
Airway strategy: Awake nasal fiberoptic intubation guided by CBCT findings.
Outcome: Successful first-pass intubation and uneventful perioperative course.
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