Extradural haematoma after temporomandibular joint arthroscopy. A case report

Mt. J. Oral Maxill@~c. Surg. 1993; 22:332-335 Printed in Denmark. All rights reserved

Copyright © Munksgaard 1993 [ntematiotTa[Journa]of

Oral& MaxillofacialSurgery ISSN 0901-5027

Extradural haematoma after temporomandibular joint

Michael A. Murphy, Keith C. Silvester, T. Y. K. Chan Royal London Hospital, Whitechapel, London, UK

arthr0sc0py A case report M. A. Murphy, K. C. Silvestet; T Y IC Chan." Extradural haematoma after ternporomandibular joint arthroscopy. A case report. Int, J. Oral MaxilloJac. Surg. 1993; 22." 332 335. © M u n k s g a a r d , 1993 Abstract. A case r e p o r t o f an e x t r a d u r a l h a e m a t o m a ( E D H ) a f t e r t e m p o r o m a n d i b u l a r j o i n t a r t h r o s c o p y is p r e s e n t e d . T h e p o s s i b l e c a u s e o f this u n u s u a l o c c u r rence is discussed.

Temporomandibular joint (TMJ) a r t h r o s c o p y for T M J d y s f u n c t i o n is b e i n g p e r f o r m e d w i t h i n c r e a s i n g frequency. I n d i c a t i o n s i n c l u d e d i a g n o s i s in resistant cases o f i n t e r n a l d e r a n g e m e n t a n d t r e a t m e n t o f such entities as a n t e r i orly d i s p l a c e d m e n i s c u s , a d h e s i o n s , a n d hypermobility 3'~°'~9'2°. C o m p l i c a t i o n s are u n c o m m o n . A case is r e p o r t e d o f a 27year-old w o m a n w h o d e v e l o p e d an extradural haematoma (EDH) after T M J a r t h r o s c o p y . This, to o u r k n o w l edge, has n e v e r b e e n r e p o r t e d b e f o r e .

Case report The patient had a 12-year history of bilateral pain and clicking related to her TMJs, the left worse than the right. At various times during this period, she had conservative treatment with exercises, a soft bite guard, and intermaxillary fixation (on three occasions!), all of which gave some initial improvement, but were followed by a recurrence of symptoms after a few months. She represented with an exacerbation of symptoms. On examination, there was tenderness over both TMJs with an interincisal opening of 19 ram. A clinical diagnosis of bilateral anterior meniscal displacement without reduction was made. Two months later, she underwent left TMJ

arthroscopy which comprised lysis of adhesions and lavage. This resulted in a resolution of symptoms on that side. Four months later, a right TMJ arthroscopy was perforrned for persistent pain on that side. This was undertaken by an experienced operator in this field. Preoperative magnetic resonance imaging (MRI) for assessment of the meniscal position (Fig. 1) showed no evidence of an intracranial collection. The second operation was performed with a 2.7-nlm Dionics arthroscope. The meniscus was noted to be anteriorly displaced, and nonfunctional. An anterior release, conrprising division of fibres of lateral pterygoid muscle insertion into the meniscus, was performed with a Holmium Yag laser via another entry port. Adhesions in the glenoid fossa were divided with the laser. A disc-retaining suture was placed 2°. During the procedure, a copious flow of irrigation fluid (Hartmann's and N-saline) was maintained. This was injected under pressure by a spring-loaded syringe with a three-way tap between the bag of sterile irrigation fluid and the arthroscope. On the first postoperative day, the patient was alert, although slightly nauseated. When discharged the next morning, she mentioned a mild degree of double vision on gazing to the right side. She failed to attend her first review (because she was feeling unwell) and was seen 17 days postoperatively, when she c o m -

Key words: extradural haematoma; temporomandibular joint; arthroscopy. Accepted for publication 9 June 1993

plained of a significant degree of diplopia and persistent headaches, although her nausea had settled. She was referred for ophthalmologic review. A Hess chart indicated a diagnosis of right fourth nerve and partial right third nerve palsy. Orthoptic exercises were advised but gave no improvement, so that a CT scan was felt to be indicated. This showed a right-sided, extradural collection, the appearance of which was consistent with a chronic fluid collection (Fig. 2). At this stage, the patient was alert, orientated, and fully mobile, so that the radiographic findings were unexpected. The collection was consequently drained by a right temporal burr hole; at operation, the fluid was dark brown, as consistent with a liquified haematoma. A thin outer membrane was seen. Postoperatively, the headache and third and fourth nerve palsy resolved within 24 h. She had intermittent diplopia, however, for approximately 8 weeks after the procedure, but by the third postoperative visit it had totally resolved, as had her headaches apart from a slight ache at the burr hole site. A follow-up CT scan 10 days after the operation showed a small collection with minimal mass effect, but a repeat scan 2 months later showed that the collection had totally resolved.

Discussion C o m p l i c a t i o n s after T M J a r t h r o s c o p y are u n c o m m o n , t h e i n c i d e n c e s v a r y i n g

Extradural haematoma in relation to anthroscopy

333

Fig. 1. Magnetic resonance image of temporomandibular joints showing no preoperative intracranial collection.

0-15%. They are usually mild and transient 1,5,7&12'16'24. General complications such as infection and haemorrhage have been reported. In the case of the latter, the superficial temporal vessels are the most commonly involved structures, and pseudoaneurysm and arteriovenous fistula of these vessels have been reported in recent years 12,I4,17.Other complications include otologic damage, instrument breakage, facial anaesthesia and palsy, intra-articular damage to the TMJ, extravasation of fluid, and reflex bradycardia