Postobstructive pulmonary edema as a sequela of temporomandibular joint arthroscopy: A case report

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the condylar lesions had ill-defined borders characteristic of malignancy; it is speculated that in these cases the malignant process had originated in the bone itself, whereas in all other cases the tumor had originated in the joint cartilaginous tissue. All cases showed local invasion of neighboring tissues, such as the middle car, pterygoid plate, and middle cranial fossa; however, no metastasis was reported on examination or follow-up. Radical surgery was the treatment giving satisfactory results, with no reported recurrence or metastases in follow-up periods varying from a few months to several years. This may indicate that chondrosarcoma of the TMJ is a locally invasive malignant tumor that responds well to treatment by radical surgery.

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4. 5. 6. 7. 8. 9. 10.

References I. Worth HM : The temporomandibular joint, ill Principles and Practice of Ora! Radiologic Interpretation. Chicago, IL, Year Book, 1963, pp 695-696 2. Resnick D: Tumor and tumor-like lesions of bone, ill Resnick

II.

D, Nimagoma G (eds); Diagnosis of Bone and Joint Disorders. Philadelphia, PA, Saunders, 1981, pp 2654-2656 Madewell JE, Sweet DE: Tumors and tumor-like lesions in or about joints, ill Resnick D, Niwagama G (eds): Diagnosis of Bone and Joint Disorders. Philadelphia, PA, Saunders, 1981, pp 2739-2744 Cohen AS, Conso JJ: Tumors of joints and related structures, ill McCarthy OJ (ed): Arthritis and Allied Conditions. Philadelphia, PA, Lea & Fcbiger, 1989, pp 1492·1504 Weiss WW, Bennett JA: Chondrosarcoma: A rare tumor of the jaws. J Oral Maxillofac Surg 44:73, 1986 Gingrass RP: Chondrosarcoma of the mandibular joint: Report of ease. J Oral Surg 12:61,1954 Lanier VC, Wilkinson HA: Chondrosarcoma of the mandible. South Med J 64:711, 1971 Richter KJ, Freeman NS, Quick CA: Cho ndrosarcoma of th e temporomandibular joint: Report of ease. Oral Surg 32:777, 1974 Nortje 0 , Farman AG, Grotepass FW, et al: Chondrosarcoma of the mandibular condyle. Report of a case with special reference to radiographic features. Br J Oral Surg 14:101, 1976 Mossis MR, Clark SK, Porter BA, et al: Chondrosarcoma of the temporomandibular joint: Case report. Head Neck Surg 10: 113,1987 Blaustein D, Scapino R: Remodeling of the temporomandibular joint disk and posterior attachment in disk displacement specimens in relation to glycosaminoglycan content. J Plast Reconstr Surg 78:756, 1986

J Oral Maxillofac Surg 51:315-317,1993

PostobstructivePulmonary Edema as a Sequela of Temporomandibular Joint Arthroscopy: A Case Report BARRY H. HENDLER, DDS, MD,* AND LAWRENCE M. LEVIN, DMD, MDt Although temporomandibular joint (TMJ) arthroscopy, either diagnostic or surgical, is a relatively nonmorbid procedure, it has been associated with several complications. Carter and Schwaber have classified Received from the Department ofOra! and Maxillofacial Surgery, University of Pennsylvania, Philadelphia, PA. • Director Postgraduate Oral and Maxillofacial Surgery; Clinical Professor of Medicine and Surgery; and Director, Department of Oral and Maxillofacial Surgery, Medical College of Pennsylvania, Philadelphia, PA. t Assistant Professor of Oral and Maxillofacial Surgery. Address correspondence and reprint requests to Dr Levin: Hospital of the University of Pennsylvania, 5th floor Silverstein Building, 34()() Spruce St, Philadelphia, PA 19104.

© 1993 American Association of Orat and Maxillofadat Surgeons 0278-2391/93/5103-0018$3.00/0

these complications as anesthetic, inflammatory, infections, neurologic, vascular, otologic, and instrument failure.' The purpose of this article is to present an unusual case in which postobstructive pulmonary edema resulted from airway obstruction following TMJ arthroscopy.

Report of Case In August 1991, a 32-year-old women was seen at the Medical College of Pennsylvania complaining of right TMJ pain. She had previously undergone left TMJ arthroscopy, with lysis and lavage, and right TMJ arthroplasty during which an eminectomy and disc plication were performed . Approximately I year later, the left TMJ symptoms had resolved. However, she still complained of right TMJ pain and limitation of opening due in part to her inability to follow

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the proposed postoperative exercise regimen. Clinical examination and radiographic studies were consistent with adhesive capsulitis and fibrous ankylosis of the right TMJ. The patient was originally scheduled for arthroscopic surgery of the right TMJ for vaporization and ablation of adhesions using the holmium: yttrium aluminum garnetJYAG) laser. However, during surgery it was apparent that the joint space was so fibrosed that initial debridement with a motorized shaver was required. This enabled the optical fiber tip of the laser to be visualized more clearly within the superior joint space. Arthroscopy was performed with difficulty, lasting over 90 minutes and involving multiple attempts at maintaining triangulation. There was ongoing infusion of over 2 L of normal saline irrigation. Moderate swellingof the right preauricular area and mandibular anglewas noted immediately before extubation. At that time, the patient was spontaneously ventilating, with an oxygen saturation of 98%, and was fully awake and responding to verbal commands. Immediately upon extubation, however, the patient became apneic for several seconds and then developed stridor and marked inspiratory efforts associated with cyanosis. The oxygen saturation dropped to 45%, and the patient was administered succinylcholine before reintubation, Direct laryngoscopy during reintubation revealed swellingof the right soft palate as well as tracheal deviation to the left. Once ventilation was controlled, the patient's condition dramatically improved. Soon thereafter, however, the patient's condition started to deteriorate again despite adequate ventilation with 100% oxygen. Oxygen saturation dropped to 85% and copious amounts of pink frothy fluid were suetioned from the endotracheal tube. On pulmonary auscultation, abundant rales were noted in all lung fields.'A chest radiograph revealed diffuse haziness, increased vascular markings (Fig I), and multiple areas of patchy infiltrates, without cardiomegaly compatible with acute pulmonary edema. Furosemide, 40 mg IV, was administered and after 30 minutes secretions had decreased and arterial blood gas measurements had improved. The patient remained intubated overnight. Bythe next day, the chest radiograph showed marked improvement (Fig 2). Both lung fields were clear to auscultation, the palatal swellingand tracheal deviation had resolved, and the patient was extubated without complication. The patient was discharged on the second postoperative day.

Discussion TMJ arthroscopy has been associated with a variety ofintraoperative and postoperative complications. This case illustrates two uncommon but potentially lethal complications: acute airway obstruction and noncardiogenic pulmonary edema. Carter and Schwaber! included airway obstruction under anesthetic complications of TMJ surgery. They reported that difficult and lengthy triangulation procedures may lead to infusion ofa large amount ofirrigant, resulting in medial extravasation of fluid . This extravasation could be enhanced by excessive pressure during insertion of the trochar, leading to perforation of the medial capsule of the TMJ or direct puncture by the scope itself. The subsequent distention of the soft tissues may lead to edema of the medial masticatory space, lateral ph a-

FIGURE I. Radiograph of the chest showing diffuse haziness and increased vascular markings.

ryngeal space, tonsillar fossa, soft palate, uvula and ultimately to acute upper airway obstruction.' The development of postobstructive pulmonary edema associated with other conditions has been previously reported.i" Furthermore, Galvis et al reported on pulmonary edema that began after the airway obstruction was relieved.' The pathogenesis of the phenomenon appears to be multifactorial, and it is most likely related to a combination of factors, including an increase in capillary transmural hydrostatic pressure gradient, change in capillary permeability, and increased production of catecholamines, When upper airway obstruction exists, inspiration against a closed glottis (Muller maneuver) results in extreme negative pressures. This increases the hydrostatic pressure gradient, promoting the transudation of fluid into the interstitium," In addition, with severe or prolonged mechanical stress, the anatomic integrity of the pulmonary capillary wall may be disrupted, resulting in increased capillary permeability. Increased negative intrathoracic pressure causes increased venous return and the resultant increase in pulmonary blood volume leads to increased ventricular afterload. This in turn, results in decreased cardiac output, which will once again increase pulmonary venous pressure and thus promote transudation and pulmonary edema." It is well known that lack of airflow during upper airway obstruction results in arterial hypoxemia. This

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FIGURE 2. Radiograph of the chest taken on the first postoperative day showing resolution of the pulmonary edema.

alone triggers a central nervous system-mediated massive sympathetic discharge with peripheral vasoconstriction that shunts blood centrally. Increased pulmonary vascular pressure along with hypoxia-mediated pulmonary arterial constriction would force blood through the remaining vesselsat pressures high enough to result in pulmonary edema. Moreover, hypoxemia along with acidosis leads to myocardial depression. This compromise in cardiac function may lead to ventricular dysfunction that, ifsevere enough, could contribute to further pulmonary capillary leakage.' Of note is the fact that pulmonary edema also can occur following the relief of the obstruction. It is believed that relief ofthe obstruction produces an abrupt decrease in airway pressure, causing a sudden increase in venous return, which further increases pulmonary hydrostatic pressure and leads to edema.' The surgeon performing arthroscopy must be critically aware of all ways to avoid the potentially lethal complication of postobstructive pulmonary edema. First, prevention begins before extubation. The phar-

ynx must be inspected for asymmetry and the neck examined for swellingand tracheal deviation secondary to pharyngeal edema. The patient should not be extubated if these conditions exist and should be monitored until symmetry returns. Lateral pharyngeal edema secondary to saline infusion usually resolves after 2 to 4 hours, and the patient can then be extubated in a standard manner. I Egressportals should be constantly evaluated for free flow to avoid excessive infusion. Careful monitoring will avoid imbalance between inflow and outflow. In addition, minimal irrigation pressure should be maintained to decrease fluid extravasation. Gravity flow from an IV bag helps ensure controlled (minimum) pressures. Avoidance of medial capsule puncture also will help minimize inadvertent fluid extravasation. Finally, decreased operative time, attainable through an experienced, systematic approach, will aid in preventing edema. I Patients who experience pulmonary edema following upper airway obstruction should be treated with oxygen and positive end expiratory pressure. Close monitoring should include radiographic examinations of the chest and arterial blood gas measurements to assess current status and improvement. Fluid administration should be carried out with caution, and diuresis may be indicated if the patient's condition becomes worse.' In most instances, postobstructive pulmonary edema will resolve rapidly. Thus, assisted ventilation usually can be discontinued gradually without a need for aggressive therapy.

References I. Carter JB, Schwaber MK: Temporomandibular joint arthroscopy complications and their management, in Merrill RG (ed): Disorders of the TMJ: Diagnosis and Arthroscopy. Oral MaxiIlofac Surg Clin North Am 1:185, 1989 2. Galvis AG, Stool SE, Bluestone CD: Pulmonary edema following relief of acute upper airway obstruction. Ann Otol Rhinol LaryngoI89:124, 1980 3. Price SL, Hecker BR: Pulmonary oedema following airway obstruction in a patient with Hodgkin's disease. Br J Anaesthesiol 59:518, 1987 4. Lorch 00, Sahn SA: Post-extubation pulmonary edema following anesthesia induced by upper airway obstruction. Chest 90: 802, 1986 5. Scherer R, Dreyer P, Jorch G: Pulmonary edema due to partial upper airway obstruction in a child. Intensive Care Med 14: 661, 1988 6. Kamal RS, Agha S: Acute pulmonaryedema, Anesthesia 39: 464,1984