FINDINGS:
This is a 17 year-old female with a three to four month history of trismus and a longer history of joint noise with reciprocal clicking affecting her right temporomandibular joint. The patient has had significant discomfort and dysfunction. The patient underwent cone beam CT imaging which showed normal osseous structures of the joint complex. MRI demonstrated anterior displaced disk without reduction and poor translation of the right mandibular condyle. Case was discussed at length with the patient and parents. Risks, benefits and alternative therapies were reviewed. Clinical indications for arthroscopic examination under general anesthesia was reviewed with the goal of improving the range of motion of the mandible. The procedure was outlined, questions were answered. Patient is being taken to the Operating Room in an elective manner.
PROCEDURE:
The patient was taken to the OR, placed on the OR table in a supine position. The patient was induced under general anesthesia and maintained via nasotracheal intubation. The patient was prepped and draped in a standard fashion for a right TMJ arthroscopy. The arthroscopic camera and scope were noted to be in working order.
With palpation of the lateral pole of the right condylar head palpated, the lateral rim of the glenoid fossa was localized, approximately two ml of 1% Xylocaine with Epinephrine was infiltrated into the pericapsular area and into the superior joint space with a #25 needle.
With the use of a #15 Bard Parker blade, a skin puncture was made approximately one cm anterior to the tragus along the canthal tragal line. Blunt dissection followed with a mosquito hemostat to the lateral lip of the fossa. Once easily palpated, a Stryker 2.3 arthroscope cannula and blunt trocar was used to enter the superior joint space which was gained on its initial attempt. The joint was insufflated with normal saline and an exit port using a #18 gauge needle was gained. Appropriate irrigant flow was gained. Visualization of the superior joint space proceeded.
The scope was well placed in the posterior cul-de-sac. No increased vascular markings were noted along the posterior attachment. Minor scuffing along the roof of the fossa denoted our entry point. Manipulation of the scope in and around the confines of the posterior capsule extending anterior over the level of the condylar head, the junction of the fibrocartilage was not noted. Retrodiscal tissue was covering the bulk of the condylar head with the fibrocartilage positioned anteriorly and not reducing with jaw motion. Manipulation of the condyle and the scope along the medial recess extending to the superior cul-de-sac was attempted but not appropriately gained. No perforations were noted of the disc complex. Mobilization of the joint was completed easily though good visualization of anterior cul-de-sac was not fully made.
After approximately 150 to 175 ml of normal saline irrigant completed, no significant adhesions were noted, disk was not fully visualized due to its anterior displacement. All instrumentation was removed. Pressure was placed in the area of the puncture site. No excessive bleeding was noted. A 5-0 fast gut suture was placed at the entry point.
This concluded the surgical portion of the case. The patient was extubated in the Operating Room, taken to the Recovery Room in stable condition.
