Keywords
dislocation - condylectomy - temporal fossa
Introduction
Temporomandibular joint (TMJ) dislocation is the clinical condition where the head
of the condyle is displaced out of the glenoid fossa.[1] It represents ~3% of all dislocated joints in the body.[2] Patients usually present with pain in the preauricular region, difficulty in closing
the mouth, anterior open bite, and deviated chin, causing severe pain and discomfort
to the patient.
Usually, it occurs when the TMJ is subjected to excessive movement beyond its normal
range[3] or following any traumatic injury to the TMJ.[4] Similarly, mandibular condyle tends to get dislocated by excessive maneuvering during
tracheal intubation under general anesthesia.[5]
[6]
[7] It can occur at any time during laryngoscopy while intubation or extubation.[6] Here, we report a case of dislocation of TMJ following tracheal intubation in a
60-year-old woman that was overlooked for a prolonged period necessitating the resection
of the condyle.
Anesthesiologists, surgical team, and other health professionals should be aware regarding
the prevention, early diagnosis, and manual reduction in condyle into the glenoid
fossa at the earliest to preclude an aggressive treatment as mentioned in the present
case.
Case Presentation
A 60-year-old woman reported to our department with difficulty in closing the mouth
for the last 4 weeks. History of present illness reveals difficulty in closing the
mouth, chewing, and speaking following hysterectomy under general anesthesia 4 weeks
ago.
The patient was treated with analgesics and muscle relaxants during the postoperative
period following hysterectomy. Later, when the symptoms were not subsided for an extended
period of time, the patient was referred to the dentist for a complete examination.
The patient was suspected to have dislocations of the mandibular condyles and the
closed manual reduction was attempted several times under local anesthesia by the
dentist that was unsuccessful.
Clinical examination revealed hollowness in the bilateral preauricular region with
restricted lower jaw movement and inability to close or open mouth. A three-dimensional
computed tomography showed dislocated condyle in the anterior direction on the left
side and into the temporal fossa on the right side ([Fig. 1A], [B]).
Fig. 1 Three-dimensional CT images depicting dislocation of condyles in the anterior direction
on left side and in the temporal fossa on the right side (white arrows). CT, computed
tomography.
Under general anesthesia, the manual reduction was performed. Left condyle was reduced
into the glenoid fossa manually but not on the right side. So, the TMJ on the right
side was opened through the preauricular incision. Dislocation of right mandibular
condyle into the temporal fossa was noticed on exposing the joint; manual reduction
could not be achieved as it was being obstructed by the zygomatic arch. Hence, condylectomy
was done on the right side ([Fig. 2]).
Fig. 2 Intraoperative image showing condylectomy on right side.
Immobilization of the mandible using eyelet wiring was done for 4 weeks post condylectomy
and then physiotherapy was initiated. A postoperative panoramic radiograph was taken
to assess the TMJ ([Fig. 3]).
Fig. 3 Postoperative panoramic radiograph showing condylectomy on right side and condyle
in the glenoid fossa on left side (white arrows).
Patient was followed up for a period of 6 months. There was no difficulty in closing
and opening the mouth during the follow-up period. Slight deviation of mandible on
the right side was observed.
Discussion
Dislocation of mandibular condyles following general anesthesia has been mentioned
in the literature.[5]
[6]
[7] It is often unnoticed unless patient complains of pain and swelling during the postoperative
period. Difficulty in opening and closing the mouth for a prolonged period of time
causes severe discomfort and embarrassment to the patient.
Unawareness of the anesthesiologists or surgical team with the dislocation of TMJ
seems to be contributing factor for delayed diagnosis and its treatment.[6]
Prabhakar and Sigla[8] reported a case of bilateral dislocation of condyles into the temporal fossa following
an injury to the chin region. The presence of rounded mandibular condyle and elasticity
of zygomatic arch are considered to be the contributing factors for dislocation of
mandibular condyle into the temporal fossa.[9]
The simple manual reduction is considered to be the first treatment option for any
type of dislocation. Any delay in the reduction may induce fibrosis of the soft tissues
around the joint that may further make reduction difficult and necessitates condylectomy,[9] which in turn reduces ramus height and deviation of the mandible toward affected
side.
In the present case, manual reduction was planned under general anesthesia as the
patient was apprehensive due to previous repeated attempts toward repositioning of
condyles under local anesthesia. Left condyle could be reduced into glenoid fossa
but not on right side. Difficulty in reducing condyle on the right side may be due
to the presence of fibrous tissue and obstruction of condyle by zygomatic arch.
Conclusion
There is a possibility of mandibular condyles getting dislocated during tracheal intubation
under general anesthesia. Anesthesiologists, surgical team, and other health professionals
should be aware of this iatrogenic complication such that early intervention can be
initiated.
