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Conservative surgical management of synovial chondromatosis
LETTERS TO THE EDITOR
Conservative surgical management of synovial ehondromatosis To the editor:
A 43-year-old woman had a 15-mm palpable mass in the right preanricular region; it had been present for 2 years. The mass was smooth, well-circumscribed, deeply fixed, and non-tender. Facial nerve function was normal. The patient had previously experienced fightsided facial pain that had been diagnosed as myofascial in origin. Because a parotid tumor was suspected, a fine-needle aspirate was performed; it revealed ductal cells on a mucoid background. A computerized tomography assessment was arranged, and a date was set for surgery, pending a superficial parotidectomy. Radiologic interpretation reported normal parotid gland anatomy with the characteristic signs of synovial chondromatosis of the fight temporomandibular joint (Figs. 1 and 2). Three masses of tissue were identified: lateral, medial, and posterior. The contour of the condylar head was normal. After induction of general anesthetic, a modified preauricular approach was made to the joint, with incision of the capsule releasing the lateral mass. Distraction of the condylar head allowed a fragmented removal of the posterior mass. The medial mass was left untouched because of the risk of damage to deep anatomic structures. The condylar head was found to be smooth, and closure was obtained with preservation of the synovium, capsule, and condyle. Through histologic analysis, the removed fragments were found to consist of cartilagenous tissue with variable central calcification. Eighteen months after surgery, the patient was pain-free with normal function; radiographic follow-up showed no signs of recurrence of the cartilagen0us metaplasia. The common diagnostic error in synovial chondromatosis of the temporomandibular joint was made in this case: it was initially mistaken for a parotid tumor. This demonstrates the importance of preoperative radiologic assessment. As far as treatment and surgery are concerned, it has historically been posited in the literature that complete removal of the synovium is necessary to avoid recurrence, with a condylectomy or condylotomy used as necessary to allow surgical exposure. Such an approach carries with it a high morbidity. The effects of conservative and radical surgery have been studied. A study by Christensen and Poulsen t reported a recurrence in 30% of cases treated with synovectomy. Literature reviews by Kusen 2 and Ballard and Weiland 3 have shown that incomplete removal of 592
Fig. 1. Computerized tomography scan in the axial plane.
Fig. 2. Computerized tomography scan in the coronal plane.
the cartilagenous bodies and synovium has not led to recurrence, in some cases up to 9 years after surgery. A further study, by Coolican and Dandy, 4 demonstrated that the rate of recurrence was less in patients treated
December 1997 ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
Letters to the editor 593
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
Volume 84, Number 6 by arthroscopic surgery and maintenance of the synovium than in patients treated by open surgery. The preceding information supports taking a conservative approach in the management of synovial chondromatosis in the absence of condylar head or glenoid fossa erosion. The causes of recurrence remain unknown. Trauma is cited as the most common cause of the primary and secondary forms of synovial chondromatosis, and perhaps persistent trauma postoperatively could induce a recurrence.
Gary Bell, FDS, RCS(Ire), FDS, RCS(Eng) Claire Wilson Sharp, MRCP, FRCR Le Roux Fourie, FRCS, M.Med, FCS(S.A.) David Hutchinson, FDS, RCS(Eng), D. Orth. RCS(Eng) City General Hospital, Carlisle, England Pinderfields Hospital, Wakefield, England REFERENCES
1. Christensen JH, Poulsen JO. Synovial chondromatosis. Acta Orthop Scand 1975;46:919-25. 2. Kusen GJ. Chondromatosis:report of a case. J Oral Surg 1969; 27:735-8. 3. Ballard R, Weiland LH. Synovial chondromatosis of the temporomandibularjoint. Cancer 1972;30:791-5. 4. Coolican MR, Dandy DJ. Arthroscopicmanagementof synovial chondromatosis of the knee: findings and results in 18 cases. J Bone Joint Surg Br 1989;71:498-500.
Oral surgery for liver transplant patients To the editor: We know that the risks of infection are greater in a patient who is i mmunodepressed. 1 Consequently, it is logical to eliminate infected and periodontally involved teeth before liver transplant surgery. We are also aware of the risk of bleeding after extractions in a patient who is liver-deficient. 2 Post-extraction bleeding may provoke or worsen an existing encephalopathy and lead to death. Blood that is ingested increases the level of nitrogen that the patient's liver cannot purify. Preparation for oral surgery includes the administration of fresh plasma as well as platelets. A patient who bleeds continually after oral surgery will rapidly be deprived of plasmatic enzymes; this deprivation might not stop despite massive administration of blood products. Even though such a patient is treated with blood products before oral surgery, we must use local means of hemostasis that can provide pressure at the surgical site and protect it. We have devised hemostatic stents with these two objectives in mind--pressure at the surgical site for
Fig. 1. Surgical stent 8 days after surgery. Coloration is caused by Eludril mouthwash. Only sutures can stabilize stent in this case.
many days and adequate protection. When we started, 3 the surgical stent was made only of polyurethane sheets. Then we added 0.5 nun steel wire. We now use 0.8 m m wire, which permits segmentation and is more comfortable for the patient. With this appliance it is possible to use a single section only, depending on the site of the extractions to be performed. The stent is fixed with sutures (Fig. 1) that maintain its stability and prevent not only food impaction but also the stent's accidental removal by the patient. While the stent is being worn, the patient remains in the hospital under constant observation, and the patient and the family are made aware of the potential risks which may occur during our intervention. In spite of a greatly disturbed hemostatic mechanism in patients about to undergo a liver transplant, we have been able to perform indicated oral surgery without postoperative bleeding complications. We have used this technique for the last 4 years and have treated 32 patients.
Gdrard Bader, DDS, PhD Michel Mesner, MD Sophie Lejeune, DDS Service de Pathologie et Chirurgie Buccale Rennes University Hospital Center REFERENCES
1. Svirsky JA, Saravia ME. Dental management of patients after liver transplantation. Oral Surg Oral Med Oral Patbol 1989;67: 541-6. 2. Rakocz M, Mazard A, Varon D, Spierer S, Blinder D, Martinowitz U. Dental extractions in patients with bleeding disorders: the use of fibrin glue. Oral Surg Oral Med Oral Pathol 1993;75:280-2. 3. Bader G, Glez D, De Labarthe C, Gagnot G. Les goutti~res thermoform6es dans ia pr6vention des h6morragies postextractionnelles. Acta Odonto Stomatol 1994;186:213-20.
Conservative surgical management of synovial ehondromatosis To the editor:
A 43-year-old woman had a 15-mm palpable mass in the right preanricular region; it had been present for 2 years. The mass was smooth, well-circumscribed, deeply fixed, and non-tender. Facial nerve function was normal. The patient had previously experienced fightsided facial pain that had been diagnosed as myofascial in origin. Because a parotid tumor was suspected, a fine-needle aspirate was performed; it revealed ductal cells on a mucoid background. A computerized tomography assessment was arranged, and a date was set for surgery, pending a superficial parotidectomy. Radiologic interpretation reported normal parotid gland anatomy with the characteristic signs of synovial chondromatosis of the fight temporomandibular joint (Figs. 1 and 2). Three masses of tissue were identified: lateral, medial, and posterior. The contour of the condylar head was normal. After induction of general anesthetic, a modified preauricular approach was made to the joint, with incision of the capsule releasing the lateral mass. Distraction of the condylar head allowed a fragmented removal of the posterior mass. The medial mass was left untouched because of the risk of damage to deep anatomic structures. The condylar head was found to be smooth, and closure was obtained with preservation of the synovium, capsule, and condyle. Through histologic analysis, the removed fragments were found to consist of cartilagenous tissue with variable central calcification. Eighteen months after surgery, the patient was pain-free with normal function; radiographic follow-up showed no signs of recurrence of the cartilagen0us metaplasia. The common diagnostic error in synovial chondromatosis of the temporomandibular joint was made in this case: it was initially mistaken for a parotid tumor. This demonstrates the importance of preoperative radiologic assessment. As far as treatment and surgery are concerned, it has historically been posited in the literature that complete removal of the synovium is necessary to avoid recurrence, with a condylectomy or condylotomy used as necessary to allow surgical exposure. Such an approach carries with it a high morbidity. The effects of conservative and radical surgery have been studied. A study by Christensen and Poulsen t reported a recurrence in 30% of cases treated with synovectomy. Literature reviews by Kusen 2 and Ballard and Weiland 3 have shown that incomplete removal of 592
Fig. 1. Computerized tomography scan in the axial plane.
Fig. 2. Computerized tomography scan in the coronal plane.
the cartilagenous bodies and synovium has not led to recurrence, in some cases up to 9 years after surgery. A further study, by Coolican and Dandy, 4 demonstrated that the rate of recurrence was less in patients treated
December 1997 ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
Letters to the editor 593
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
Volume 84, Number 6 by arthroscopic surgery and maintenance of the synovium than in patients treated by open surgery. The preceding information supports taking a conservative approach in the management of synovial chondromatosis in the absence of condylar head or glenoid fossa erosion. The causes of recurrence remain unknown. Trauma is cited as the most common cause of the primary and secondary forms of synovial chondromatosis, and perhaps persistent trauma postoperatively could induce a recurrence.
Gary Bell, FDS, RCS(Ire), FDS, RCS(Eng) Claire Wilson Sharp, MRCP, FRCR Le Roux Fourie, FRCS, M.Med, FCS(S.A.) David Hutchinson, FDS, RCS(Eng), D. Orth. RCS(Eng) City General Hospital, Carlisle, England Pinderfields Hospital, Wakefield, England REFERENCES
1. Christensen JH, Poulsen JO. Synovial chondromatosis. Acta Orthop Scand 1975;46:919-25. 2. Kusen GJ. Chondromatosis:report of a case. J Oral Surg 1969; 27:735-8. 3. Ballard R, Weiland LH. Synovial chondromatosis of the temporomandibularjoint. Cancer 1972;30:791-5. 4. Coolican MR, Dandy DJ. Arthroscopicmanagementof synovial chondromatosis of the knee: findings and results in 18 cases. J Bone Joint Surg Br 1989;71:498-500.
Oral surgery for liver transplant patients To the editor: We know that the risks of infection are greater in a patient who is i mmunodepressed. 1 Consequently, it is logical to eliminate infected and periodontally involved teeth before liver transplant surgery. We are also aware of the risk of bleeding after extractions in a patient who is liver-deficient. 2 Post-extraction bleeding may provoke or worsen an existing encephalopathy and lead to death. Blood that is ingested increases the level of nitrogen that the patient's liver cannot purify. Preparation for oral surgery includes the administration of fresh plasma as well as platelets. A patient who bleeds continually after oral surgery will rapidly be deprived of plasmatic enzymes; this deprivation might not stop despite massive administration of blood products. Even though such a patient is treated with blood products before oral surgery, we must use local means of hemostasis that can provide pressure at the surgical site and protect it. We have devised hemostatic stents with these two objectives in mind--pressure at the surgical site for
Fig. 1. Surgical stent 8 days after surgery. Coloration is caused by Eludril mouthwash. Only sutures can stabilize stent in this case.
many days and adequate protection. When we started, 3 the surgical stent was made only of polyurethane sheets. Then we added 0.5 nun steel wire. We now use 0.8 m m wire, which permits segmentation and is more comfortable for the patient. With this appliance it is possible to use a single section only, depending on the site of the extractions to be performed. The stent is fixed with sutures (Fig. 1) that maintain its stability and prevent not only food impaction but also the stent's accidental removal by the patient. While the stent is being worn, the patient remains in the hospital under constant observation, and the patient and the family are made aware of the potential risks which may occur during our intervention. In spite of a greatly disturbed hemostatic mechanism in patients about to undergo a liver transplant, we have been able to perform indicated oral surgery without postoperative bleeding complications. We have used this technique for the last 4 years and have treated 32 patients.
Gdrard Bader, DDS, PhD Michel Mesner, MD Sophie Lejeune, DDS Service de Pathologie et Chirurgie Buccale Rennes University Hospital Center REFERENCES
1. Svirsky JA, Saravia ME. Dental management of patients after liver transplantation. Oral Surg Oral Med Oral Patbol 1989;67: 541-6. 2. Rakocz M, Mazard A, Varon D, Spierer S, Blinder D, Martinowitz U. Dental extractions in patients with bleeding disorders: the use of fibrin glue. Oral Surg Oral Med Oral Pathol 1993;75:280-2. 3. Bader G, Glez D, De Labarthe C, Gagnot G. Les goutti~res thermoform6es dans ia pr6vention des h6morragies postextractionnelles. Acta Odonto Stomatol 1994;186:213-20.