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The effect of temporomandibular joint arthroscopy on ear function
J Oral Maxillofac 47:1022-1025,
Surg
1989
The Effect of Temporomandibular Joint Arthroscopy on Ear Function JERRY L. JONES, DDS, MD,* AND KARL L. HORN, MDt
Many patients with temporomandibular joint (TMJ) dysfunction also complain of subjective symptoms of ear dysfunction. This study was undertaken to evaluate preoperatively patients with ear complaints associated with TMJ pain and dysfunction and to examine the effect of essentially uncomplicated TMJ arthroscopy on subsequent ear function. Fourteen patients (22 joints) were examined arthroscopically. The patients were evaluated by an otologist, and hearing tests were obtained pre- and postoperatively. All patients had normal audiometric studies preoperatively, and these remained unchanged postoperatively. It was concluded that uncomplicated arthroscopy of the TMJ does not cause ear dysfunction.
With the increasing use of diagnostic and therapeutic arthroscopy of the temporomandibular joint (TMJ), complications related to these procedures are beginning to be reported. l-3These include injury to local nerves and vessels, injury to articular surfaces, fracture of the glenoid fossa, infection and injury to the external and/or middle ear, and one report of conductive hearing 10ss.~,~,~This study was undertaken to determine whether patients with subjective and objective (magnetic resonance imaging [MRI], arthrographic) evidence of TMJ dysfunction have abnormal audiometric tests, and whether apparently uncomplicated TMJ arthroscopy causes abnormal ear function.
(MRI, arthrography) evidence of internal derangement underwent diagnostic and/or therapeutic arthroscopy. All patients reported symptoms of ear pain or dysfunction, ie, tinnitus or fullness. Preoperatively and postoperatively, external otoscopy was performed by both the operating oral and maxillofacial surgeon and an otologist. Pure tone audiometry and impedence tympanometry were performed before arthroscopy and within 48 hours postoperatively. The arthroscopic procedures were performed, as previously described by others,4T6V7 with the use of a 1.9- or 2.7-mm Wolfe arthroscope. All procedures were performed on an outpatient basis, and postoperative management was consistent with what has been described by others.4*7
Materials and Methods
Results
Fourteen patients (22 joints), who had failed to respond to conventional conservative management of TMJ pain and dysfunction and who had objective
Twenty-two joints in 14 patients (12 female, two male) were examined. Seven patients (eight joints) also underwent blunt, blind lysis of adhesions. Two recognized complications occurred during the operative procedures. One patient (P.R.) had a run of premature ventricular contractions with a bigeminal pattern after dilation of one joint space with saline and a 1:2OO,OOO epinephrine solution. The arrhythmia lasted a short time, and no specific treatment was necessary. On examination of the joint space, a perforation of the medial capsule was noted, and it
* In private practice, Albuquerque, New Mexico. t In private practice, Neurotology, Albuquerque, New Mexico. Address correspondence and reprint requests to Dr Jones: 7007 Wyoming NE A-2, Albuquerque, NM 87109. 0 1989 American Association geons 0278-2391/89/4710-0003$3.00/O
of Oral and Maxillofacial
Sur-
1022
1023
JONES AND HORN
was assumed that the vasoconstrictive solution had been placed in a vessel medial to the joint. Two other patients had external canal contusions found on postoperative otoscopy (Table 1). Of the 14 patients one (M.B.) had a mild highfrequency deficit found on the preoperative study, and the postoperative examination was essentially identical (Fig 1). The remaining preoperative studies were all normal. Although two patients exhibited contusion of the anterior wall of the cartilagenous external auditory canal, all patients, regardless of their arthroscopic diagnosis and surgical manipulation, showed no significant change in postoperative audiometric testing (Table 1). The preand post-operative audiometric findings in one patient (B.A.) in whom a cartilagenous ear canal contusion was identified are shown in (Fig 2). There Table 1.
were no complaints of vertigo or blocked ears in these patients, and there were no infections. Discussion
The initial hypothesis in this study was that definable postoperative conductive hearing deficits would be identified as a result of middle ear effusion from surgical edema and/or copious irrigation entering the middle ear through small defects in the petrotympanic fissure or the chorda tympani canal. However, no hearing deficits were identified in any of the 14 patients. Direct damage of middle ear structure would require insertion of an instrument through the bony tympanic ring. In the infant, the foramen of
Summary of Patients and Audiometric Testing
Patient
Sex/Age (yr)
Joint
Diagnosis
Treatment
Preoperative Audiometric Testing
Complications
P.R.
F/23
L ADD R Synovitis
DX
WNL
Ventricular ectopy
B.A.
F/47
Adhesions WI perforation
L&L
WNL
Canal contusion
G.T.
Ml25
ADD
DX
WNL
None
P.D.
F/2 1
WNL
DX
WNL
None
S.P.
F/42
WNL
DX
WNL
None
MS.
Ml30
WNL
DX
WNL
Canal contusion
N.S.
F/42
R ADD WI adhesions L ADD
L&L
WNL
None
F.H.
F/40
Adhesions WI perforations
L&L
WNL
None
C.H.
F/3 1
ADD WI adhesions
L&L
WNL
None
C.M.
F/33
L ADD, adhesions R WNL
L&L
WNL
None
M.K.S.
F/33
L ADD WI adhesions R mild synovitis
L&L
WNL
None
M.B.
F/49
L
ADD WI synovitis
DX
Mild highfrequency hearing loss
None
C.H.
F/23
L
Adhesions WI perforation
L&L
WNL
None
S.B.
F/28
R
ADD WI
DX
WNL
None
Abbreviations:
ADD, anteriorly displaced disc; WNL, within normal limits; L&L, lysis and lavage; DX, diagnostic arthroscopy.
1024
EFFECT OF TMJ ARTHROSCOPY
ON EAR FUNCTION
FIGURE 2. Audiogram (rap) and tympanogram (bottom) of patient with ear canal contusion.
FIGURE 1. Audiogram (top) and tympanogram (bottom) of patient with high-frequency hearing deficit.
Huschke is a relatively large defect in the anterior inferior tympanic ring; in rare cases of agenesis, this defect may persist in the adult and represent a potential site of entrance into the middle ear from the posterior aspect of the temporomandibular joint (Fig 3). In general, however, this route of middle ear trauma is unlikely due to the thickness of the anterior tympanic ring. A more likely route of injury is through the bonecartilage junction of the external auditory canal. Indeed, ecchymosis was noted in two of our patients at this site. Improper insertion of the trocar or vigorous inspection or instrumentation of the posterior
aspect of the joint may potentially lead to interruption of the external auditory canal at the postglenoid tubercle. At this point, an instrument is only several millimeters from insertion through the tympanic membrane into the middle ear. We believe that proper identification of the glenoid recess when the mandible is positioned anteriorly, and location of the lateral aspect of the fossa with the trocar, are absolutely necessary before further advancement of the trocar or arthroscope. Although it is common for patients with internal derangement of the TMJ to have symptoms of ear pain or dysfunction, our results suggest that most patients probably have no auditory pathology. However, this may not be true in all patients, and an otologic consultation should be obtained in those with uncertain history or positive physical findings. Our results suggest that with the routine use of arthroscopy there is probably no change in audio-
T R
Fissure
”
FIGURE 3. Anatomy of the glenoid fossa. Note the location of the foramen of Huschke.
1025
JONES AND HORN
metric testing, and therefore ear function. Moreover, although all of the patients studied reported subjective symptoms of ear dysfunction preoperatively, all were found to have normal audiometric examinations. References I. Westesson PL, Eriksson L, Liedberg L: The risk of damage to facial nerve, superficial temporal vessels, discs, and articular surfaces during arthroscopic examination of the temporomandibular joint. Oral Surg 2:124, 1986 2. McCain JP: Arthroscopy of the human temporomandibular
3. 4.
5.
6. 7.
joint. Washington, DC, AAOMS Proceedings, September 1985 Holmund A, Hellsing C: Arthroscopy of the TMJ. An autopsy study. Int J Oral Surg 14:169, 1985 Sanders B: Arthroscopic surgery of the temporomandibular joint: Treatment of internal derangement with persistent closed lock. Oral Surg Oral Med Oral Path01 62:361, 1986 Van Sickels JE, Nishioka GJ, Hegewald MD, et al: Middle ear injury resulting from temporomandibularjoint arthroscopy. J Oral Maxillofac Surg 45:%2, 1987 Goss A, Bosanquet A: Temporomandibular joint arthroscopy. J Oral Maxillofac Surg 44:614, 1986 Tarro AW: Arthroscopic diagnosis and surgery of the temporomandibular joint. Oral Maxillofac Surg 46:282, 1988
Surg
1989
The Effect of Temporomandibular Joint Arthroscopy on Ear Function JERRY L. JONES, DDS, MD,* AND KARL L. HORN, MDt
Many patients with temporomandibular joint (TMJ) dysfunction also complain of subjective symptoms of ear dysfunction. This study was undertaken to evaluate preoperatively patients with ear complaints associated with TMJ pain and dysfunction and to examine the effect of essentially uncomplicated TMJ arthroscopy on subsequent ear function. Fourteen patients (22 joints) were examined arthroscopically. The patients were evaluated by an otologist, and hearing tests were obtained pre- and postoperatively. All patients had normal audiometric studies preoperatively, and these remained unchanged postoperatively. It was concluded that uncomplicated arthroscopy of the TMJ does not cause ear dysfunction.
With the increasing use of diagnostic and therapeutic arthroscopy of the temporomandibular joint (TMJ), complications related to these procedures are beginning to be reported. l-3These include injury to local nerves and vessels, injury to articular surfaces, fracture of the glenoid fossa, infection and injury to the external and/or middle ear, and one report of conductive hearing 10ss.~,~,~This study was undertaken to determine whether patients with subjective and objective (magnetic resonance imaging [MRI], arthrographic) evidence of TMJ dysfunction have abnormal audiometric tests, and whether apparently uncomplicated TMJ arthroscopy causes abnormal ear function.
(MRI, arthrography) evidence of internal derangement underwent diagnostic and/or therapeutic arthroscopy. All patients reported symptoms of ear pain or dysfunction, ie, tinnitus or fullness. Preoperatively and postoperatively, external otoscopy was performed by both the operating oral and maxillofacial surgeon and an otologist. Pure tone audiometry and impedence tympanometry were performed before arthroscopy and within 48 hours postoperatively. The arthroscopic procedures were performed, as previously described by others,4T6V7 with the use of a 1.9- or 2.7-mm Wolfe arthroscope. All procedures were performed on an outpatient basis, and postoperative management was consistent with what has been described by others.4*7
Materials and Methods
Results
Fourteen patients (22 joints), who had failed to respond to conventional conservative management of TMJ pain and dysfunction and who had objective
Twenty-two joints in 14 patients (12 female, two male) were examined. Seven patients (eight joints) also underwent blunt, blind lysis of adhesions. Two recognized complications occurred during the operative procedures. One patient (P.R.) had a run of premature ventricular contractions with a bigeminal pattern after dilation of one joint space with saline and a 1:2OO,OOO epinephrine solution. The arrhythmia lasted a short time, and no specific treatment was necessary. On examination of the joint space, a perforation of the medial capsule was noted, and it
* In private practice, Albuquerque, New Mexico. t In private practice, Neurotology, Albuquerque, New Mexico. Address correspondence and reprint requests to Dr Jones: 7007 Wyoming NE A-2, Albuquerque, NM 87109. 0 1989 American Association geons 0278-2391/89/4710-0003$3.00/O
of Oral and Maxillofacial
Sur-
1022
1023
JONES AND HORN
was assumed that the vasoconstrictive solution had been placed in a vessel medial to the joint. Two other patients had external canal contusions found on postoperative otoscopy (Table 1). Of the 14 patients one (M.B.) had a mild highfrequency deficit found on the preoperative study, and the postoperative examination was essentially identical (Fig 1). The remaining preoperative studies were all normal. Although two patients exhibited contusion of the anterior wall of the cartilagenous external auditory canal, all patients, regardless of their arthroscopic diagnosis and surgical manipulation, showed no significant change in postoperative audiometric testing (Table 1). The preand post-operative audiometric findings in one patient (B.A.) in whom a cartilagenous ear canal contusion was identified are shown in (Fig 2). There Table 1.
were no complaints of vertigo or blocked ears in these patients, and there were no infections. Discussion
The initial hypothesis in this study was that definable postoperative conductive hearing deficits would be identified as a result of middle ear effusion from surgical edema and/or copious irrigation entering the middle ear through small defects in the petrotympanic fissure or the chorda tympani canal. However, no hearing deficits were identified in any of the 14 patients. Direct damage of middle ear structure would require insertion of an instrument through the bony tympanic ring. In the infant, the foramen of
Summary of Patients and Audiometric Testing
Patient
Sex/Age (yr)
Joint
Diagnosis
Treatment
Preoperative Audiometric Testing
Complications
P.R.
F/23
L ADD R Synovitis
DX
WNL
Ventricular ectopy
B.A.
F/47
Adhesions WI perforation
L&L
WNL
Canal contusion
G.T.
Ml25
ADD
DX
WNL
None
P.D.
F/2 1
WNL
DX
WNL
None
S.P.
F/42
WNL
DX
WNL
None
MS.
Ml30
WNL
DX
WNL
Canal contusion
N.S.
F/42
R ADD WI adhesions L ADD
L&L
WNL
None
F.H.
F/40
Adhesions WI perforations
L&L
WNL
None
C.H.
F/3 1
ADD WI adhesions
L&L
WNL
None
C.M.
F/33
L ADD, adhesions R WNL
L&L
WNL
None
M.K.S.
F/33
L ADD WI adhesions R mild synovitis
L&L
WNL
None
M.B.
F/49
L
ADD WI synovitis
DX
Mild highfrequency hearing loss
None
C.H.
F/23
L
Adhesions WI perforation
L&L
WNL
None
S.B.
F/28
R
ADD WI
DX
WNL
None
Abbreviations:
ADD, anteriorly displaced disc; WNL, within normal limits; L&L, lysis and lavage; DX, diagnostic arthroscopy.
1024
EFFECT OF TMJ ARTHROSCOPY
ON EAR FUNCTION
FIGURE 2. Audiogram (rap) and tympanogram (bottom) of patient with ear canal contusion.
FIGURE 1. Audiogram (top) and tympanogram (bottom) of patient with high-frequency hearing deficit.
Huschke is a relatively large defect in the anterior inferior tympanic ring; in rare cases of agenesis, this defect may persist in the adult and represent a potential site of entrance into the middle ear from the posterior aspect of the temporomandibular joint (Fig 3). In general, however, this route of middle ear trauma is unlikely due to the thickness of the anterior tympanic ring. A more likely route of injury is through the bonecartilage junction of the external auditory canal. Indeed, ecchymosis was noted in two of our patients at this site. Improper insertion of the trocar or vigorous inspection or instrumentation of the posterior
aspect of the joint may potentially lead to interruption of the external auditory canal at the postglenoid tubercle. At this point, an instrument is only several millimeters from insertion through the tympanic membrane into the middle ear. We believe that proper identification of the glenoid recess when the mandible is positioned anteriorly, and location of the lateral aspect of the fossa with the trocar, are absolutely necessary before further advancement of the trocar or arthroscope. Although it is common for patients with internal derangement of the TMJ to have symptoms of ear pain or dysfunction, our results suggest that most patients probably have no auditory pathology. However, this may not be true in all patients, and an otologic consultation should be obtained in those with uncertain history or positive physical findings. Our results suggest that with the routine use of arthroscopy there is probably no change in audio-
T R
Fissure
”
FIGURE 3. Anatomy of the glenoid fossa. Note the location of the foramen of Huschke.
1025
JONES AND HORN
metric testing, and therefore ear function. Moreover, although all of the patients studied reported subjective symptoms of ear dysfunction preoperatively, all were found to have normal audiometric examinations. References I. Westesson PL, Eriksson L, Liedberg L: The risk of damage to facial nerve, superficial temporal vessels, discs, and articular surfaces during arthroscopic examination of the temporomandibular joint. Oral Surg 2:124, 1986 2. McCain JP: Arthroscopy of the human temporomandibular
3. 4.
5.
6. 7.
joint. Washington, DC, AAOMS Proceedings, September 1985 Holmund A, Hellsing C: Arthroscopy of the TMJ. An autopsy study. Int J Oral Surg 14:169, 1985 Sanders B: Arthroscopic surgery of the temporomandibular joint: Treatment of internal derangement with persistent closed lock. Oral Surg Oral Med Oral Path01 62:361, 1986 Van Sickels JE, Nishioka GJ, Hegewald MD, et al: Middle ear injury resulting from temporomandibularjoint arthroscopy. J Oral Maxillofac Surg 45:%2, 1987 Goss A, Bosanquet A: Temporomandibular joint arthroscopy. J Oral Maxillofac Surg 44:614, 1986 Tarro AW: Arthroscopic diagnosis and surgery of the temporomandibular joint. Oral Maxillofac Surg 46:282, 1988