Complications of TMJ Surgery

Question 1

What are some complications of TMJ surgery (9)

Answer 1

-otitis externa
-otitis media
-broken instrument during arthroscopy/arthrocentesis
-TM rupture/hemotympanium
-Violation of middle cranial fossa
-damage to temporal branch of facial nerve
-auriculotemporal nerve syndrome/ Frey syndrome
-bleeding during condylotomy
-bleeding during diskectomy

Question 2

what does patient complain of when they have otitis externa and what’s treatment?

Answer 2

infection of external auditory canal
pain on movement or pressure of ear
tx. topical fluoroquinoline otic products

Question 3

why tx topical fluoroquinolones for otitis externa?

Answer 3

coverage for pseudomonas- most common bacteria in otitis externa

Question 4

what does otoscopy reveal for otitis externa?

Answer 4

edematous external auditory canal with possible discharge

Question 5

what does otoscopy reveal for otitis media

Answer 5

full or bulging tympanic membrane or possible purulence if there is perforation

Question 6

tx otitis media

Answer 6

amoxicillin
ent consult for myringotomy tubes

Question 7

what does patient complain of with otitis media?

Answer 7

inflammation of middle ear structures
-ear pain, difficulty hearing and fever

Question 8

how to you tx broken instrument during arthroscopy/arthocentesis?

Answer 8

if able to visulize and have arthroscopic training remove
if can’t visualize, obtain radiographs in muiltiple planes for identification
-open approach

Question 9

Tx tympanic membrane rupture/hemotymapanium

Answer 9

-ENT consult
-if External auditory canal damaged place sponge impregnanted w/ antibiotic and suture to maintain opening of external auditory canal.
-antibiotic-hydrocortisone suspension x 14 days, monitor for post op granulation tissue

Question 10

how to remove post op granulation tissue in tympanic membrane rupture?

Answer 10

bipolar cautery
-silver nitrate

Question 11

antibiotic for tx of violation of middle cranial fossa

Answer 11

cotrimoxazole as its bactericidal and enters cerebral spinal fluid

Question 12

suspect violation of middle cranial fossa, what do you do?

Question 13

if you suspect Cerbrospinal fluid leak post op what do you do?

Answer 13

CT scan/ MRI, consult neurosurgery on desired imaging.

Question 14

suspect cerbrospinal fluid,what to do with patient?
do small cerbrospinal fluid leaks heal?

Answer 14

HOB elevation greater than 30 degrees
cotrimoxazole
small CSF leaks heal spontaneously within 1 week

Question 15

how thick is the middle cranial fossa?

Answer 15

0.9 mm thick

Question 16

where is the temporal branch of the facial nerve ?

Answer 16

2 cm anterior to bony external auditory canal

Question 17

what did al kayat study say facial nerve is

Answer 17

range of 0.8 cm-3.5 cm

Question 18

what does the temporal branch of the facial nerve innervate?

Answer 18

frontalis
orbicularis
corrugator supercilii

Question 19

what happens to injuries w/ facial nerve?
who do you consult

Answer 19

most resolve in 3-6 months, observation warrented.
consult opthomology

Question 20

what do you need to do to the eye if there is injury with facial nerve?

Answer 20

lubrication and taping of eye to prevent keratoconjunctivities.
-physical therapy w/ electrical stimulation

Question 21

permanent injury to facial nerve, what is tx?

Answer 21

gold weights implants can be placed in upper eyelid for permanent defect.

Question 22

signs and symptoms of auriculotermporal nerve syndrome (frey’s syndrome)

Answer 22

gustatory sweating
flushing
warmth
over temporal and preauricular areas.

Question 23

when does freys syndrome occur

Answer 23

auriculotemporal nerve damage
most commonly in arthroscopy
usually temporary and resolves w/i 6 months

Question 24

how to evaluate patient with auriculotemporal nerve syndrome?

Answer 24

Minor test

Question 25

what is minor test

Answer 25

starch-iodine solution of 3 grams iodine 20 g castor oil 200 ml absolute alcohol applied to preauricular area gustatory sweating illicited by having patient chew on lemon drop + test yellow mixture turns blue

Question 26

tx for + minor test

Answer 26

16-80 IU of botulinum A subQ injection results in resolution in 1 weeks scopolamine ointment (anticholinergic properties) -surgical transection of innervation

Question 27

bleeding during condylotomy is from where?

Answer 27

internal maxillary artery and its branches

Question 28

where does internal maxillary artery run?

Answer 28

3 mm medial from the mid sig-moid notch and 20 mm below condylar head

Question 29

what is a commonly damaged vessel during condylotomy?

Answer 29

masseteric artery

Question 30

what can cause bleeding during diskectomy?

Answer 30

-retrodiscal tissue -lateral pterygoid muscle -middle meningeal artery

Question 31

where is middle meningeal artery found?

Answer 31

31 mm medial zygomatic arch 2.4 mm anterior from heigh of the glenoid fossa.

Question 32

how to manage bleeding in diskectomy?

Answer 32

-visualize vessels, cauterize or ligate -hold pressure x 5 mins -thrombin soaked gauze, collagen sponges,tissue adhesives -IR for embolization if bleeding not controlled by hemostatic measures. -carotid artery cut down

Question 33

explain carotid artery cut down for uncontrollable bleeding

Answer 33

5 cm neck incision 2 cm below the inferior border of the mandible Sternocleidomasotid muscle is retracted posterioly blunt dissection to carotid sheath internal jugular vein retracted posteriorly to reveal common carotid

Question 34

where does hypoglossal nerve cross

Answer 34

hypoglossal nerve will cross above carotid bifurcation

Question 35

where to ligate carotid artery

Answer 35

above the facial branch, 3rd of anterior branches, blood flow has been found to be reduced by 73% when ligated.