Procedures Intermediate Format Temporomandibular Joint Arthroscopy

Objectives Assess the related terminology and pathophysiology of the TMJ. Analyze the diagnostic interventions for a patient undergoing a _______________. Plan the intraoperative course for a patient undergoing_____________. Assemble supplies, equipment, and instrumentation needed for the procedure.

Objectives Choose the appropriate patient position Identify the incision used for the procedure Analyze the procedural steps for TMJ Arthroscopy. Describe the care of the specimen

Terms and Definitions Bruxism Malocclusion

Definition/Purpose of Procedure Temporomandibular Joint (TMJ) Disorder occurs when the muscles used in chewing and the joints of the jaw fail to work in combination with each other.

A & P : TMJ

Pathophysiology Causes: Bruxism, Malocclusion, Arthritis, Trauma

Pathophysiology Signs & Symptoms Pain, clicking, limited range-of- motion, spasms, asymmetry

Diagnosis Linear CT and MRI

Treatment 5-10 % dx w/TMJ Dysfunction fail to have relief of medical tx, and require surgery Antiinflammatories, soft diet, hot compresses, muscle relaxants >2 weeks: intraoral occlusion splints, med tx Recurrent or chronic: permanent dental correction

Surgical Intervention: Special Considerations Patient Factors –Outpatient –H& P, Blood chemistries, CBC, PT, PTT, U/A, serum HCG, Chest x-ray or ECG as appropriate Room Set-up –X-rays in room

Surgical Intervention: Positioning Position during procedure –Supine w/head donut pillow, tuck arms to side Supplies and equipment –Arm sleds, headring pillow Special considerations: high risk areas –Elbows—ulnar nerves Prep –Shave preauricular area –Cotton to ears to prevent pooling of povidone-iodine & caution w/eyes; entire facial area prepped from hairline, down to shoulder, and laterally to include mouth and chin

Surgical Intervention: Special Considerations/Incision Special considerations –Nasal intubation –Prophylactic antibiotics & steriods State/Describe incision –Small stab incision w/# 11 before trocar is introduced at superior joint space

Surgical Intervention: Supplies General: basic pack drape and split head sheet, gowns & gloves, towels, basin set, prep set, sterile adhesive wound drape, irrigation pouch, skin marker, raytex, Specific –Suture & Blades (# 11) –Medications on field (name & purpose) –Catheters & Drains: n/a –Drapes: head turban for initial drape; pad pt forehead with a folded towel; plastic adhesive wound drape to cover ET tube and mouth; split sheet and large sheet for body drape, (laser: 4 wet towels around pt’s face; moistened cotton in external auditory canals, irrigation collection pouch at base of ear and TMJ)

Surgical Intervention: Supplies cont’d 2 60 mL syringes 4 10 mL syringes 1 1-mL syringe Needles: 18 g, 21 g, 25 g Skin stapler Eye pads Sterile water and saline 1000 mL Lactated Ringers for irrigation 30 in extension tubing Stopcock

Surgical Intervention: Instruments General: suction, Lactated Ringer’s IV bag for irrigation, marking pen Specific –TMJ instrument set 0 degree arthroscope 30-degree arthroscope 70-degree arthroscope Cannulas Sharp & dull obturators –Light cord, camera & cord, small joint rotary shaver

Surgical Intervention: Equipment General: suction system Specific –Monitor/light source/camera tower, shaver control unit, IV pole for irrigant –Fluid infusion system –Bipolar ESU –Holmium laser

Surgical Intervention: Procedure Steps Irrigation solution is injected into the joint space to distend the capsule –LR solution is preloaded in syringe w/needle attached. After small stab incision is placed, surgeon inserts a sheath w/sharp obturator into superior joint space. After space is entered, the sharp is replaced with a dull obturator to further direct the sheath into the joint without damaging the intraarticular tissue or adjacent neurovascular structures. –#11 blade with # 7 handle will be ready –Trocar/cannula is preassembled. Expect trocor to be returned. Be prepared to assist with connections of video/light cord connections.

Surgical Intervention: Procedure Steps Irrigation is infused into the joint –LR solution is connected to the cannua via extension tubing Joint is examined –Prepare to operate remote control for still photos If functional surgery is needed, a second stab wound is made –Pass skin knife. Prepare additional equipment (probe, shaver, grasper) Final visual inspection is performed –Additional photos may be taken

Surgical Intervention: Procedure Steps Cannuale are removed and excess fluid removed –Prepare for closure; count Wound is closed and dressing placed –Pass suture; prepare dressings, reorganize equipment & supplies if procedure is bilateral Steps may be repeated contralaterally –Repeat steps

Counts Initial: sponges and sharps First closing Final closing –Sponges –Sharps

Specimen & Care Identified as n/a or as specified (eg chondromalacia) Handled: routine, etc.

Postop Considerations Immediate –ROM of jaw limited –Suction and Emergency airway supplies readily available; Elevate HOB 30 degrees –Ice for pain and swelling –Liquid or soft diet for several days Prognosis: good—may recur if behaviors not resolved; PT may begin in hrs post-op. Complications: hemorrhage, infection, recurrence –Joint damage, destruction of middle ear ossicles, perforation into middle cranial fossa, injury to auriculotemporal nerve

Resources STST pp , Procedure Rodau; Baker-Gill, Levin; “Arthroscopic Temporomandibular Joint Surgery”, AORN Journal Nov 1993, 58: 5.