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Unrecognized bilateral temporomandibular joint dislocation after general anesthesia with a delay in diagnosis and management: a case report.

Pillai S, Konia MR - J Med Case Rep (2013)

Bottom Line: The cause of her misdiagnosis was multifactorial - opioid-related sedation, language and cultural barrier, and unfamiliarity with the pathology.Her diagnosis was proven 18 hours after the completion of surgery with a plain X-ray.A manual closed reduction was performed with minimal sedation by oral surgery.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Anesthesiology, University of Minnesota, B-515 Mayo Memorial Building, 420 Delaware Street SE, Mayo Mail Code 294, Minneapolis, MN 55455, USA. konia012@umn.edu.

ABSTRACT

Introduction: Anterior bilateral temporomandibular joint dislocation is not an uncommon occurrence and has been reported before. However, its diagnosis can easily be overlooked, especially by clinicians who are unfamiliar with this pathology. Continuous discussion of the pathology is required to prevent delays in diagnosis, which can lead to long-term sequelae for the patient.

Case presentation: We present the case of a 66-year-old Somali woman who experienced a bilateral anterior temporomandibular joint dislocation after a general anesthetic for an exploratory laparotomy for excision of a pelvic sarcoma. She first presented in the intensive care unit with preauricular pain and an inability to close her mouth, and was initially misdiagnosed and treated for a muscle spasm. The cause of her misdiagnosis was multifactorial - opioid-related sedation, language and cultural barrier, and unfamiliarity with the pathology. Her diagnosis was proven 18 hours after the completion of surgery with a plain X-ray. A manual closed reduction was performed with minimal sedation by oral surgery.

Conclusion: We provided an in-depth discussion of temporomandibular joint dislocation and suggest a simple test that would prevent delayed diagnosis of temporomandibular joint dislocation in any patient undergoing general anesthesia. A normal mandibular excursion should be tested in every patient after surgery in the postoperative care unit, by asking the patient to open and close their mouth during the immediate postoperative recovery period or passively performing the range of motion test.

No MeSH data available.


Related in: MedlinePlus

Lateral X-ray depicting anterior dislocation of the temporomandibular joint.
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Figure 1: Lateral X-ray depicting anterior dislocation of the temporomandibular joint.

Mentions: During the night, a nurse notified the on-call surgery resident that our patient was unable to close her mouth, and appeared to be in severe pain. After examining our patient, a diagnosis of muscle spasm was made and a hydromorphone patient-controlled analgesia was ordered. In the morning, the primary surgical team, followed by the SICU team, examined our patient, who was still unable to close her mouth. Both teams considered the diagnosis of muscle spasm as the most likely etiology. A rotating anesthesiology resident on the SICU team proposed a diagnosis of TMJ dislocation. Imaging confirmed the diagnosis of anterior bilateral TMJ dislocation (FigureĀ 1). The oral surgery team were consulted and our patient was seen in the afternoon. With 1mg of diazepam, the dislocation was reduced without difficulty via an intraoral closed reduction technique.


Unrecognized bilateral temporomandibular joint dislocation after general anesthesia with a delay in diagnosis and management: a case report.

Pillai S, Konia MR - J Med Case Rep (2013)

Lateral X-ray depicting anterior dislocation of the temporomandibular joint.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4016029&req=5

Figure 1: Lateral X-ray depicting anterior dislocation of the temporomandibular joint.
Mentions: During the night, a nurse notified the on-call surgery resident that our patient was unable to close her mouth, and appeared to be in severe pain. After examining our patient, a diagnosis of muscle spasm was made and a hydromorphone patient-controlled analgesia was ordered. In the morning, the primary surgical team, followed by the SICU team, examined our patient, who was still unable to close her mouth. Both teams considered the diagnosis of muscle spasm as the most likely etiology. A rotating anesthesiology resident on the SICU team proposed a diagnosis of TMJ dislocation. Imaging confirmed the diagnosis of anterior bilateral TMJ dislocation (FigureĀ 1). The oral surgery team were consulted and our patient was seen in the afternoon. With 1mg of diazepam, the dislocation was reduced without difficulty via an intraoral closed reduction technique.

Bottom Line: The cause of her misdiagnosis was multifactorial - opioid-related sedation, language and cultural barrier, and unfamiliarity with the pathology.Her diagnosis was proven 18 hours after the completion of surgery with a plain X-ray.A manual closed reduction was performed with minimal sedation by oral surgery.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Anesthesiology, University of Minnesota, B-515 Mayo Memorial Building, 420 Delaware Street SE, Mayo Mail Code 294, Minneapolis, MN 55455, USA. konia012@umn.edu.

ABSTRACT

Introduction: Anterior bilateral temporomandibular joint dislocation is not an uncommon occurrence and has been reported before. However, its diagnosis can easily be overlooked, especially by clinicians who are unfamiliar with this pathology. Continuous discussion of the pathology is required to prevent delays in diagnosis, which can lead to long-term sequelae for the patient.

Case presentation: We present the case of a 66-year-old Somali woman who experienced a bilateral anterior temporomandibular joint dislocation after a general anesthetic for an exploratory laparotomy for excision of a pelvic sarcoma. She first presented in the intensive care unit with preauricular pain and an inability to close her mouth, and was initially misdiagnosed and treated for a muscle spasm. The cause of her misdiagnosis was multifactorial - opioid-related sedation, language and cultural barrier, and unfamiliarity with the pathology. Her diagnosis was proven 18 hours after the completion of surgery with a plain X-ray. A manual closed reduction was performed with minimal sedation by oral surgery.

Conclusion: We provided an in-depth discussion of temporomandibular joint dislocation and suggest a simple test that would prevent delayed diagnosis of temporomandibular joint dislocation in any patient undergoing general anesthesia. A normal mandibular excursion should be tested in every patient after surgery in the postoperative care unit, by asking the patient to open and close their mouth during the immediate postoperative recovery period or passively performing the range of motion test.

No MeSH data available.


Related in: MedlinePlus