Condylar resorption of the temporomandibular joint following arthroscopy in a patient with essential thrombocythemia

Abstract

Condylar resorption of the temporomandibular joint (TMJ) is a poorly understood phenomenon that is the subject of much controversy. The etiology, diagnosis, and management of this condition have yet to achieve consensus. This case report describes a unique case of condylar resorption of uncertain etiology. The patient was a 49-year-old white female with complaints of left temporomandibular joint pain and numbness associated with reduced opening (35 mm). Over the previous 5 months, following abdominal surgery with oral endotracheal intubation, she noted increasing difficulty opening her jaw and pain. On a visual analog scale she reported a constant sharp aching (7/10) pain of the left joint that increased with function and decreased with resting the jaw. Her past medical history was significant for essential thrombocythemia, hypertension, hypothyroidism, and depression. Her medications included anagrelide, aspirin, hydrochlorothiazide/spironolactone, levothyroxine, and sertraline. An MRI revealed left disc displacement without reduction as well as a sound bony condyle consistent with TMJ plain films. She was unresponsive to 10 weeks of treatment provided by her general dentist consisting of a biteguard and analgesics. Given the refractory nature of the patient's complaint to this treatment, she was given the options of further nonsurgical or surgical management. In consultation with an oral and maxillofacial surgeon, she elected to undergo arthroscopy of the left joint. Under general anaesthesia, arthroscopy was performed. During the procedure, excessive intra-articular hemorrhage was repeatedly encountered, resulting in obliteration of the entry lumen of the arthroscope and outflow port. Initially following surgery the patient was able to open 32 mm with stretch to 38 mm, but with deviation to the left and heavy anterior occlusion. Two months following the procedure, the patient continued to experience dysfunction and pain. A course of physical therapy with gentle mobilization of the left TMJ was prescribed. The patient was lost to follow-up owing to a family member's illness. Five months later, she presented to the office not having pursued physical therapy, but was completely pain free with normal mandibular opening (45 mm). She complained that her “bite was off” and had progressively worsened. Clinically, a right posterior openbite was present accompanied by marked facial asymmetry. She had no pain upon palpation or with function of the left TMJ but deviated to the left upon opening. TMJ plain films, tomograms, and CT scan revealed marked resorption and surface irregularities of the left condylar head. The patient declined further treatment and was followed for 3 years. She remained clinically stable with no further deterioration. It is hypothesized that the resorption of the left condyle may have been due to hemarthrosis with possible thrombosis of the microvasculature of the synovial tissues and/or condyle, precipitated by the arthroscopic procedure. Alternatively, the resorptive process may have been initiated with jaw manipulation during the abdominal surgery, and progressed during the observed time period. Based upon this experience, it would appear that surgical procedures involving the TMJ in a patient with thrombocythemia should be undertaken with caution. Conversely, maximal management of the underlying pathology may have given improved results.