PSEUDOANEURYSM
1226 J Oral Maxillofac
AS COMPLICATION
OF ARTHROSCOPY
Surg
49.1226-1228.1991
Pseudoaneurysm as a Complication of Arthroscopy: A Case Report ANNA KORNBROT, DMD,* ALLAN S. SHAW, DWt AND MICHAEL R. TOOHEY, DMD$. Arthroscopy of the temporomandibular joint has several potential complications. The list includes injury to nerves, blood vessels, ears, instrument breakage, and infection. Vascular injuries are generally due to puncture of the superficial temporal artery, superficial temporal vein, and/or intraarticular bleeding. This report describes yet another complication of arthroscopic surgery, a pseudoaneurysm of the superficial temporal artery. This aneurysm developed 4 weeks after the arthroscopic procedure was performed. Report of a Case In February 1988, a 36-year-old woman presented to The Graduate Hospital Temporomandibular Joint Service complaining of severe pain on the left side of her face, limitation of opening, and pain on mouth opening and chewing. She was involved in a motor vehicle accident I month before her visit. She had a previous history of sagittal ramus osteotomy to correct a malocclusion. She also related a history of temporomandibular joint problems that had been successfully treated several years previously by conservative means. Conservative therapy was initially instituted, which included a soft diet, application of moist heat, jaw rest. and a nonsteroidal anti-inflammatory medication. She showed only slight improvement after several weeks. Computed tomography (CT) and magnetic resonance imaging (MRI) studies were done. The scan showed gross deformity of the left mandibular condyle. with flattening, osteophyte formation, and some posterior erosion. Magnetic reso-
Received from The Graduate Hospital, Philadelphia, PA. * Co-Director, TMJ Service. t Chairman, Department of Dental Medicine; Co-Director, TMJ Service. f Attending, TMJ Service. Address correspondence and reprint requests to Dr Kornbrot: The Graduate Hospital, TMJ Service, Suite 504, Medical Office Bldg, 1740 South St, Philadelphia. PA 19146. 0 1991 American geons
Association
0278-23911911491 l-0018$3.00/0
of Oral and Maxillofacial
Sur-
nance imaging of the left joint showed similar bony changes (a grossly deformed condyle with flattening. sclerosis and spur formation) as well as a deformed and anteriorly displaced disc without evidence of recapture on opening. A flat-plane mandibular appliance was fabricated and worn fulltime for 8 weeks. The patient also received physical therapy 3 times a week during this period. She responded to the regimen with an increase of opening and a decrease in pain. She showed improvement for about 5 months when, after eating something hard, she noticed a return of pain. Arthroscopy was performed on the left temporomandibular joint and lysis and lavage of the joint were done. The patient tolerated the procedure well. but showed little improvement. Open joint surgery was done 3 months later. Arthroplasty with disc resection was performed. The patient, after 1 week, was completely pain free on the left side. One month later, however, she began complaining of right-sided problems, including pain. ringing in her ears, and muscle spasms. Splint therapy, physical therapy, and anti-inflammatory medication for 3 months did not improve the condition. An MRI of the right temporomandibular joint revealed anterior dislocation of the disc with reduction on opening and sclerosis of the condyle and eminence. Arthroscopy of the right temporomandibular joint, including lysis and lavage, was performed on 4127189. The joint space was found to contain multiple synovial proliferations and hyperemia of the retrodiscal tissues was noted. The procedure was uneventful. with no unusual bleeding or swelling noted. The patient did well postoperatively until 5122189, almost 4 weeks after the procedure, when the patient presented with an area of right preauricular swelling of approximately 5 days’ duration. The well-defined and fluid-filled swelling was located just superior to the incision made for the arthroscope. Ausculation revealed no bruits and the area was nonpulsatile. The site was prepared and draped, and 10 mL of blood was aspirated from the area. The area bled profusely, but the bleeding was controlled with pressure. The next day, the swelling had returned and was now pulsatile. An arteriogram. including a selective study of the right common carotid and external carotid artery and a supraselective study of the right superficial temporal artery, was performed. A pseudoaneurysm was found arising from the bifurcation of the anterior branch of the right superficial temporal artery (Fig 1). A l-mm coil was used to successfully embolize the pseudoaneurysm of the right superficial temporal artery. Postoperatively, a right ca-
KORNBROT.
1227
SHAW. AND TOOHEY
In our case, the patient’s arthroscopic procedure proceeded without any apparent difftculty. No excessive intraoperative bleeding or postoperative swelling were noted, and the patient no clinical complaints until a discrete mass appeared in the preauricular area almost 4 weeks later. The rapidity with which a pseudo- or false aneurysm appears is dependent on the nature of the tissues adjacent to the vascular laceration and on the arterial defect. Pseudoaneurysms may result from either sharp or blunt trauma, causing vessel laceration with or without transection of the vessel. The blood enters into the tissues and this continues until the pressure in the hematoma is large enough to counterbalance the arterial pressure. The hematoma will then liquefy in the center and produce an endothelially lined pulsatile cavity continuous with the vessel.5-7 The differential diagnosis for such a soft-tissue lesion must include a vascular lesion. A carotid angiogram must be performed to diagnose an aneurysm. Treatment for such lesions include vessel ligation, total excision, and arterial embolization. In an area where good collateral circulation exists, embolization can achieve proximal and distal control of the injured vessel.
FIGURE I.
Arteriogram showing pseudoaneurysm.
rotid angiogram was performed, which showed complete embolization of the pseudoaneurysm (Fig 2). The patient did well after the procedure, with a decrease in swelling and pain. By 7449, the swelling had entirely resolved and the patient had no further temporomandibular joint complaints. At her last examination, all findings were negative.
Discussion Postoperative complications of arthroscopy have been classified by Carter and Schwaber’ into anesthetic, infectious, neurologic, vascular, instrument failure, otologic, and inflammatory problems. Vascular injury in the area of temporomandibular joint arthroscopy most often affects the superIicia1 temporal artery and/or vein. In 50 cases of arthroscopy performed by Gross and Bosanquet,’ three cases of bleeding from branches of the superficial temporal artery occurred. Westesson et al3 showed that the puncture site in temporomandibular joint arthroscopy is located very close to the superficial temporal vein and artery. However, in these cadaver studies, no damage to the vessels was experienced. In another study, Greene et al4 reported experiencing clinical injury to these vessels during arthroscopy, but the bleeding was controlled with pressure.
FIGURE 2. Arteriogram tion of pseudoaneurism.
after embolization
showing elimina-
1228
POLYCYSTIC PAROTID DISEASE
References 1. Merrill RG: Disorders of the TMJ I: Diagnosis and Arthroscopy. Oral Maxillofac Surg Clin North Am I(1 1, 1989 2. Goss AN, Bosanquet AG: Temporomandibularjoint arthroscopy. J Oral Maxillofac Surg 44:614. 1986 3. Westesson P, Ericksson L. Liedberg J: The risk of damage to facial nerve, superficial temporal vessels, disk and articular surfaces during arthroscopic examination of the temporomandibular joint. Oral Surg 62: 124. 1986 4. Greene MW, Huckney FL. Van Sickles JE: Arthroscopy of the temporomandibular joint: An anatomic perspective. J Oral Maxillofac Surg 47:386, 1989 5. Cooperband BR. Friedel W. Bhatt GM. et al: False aneu-
J Oral Maxlllofac 49:122e-1231,
rysm of the facial artery. J Oral Maxillofac Surg 47: 1327. 1989 6. Wineland PL, Topazian RG, Marble HB: False aneurysm of the facial artery. J Oral Surg 34:642. 1976 7. O’Brian CE: An unusual complication following facial trauma. Int J Oral Surg 10:241, 1981 tsuppl 1) 8. Peoples JR, Herbrosa EG, Dion J: Management of internal maxillary artery hemorrhage from temporomandibular joint surgery via selective embolization. J Oral Maxillofac Surg 46: 1005, 1988 9. Moses JJ, Topper DC: Arteriovenous
fistula: A unusual complication associated with arthroscopic temporomandibular joint surgery. J Oral Maxillofac Surg 48: 1220, 1990 IO. Kaban LB: Complications, Poor Results and Treatment Failures: Diagnosis, Prevention and Management. Oral Maxillofac Surg Clin North Am 2(3), 1990
Surg
1991
Polycystic
Parotid Disease:
A Case Report LOUIS MANDEL, DDS,* AND AYFER KAYNAR, DDSt
Polycystic parotid disease (PPD) is an unusual parotid disorder; only six cases have been reported. ‘-’ The purpose of this article is to review the characteristics of this disease and add another case, with some new findings, to the literature. Seifert’ first identified PPD in his report of two cases. Subsequently, Dobson’ presented one case and Batsakis3 recorded three cases. It is possible that an earlier case report by Mikalyka4 also belongs in the category of PPD, but definitive evidence from a biopsy specimen was not obtained. Polycystic parotid disease is but one of a variety of cystic lesions that occur in the salivary glands. Mucoceles, ranulas, parotid duct cysts, branchiogenie cysts, lymphoepithelial cysts, and cystic areas in salivary gland neoplasms have been included in this category. Polycystic parotid disease represents the newest addition to the group.
Received from the Salivary Gland Center, Columbia University School of Dental and Oral Surgery, New York. * Director: Clinical Professor. Division of Oral and Maxillofacial Surgery. t Visiting Research Fellow; School of Dentistry, University of Istanbul, Turkey. Address correspondence and reprint requests to Dr Mandel: Division of Oral and Maxillofacial Surgery,Columbia University School of Dental and Oral Surgery, 630 West 168th St, New York, NY 10032. 0 1991 American geons
Association
0278-2391/91/491
l-0019$3.00/0
of Oral and Maxillofacial
Sur-
Etiology The cysts in PPD are believed to result from a congenital malformation of the ductal system.‘.’ Since intercalated ducts can be seen microscopically opening into the cysts, the defect is thought to arise from these small structures. Signs and Symptoms The six reported cases have been reviewed by Batsakis.3 All six patients, with an age range of 6 to 65 years, were females. Five patients suffered from bilateral parotid cystic disease, and one had unilateral parotid disease. The classic history is one of intermittent parotid swellings, usually unrelated to meals, beginning in childhood. The swellings are transient and cause no apparent distress. Progression into adult life brings on more significant discomfort. Minimal sialochemical signs of inflammatory change are evident initially.’ More significant infectious changes, with associated sialochemical alterations, can be expected with aging. Dobson’ reported that the sialogram revealed small cystic areas producing a tine sialectic pattern. However, multicysts were observed grossly and histologically in surgical specimens of the involved parotid glands whose major ducts were normal.‘-4 Such a pathologic picture should be portrayed sia-
1226 J Oral Maxillofac
AS COMPLICATION
OF ARTHROSCOPY
Surg
49.1226-1228.1991
Pseudoaneurysm as a Complication of Arthroscopy: A Case Report ANNA KORNBROT, DMD,* ALLAN S. SHAW, DWt AND MICHAEL R. TOOHEY, DMD$. Arthroscopy of the temporomandibular joint has several potential complications. The list includes injury to nerves, blood vessels, ears, instrument breakage, and infection. Vascular injuries are generally due to puncture of the superficial temporal artery, superficial temporal vein, and/or intraarticular bleeding. This report describes yet another complication of arthroscopic surgery, a pseudoaneurysm of the superficial temporal artery. This aneurysm developed 4 weeks after the arthroscopic procedure was performed. Report of a Case In February 1988, a 36-year-old woman presented to The Graduate Hospital Temporomandibular Joint Service complaining of severe pain on the left side of her face, limitation of opening, and pain on mouth opening and chewing. She was involved in a motor vehicle accident I month before her visit. She had a previous history of sagittal ramus osteotomy to correct a malocclusion. She also related a history of temporomandibular joint problems that had been successfully treated several years previously by conservative means. Conservative therapy was initially instituted, which included a soft diet, application of moist heat, jaw rest. and a nonsteroidal anti-inflammatory medication. She showed only slight improvement after several weeks. Computed tomography (CT) and magnetic resonance imaging (MRI) studies were done. The scan showed gross deformity of the left mandibular condyle. with flattening, osteophyte formation, and some posterior erosion. Magnetic reso-
Received from The Graduate Hospital, Philadelphia, PA. * Co-Director, TMJ Service. t Chairman, Department of Dental Medicine; Co-Director, TMJ Service. f Attending, TMJ Service. Address correspondence and reprint requests to Dr Kornbrot: The Graduate Hospital, TMJ Service, Suite 504, Medical Office Bldg, 1740 South St, Philadelphia. PA 19146. 0 1991 American geons
Association
0278-23911911491 l-0018$3.00/0
of Oral and Maxillofacial
Sur-
nance imaging of the left joint showed similar bony changes (a grossly deformed condyle with flattening. sclerosis and spur formation) as well as a deformed and anteriorly displaced disc without evidence of recapture on opening. A flat-plane mandibular appliance was fabricated and worn fulltime for 8 weeks. The patient also received physical therapy 3 times a week during this period. She responded to the regimen with an increase of opening and a decrease in pain. She showed improvement for about 5 months when, after eating something hard, she noticed a return of pain. Arthroscopy was performed on the left temporomandibular joint and lysis and lavage of the joint were done. The patient tolerated the procedure well. but showed little improvement. Open joint surgery was done 3 months later. Arthroplasty with disc resection was performed. The patient, after 1 week, was completely pain free on the left side. One month later, however, she began complaining of right-sided problems, including pain. ringing in her ears, and muscle spasms. Splint therapy, physical therapy, and anti-inflammatory medication for 3 months did not improve the condition. An MRI of the right temporomandibular joint revealed anterior dislocation of the disc with reduction on opening and sclerosis of the condyle and eminence. Arthroscopy of the right temporomandibular joint, including lysis and lavage, was performed on 4127189. The joint space was found to contain multiple synovial proliferations and hyperemia of the retrodiscal tissues was noted. The procedure was uneventful. with no unusual bleeding or swelling noted. The patient did well postoperatively until 5122189, almost 4 weeks after the procedure, when the patient presented with an area of right preauricular swelling of approximately 5 days’ duration. The well-defined and fluid-filled swelling was located just superior to the incision made for the arthroscope. Ausculation revealed no bruits and the area was nonpulsatile. The site was prepared and draped, and 10 mL of blood was aspirated from the area. The area bled profusely, but the bleeding was controlled with pressure. The next day, the swelling had returned and was now pulsatile. An arteriogram. including a selective study of the right common carotid and external carotid artery and a supraselective study of the right superficial temporal artery, was performed. A pseudoaneurysm was found arising from the bifurcation of the anterior branch of the right superficial temporal artery (Fig 1). A l-mm coil was used to successfully embolize the pseudoaneurysm of the right superficial temporal artery. Postoperatively, a right ca-
KORNBROT.
1227
SHAW. AND TOOHEY
In our case, the patient’s arthroscopic procedure proceeded without any apparent difftculty. No excessive intraoperative bleeding or postoperative swelling were noted, and the patient no clinical complaints until a discrete mass appeared in the preauricular area almost 4 weeks later. The rapidity with which a pseudo- or false aneurysm appears is dependent on the nature of the tissues adjacent to the vascular laceration and on the arterial defect. Pseudoaneurysms may result from either sharp or blunt trauma, causing vessel laceration with or without transection of the vessel. The blood enters into the tissues and this continues until the pressure in the hematoma is large enough to counterbalance the arterial pressure. The hematoma will then liquefy in the center and produce an endothelially lined pulsatile cavity continuous with the vessel.5-7 The differential diagnosis for such a soft-tissue lesion must include a vascular lesion. A carotid angiogram must be performed to diagnose an aneurysm. Treatment for such lesions include vessel ligation, total excision, and arterial embolization. In an area where good collateral circulation exists, embolization can achieve proximal and distal control of the injured vessel.
FIGURE I.
Arteriogram showing pseudoaneurysm.
rotid angiogram was performed, which showed complete embolization of the pseudoaneurysm (Fig 2). The patient did well after the procedure, with a decrease in swelling and pain. By 7449, the swelling had entirely resolved and the patient had no further temporomandibular joint complaints. At her last examination, all findings were negative.
Discussion Postoperative complications of arthroscopy have been classified by Carter and Schwaber’ into anesthetic, infectious, neurologic, vascular, instrument failure, otologic, and inflammatory problems. Vascular injury in the area of temporomandibular joint arthroscopy most often affects the superIicia1 temporal artery and/or vein. In 50 cases of arthroscopy performed by Gross and Bosanquet,’ three cases of bleeding from branches of the superficial temporal artery occurred. Westesson et al3 showed that the puncture site in temporomandibular joint arthroscopy is located very close to the superficial temporal vein and artery. However, in these cadaver studies, no damage to the vessels was experienced. In another study, Greene et al4 reported experiencing clinical injury to these vessels during arthroscopy, but the bleeding was controlled with pressure.
FIGURE 2. Arteriogram tion of pseudoaneurism.
after embolization
showing elimina-
1228
POLYCYSTIC PAROTID DISEASE
References 1. Merrill RG: Disorders of the TMJ I: Diagnosis and Arthroscopy. Oral Maxillofac Surg Clin North Am I(1 1, 1989 2. Goss AN, Bosanquet AG: Temporomandibularjoint arthroscopy. J Oral Maxillofac Surg 44:614. 1986 3. Westesson P, Ericksson L. Liedberg J: The risk of damage to facial nerve, superficial temporal vessels, disk and articular surfaces during arthroscopic examination of the temporomandibular joint. Oral Surg 62: 124. 1986 4. Greene MW, Huckney FL. Van Sickles JE: Arthroscopy of the temporomandibular joint: An anatomic perspective. J Oral Maxillofac Surg 47:386, 1989 5. Cooperband BR. Friedel W. Bhatt GM. et al: False aneu-
J Oral Maxlllofac 49:122e-1231,
rysm of the facial artery. J Oral Maxillofac Surg 47: 1327. 1989 6. Wineland PL, Topazian RG, Marble HB: False aneurysm of the facial artery. J Oral Surg 34:642. 1976 7. O’Brian CE: An unusual complication following facial trauma. Int J Oral Surg 10:241, 1981 tsuppl 1) 8. Peoples JR, Herbrosa EG, Dion J: Management of internal maxillary artery hemorrhage from temporomandibular joint surgery via selective embolization. J Oral Maxillofac Surg 46: 1005, 1988 9. Moses JJ, Topper DC: Arteriovenous
fistula: A unusual complication associated with arthroscopic temporomandibular joint surgery. J Oral Maxillofac Surg 48: 1220, 1990 IO. Kaban LB: Complications, Poor Results and Treatment Failures: Diagnosis, Prevention and Management. Oral Maxillofac Surg Clin North Am 2(3), 1990
Surg
1991
Polycystic
Parotid Disease:
A Case Report LOUIS MANDEL, DDS,* AND AYFER KAYNAR, DDSt
Polycystic parotid disease (PPD) is an unusual parotid disorder; only six cases have been reported. ‘-’ The purpose of this article is to review the characteristics of this disease and add another case, with some new findings, to the literature. Seifert’ first identified PPD in his report of two cases. Subsequently, Dobson’ presented one case and Batsakis3 recorded three cases. It is possible that an earlier case report by Mikalyka4 also belongs in the category of PPD, but definitive evidence from a biopsy specimen was not obtained. Polycystic parotid disease is but one of a variety of cystic lesions that occur in the salivary glands. Mucoceles, ranulas, parotid duct cysts, branchiogenie cysts, lymphoepithelial cysts, and cystic areas in salivary gland neoplasms have been included in this category. Polycystic parotid disease represents the newest addition to the group.
Received from the Salivary Gland Center, Columbia University School of Dental and Oral Surgery, New York. * Director: Clinical Professor. Division of Oral and Maxillofacial Surgery. t Visiting Research Fellow; School of Dentistry, University of Istanbul, Turkey. Address correspondence and reprint requests to Dr Mandel: Division of Oral and Maxillofacial Surgery,Columbia University School of Dental and Oral Surgery, 630 West 168th St, New York, NY 10032. 0 1991 American geons
Association
0278-2391/91/491
l-0019$3.00/0
of Oral and Maxillofacial
Sur-
Etiology The cysts in PPD are believed to result from a congenital malformation of the ductal system.‘.’ Since intercalated ducts can be seen microscopically opening into the cysts, the defect is thought to arise from these small structures. Signs and Symptoms The six reported cases have been reviewed by Batsakis.3 All six patients, with an age range of 6 to 65 years, were females. Five patients suffered from bilateral parotid cystic disease, and one had unilateral parotid disease. The classic history is one of intermittent parotid swellings, usually unrelated to meals, beginning in childhood. The swellings are transient and cause no apparent distress. Progression into adult life brings on more significant discomfort. Minimal sialochemical signs of inflammatory change are evident initially.’ More significant infectious changes, with associated sialochemical alterations, can be expected with aging. Dobson’ reported that the sialogram revealed small cystic areas producing a tine sialectic pattern. However, multicysts were observed grossly and histologically in surgical specimens of the involved parotid glands whose major ducts were normal.‘-4 Such a pathologic picture should be portrayed sia-
