Steroid injection and TMJ washout

This patient was seen on referral for ongoing left-sided temporomandibular joint pain. The pain and stiffness of the joint (TMJ) was long standing and recurring.

Conservative treatment methods, including physiotherapy, ultrasound and a bite-raising appliance, had not been not successful. The joint had become stiff and the patient complained of very limited opening (2cm inter-incisal).

A TMJ washout, followed by intra-articular steroid injection and manipulation of the TMJ under general anaesthesia, was advised. Kenalog contains Triamcinolone Acetonide

(Figure 1), which can be injected directly into the joint space under local anaesthetic.

Marcain is injected following this to provide a longer post operative anaesthesia.

Surgical steps

The patient was put under general anaesthetic with nasal intubation. Local anaesthetic (2% Xylocaine 1:80 000 adrenaline) was infiltrated into the TMJ joint space (Figure 2).

An irrigating syringe needle (27 Gauge) was placed into the joint space found by repeated opening and closing of the jaw (Figure 3). Two similar syringe needles were placed into the TMJ capsule (Figure 4). If they are in the correct position, the needles would move when the jaw is opened/closed. The correct position could be felt in this way as the condylar head moves.

The patient’s TMJ was manipulated and opened as far as possible to release the muscle spasm that had occurred and that was causing the limited opening.

Sterile saline was used to flush out the joint pace (Figure 5). Correct irrigation occurs if the fluid is extruded from the second syringe needle placed into the joint space (Figure 6).

Once the joint had been flushed out a Marcain local anaesthetic was applied around the joint, and the steroid (Kenalog) was placed into the capsule. The Marcain provides a longer period of post-operative anaesthesia.

The area was simply covered with a plaster, and the patient was made aware of the likelihood of a temporary facial nerve paraesthesia (Figure 7). Due to the site of the procedure, approximately 50% of patients will get some form of temporary facial nerve palsy. This will rarely last for longer than six weeks.

Following the procedure, the patient was reviewed at six weeks post-operatively. Various studies have sought to establish any detrimental effects of combining the steroid with local anaesthesia.

There is no evidence to suggest that this leads to a greater amount of postoperative pain. This method is taken from a similar arthroscopy technique used in other joints. Such a washout procedure has been found to be successful as it clears out the capsule of any possible obstructive cartilage debris.

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