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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 24-48 hrs post-op.
• Complications: hemorrhage, infection, recurrence– Joint damage, destruction of middle ear ossicles, perforation into
middle cranial fossa, injury to auriculotemporal nerve
Resources
• www.healthscout.com• STST pp. 646-647, Procedure 18-7• www.dentaljournal.com/article 6• Rodau; Baker-Gill, Levin; “Arthroscopic
Temporomandibular Joint Surgery”, AORN Journal Nov 1993, 58: 5.