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The main distinguishing feature between the 2 is endothelial cells that are normal in KD but large and atypical in ALHE. In addition, ALHE is more common in middle-aged, white females and develops in the subcutis and dermis without lymph node involvement.17 On computed tomography scans, either well defined nodular masses or ill-defined plaque-like infiltrative masses in the subcutaneous tissue associated with lymphadenopathy are reported as typical findings.18 The attenuation of the masses varies from iso- to hyperattenuated.14 On magnetic resonance images, the masses are reported to show variable signal intensity, that is, low-to-high signal intensity on T1- and T2-weighted images.14,18,19 On postcontrast computed tomography and magnetic resonance imaging, enhancement patterns vary from mild to intense and from homogeneous to heterogeneous. This variability in the degree of enhancement is thought to be attributed to the different degrees of vascular proliferation and fibrosis.14 Standard treatment of KD is not yet well established. Therapeutic options include conservative management such as intralesional and/or systemic steroids and surgical excision. In 2002, cyclosporine has also been used with good results.20 Surgical excision is the preferred method of initial treatment and also permits proper tissue diagnosis. The role of fine needle aspiration and biopsy procedures is limited in diagnosing KD,21 making surgical resection likely necessary to make the final diagnosis because the histologic features of the tumor are nonspecific and can be found in many other disease entities including reactive processes. Moreover, small biopsy specimens might not demonstrate the lobulated architecture of the whole histologic picture of this tumor. Because recurrence rates are as high as 25% after surgery,22 complete surgical excision is the treatment of choice for solitary lesions, as in our case. Kimura disease is an unusual cause of lesions in the orbit and eyelid. Although it is a rare entity in Western countries, it is important to correctly diagnose this condition because it is more common in Asian populations, and a benign process that carries a good prognosis. In conclusion, despite its rarity, it is important to understand that KD can affect all races and almost all age groups, and should be suspected when a subcutaneous mass of the head or neck including an eyelid mass is associated with eosinophilia.
REFERENCES 1. Kim HT, Szeto C. Eosinophilic hyperplastic lymphogranuloma, comparison with Mikulicz’s disease. Chin Med J 1937;23:699–700 2. Kimura TYS, Ishikawa E. On the unusual granulation combined with hyperplastic changes of lymphatic tissues. Trans Soc Pathol Jpn 1948:37 3. Li TJ, Chen XM, Wang SZ, et al. Kimura’s disease: a clinicopathologic study of 54 Chinese patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:549–555 4. Sun QF, Xu DZ, Pan SH, et al. Kimura disease: review of the literature. Intern Med J 2008;38:668–672 5. Muller-Richter UD, Moralis A, Reuther T, et al. Kimura’s disease in a white man. Head Neck 2011;33:138–140 6. Prabhakaran VC, Sachdev A, Cheung D, et al. Kimura disease of the eyelid: a clinicopathologic study with electron microscopic observations. Ophthal Plast Reconstr Surg 2006;22:495–498 7. Hidayat AA, Cameron JD, Font RL, et al. Angiolymphoid hyperplasia with eosinophilia (Kimura’s disease) of the orbit and ocular adnexa. Am J Ophthalmol 1983;96:176–189 8. Kawata R, Yoshimura K, Ichihara T, et al. Kimura’s disease of the epiglottis: resection by a lateral pharyngotomy approach. Otolaryngol Head Neck Surg 2010;142:148–149 9. Buggage RR, Spraul CW, Wojno TH, et al. Kimura disease of the orbit and ocular adnexa. Surv Ophthalmol 1999;44:79–91
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10. Yoganathan P, Meyer DR, Farber MG. Bilateral lacrimal gland involvement with Kimura disease in an African American male. Arch Ophthalmol 2004;122:917–919 11. Goldenberg D, Gatot A, Barki Y, et al. Computerized tomographic and ultrasonographic features of Kimura’s disease. J Laryngol Otol 1997;111:389–391 12. Atar S, Oberman AS, Ben-Izhak O, et al. Recurrent nephrotic syndrome associated with Kimura’s disease in a young non-Oriental male. Nephron 1994;68:259–261 13. Chen H, Thompson LD, Aguilera NS, et al. Kimura disease: a clinicopathologic study of 21 cases. Am J Surg Pathol 2004;28: 505–513 14. Takahashi S, Ueda J, Furukawa T, et al. Kimura disease: CT and MR findings. AJNR Am J Neuroradiol 1996;17:382–385 15. Sakamoto M, Komura A, Nishimura S. Hematoserological analysis of Kimura’s disease for optimal treatment. Otolaryngol Head Neck Surg 2005;132:159–160 16. Ohta N, Okazaki S, Fukase S, et al. Serum concentrations of eosinophil cationic protein and eosinophils of patients with Kimura’s disease. Allergol Int 2007;56:45–49 17. Lee JK, Almousa R, Thamboo TP, et al. Kimura disease of the eyelid in an Indian man. Clin Exp Ophthalmol 2009;37:412–414 18. Som PM, Biller HF. Kimura disease involving parotid gland and cervical nodes: CT and MR findings. J Comput Assist Tomogr 1992;16:320–322 19. Oguz KK, Ozturk A, Cila A. Magnetic resonance imaging findings in Kimura’s disease. Neuroradiology 2004;46:855–858 20. Shetty AK, Beaty MW, McGuirt WF Jr et al. Kimura’s disease: a diagnostic challenge. Pediatrics 2002;110:e39 21. Kapoor NS, O’Neill JP, Katabi N, et al. Kimura disease: diagnostic challenges and clinical management. Am J Otolaryngol 2012;33:259– 262 22. Yuen HW, Goh YH, Low WK, et al. Kimura’s disease: a diagnostic and therapeutic challenge. Singapore Med J 2005;46:179–183
Outcome of Otologic Symptoms after Temporomandibular Joint Arthrocentesis S. Tozoglu, PhD, DDS, Z. Bayramoglu, DDS,y and O. Ozkan, MDz Abstract: The objectives of this study were to determine the prevalence of otologic complaints in patients with temporomandibular joint (TMJ) closed lock (CL), and to evaluate the efficacy of arthrocentesis in temporomandibular disorder (TMD) patients with otologic symptoms. Fifty-seven patients with TMJ CL were From the Department of Oral and Maxillofacial Surgery, Akdeniz University, Faculty of Dentistry, Antalya; yDepartment of Oral and Maxillofacial Surgery; and zDepartment of ENT, Faculty of Dentistry, Ataturk University, Erzurum, Turkey, Erzincan University, Medical Faculty, Erzincan Turkey. Received October 10, 2014. Accepted for publication February 17, 2015. Address correspondence and reprint requests to Sinan Tozoglu, PhD, DDS, Associated Professor, Department of Oral and Maxillofacial Surgery, Akdeniz University, Faculty of Dentistry, Antalya, Turkey; E-mail: [email protected] The authors have no conflicts of interest to report. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001808 #
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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included in this study. The pre-treatment evaluations included assessment of the maximum mouth opening (MMO); pain level in palpation of the affected TMJ; pain level with function; and otologic complaints, including otalgia, tinnitus, vertigo, and hearing loss. Arthrocentesis treatment was performed for all the patients, and post-treatment data were recorded 1 month later. Before arthrocentesis and lavage, the mean MMO was 24.67 4.61 mm; the mean tenderness score was 7.02 1.09; and the mean score for pain in function was 6.86 1.31. Following TMJ arthrocentesis and lavage, the mean MMO was 39.81 mm 4.56 mm; the mean tenderness score was 2.37 0.65; and the mean score for pain in function was 2.45 0.69. Seventeen (29.82%) patients reported at least 1 otologic complaint, 17 (29.82%) patients reported otalgia, and 8 (14.04%) patients reported tinnitus. Vertigo was noted in 5 (8.77%) patients. Complaints of hearing loss were not noted in any of the patients. After treatment, 14 patients no longer complained of otalgia, 5 patients no longer complained of tinnitus, and 2 patients no longer complained of vertigo. This represented a significant improvement in the patients’ condition, especially in patients with otalgia (P < 0.0006). As evident from the results of this study, arthrocentesis procedures reduce both TMD symptoms and otologic complaints. Key Words: TMJ, arthrocentesis, closed lock, otalgia
O
talgia may arise from otologic causes such as middle or external ear otitis, or mastoiditis, as well as from non-otologic causes such as dental conditions, tonsillitis, neoplasms, neuralgia, and temporomandibular articulation disorders.1 Temporomandibular disorders (TMDs) such as osteoarthritis, closed lock (CL), and myofascial dysfunction are the most common non-otologic causes of ear pain.2– 4 In temporomandibular joint (TMJ) CL, the patient’s main complaints originated from the TMJ rather than the muscle.5 The intra-articular disc is located even further forward and the condyle is unable to pass over the posterior band on attempted mouth opening. The main complaint of patients with TMJ CL is a sudden inability to open the mouth wide, which is associated with localized pain in the TMJ that increases with attempted mouth opening and chewing. The patient generally also experiences joint tenderness on lateral and intrameatal palpation. In unilateral cases, the mandible will deviate to the affected side with attempted mouth opening.5 Such patients may also have otologic complaints, such as otalgia, tinnitus, vertigo, and hearing loss,1,4,6,7 although they have no pathologic conditions of the ear. Such patients generally consult otolaryngologists or oral surgeons for treatment of their symptoms.4,8 To solve the otologic complaints, it might be wise to focus on the joint problem itself in TMJ CL patients. Arthrocentesis has been used in the past to treat patients with TMJ CL (CL: anterior disk displacement without reduction).9–13 After lysis and lavage of the upper joint space of the TMJ, all patients show improvement in symptoms such as palpation, pain, limited mouth opening, and pain during function.9,10,14 In addition, an improvement in otologic symptoms is also noticed after such treatment. Although there is some available research about otologic complaints in patients with TMD, none of it investigates otologic complaints in patients with TMJ CL. Additionally, there is no available research regarding the effectiveness of arthrocentesis in TMD patients with otologic symptoms. #
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Therefore, the aim of this study is to ascertain the prevalence of otologic symptoms in TMJ CL patients, and investigate the role of arthrocentesis in the elimination of such symptoms.
MATERIAL AND METHODS This study investigated 57 TMJs of 57 patients (49 female and 8 male patients), all of whom had signs and symptoms of TMJ CL and accompanying otologic complaints. None of the patients had a history of macrotrauma. The patients ranged in age from 17 to 60 years. All the patients were clinically examined to diagnose their TMD problems. Pre-treatment data collected included medical and dental history, history of the TMD problems, and evaluation of clinical signs or symptoms. We classified the patients according to Wilkes staging.15 Patients with Wilkes stages 3, 4, and 5 were included in the study: Stage III (intermediate stage)—multiple episodes of pain, joint tenderness, temporal headaches, locking, CLs, restriction of motion, painful chewing, anterior disk displacement, moderate to marked disk thickening, normal osseous contour; stage IV (intermediate-late stage)—chronic and episodic pain, headaches, variable restriction of motion, anterior disk displacement, marked disk thickening, and abnormal bone contours; stage V (late stage)—crepitus on examination, variable and episodic pain, anterior disk displacement with disk perforation and gross deformity, and degenerative osseous changes, chronic restriction of motion, difficulty to function. The patients were also questioned about their otologic complaints, including otalgia, tinnitus, vertigo, and hearing loss. In the past, patients had received nonsurgical treatment for their TMJ problems, but mentioned that they did not perceive any benefit from this. The patients complained of limited mouth opening and pain in the affected TMJ. Histories of painful locking and limited mouth opening (15–33 mm) ranged from 2 days to 2 years. In cases in which diagnosis could not be confirmed, further investigations were done with MRI scans. All the details were recorded in a questionnaire by the examiner. Pain level was estimated using a visual analog scale (VAS) (0–10), where 0 indicated no pain, and 10, severe pain. Clinical examinations included evaluations of maximum mouth opening (MMO), pain level in palpation of the affected TMJ, and pain level on function. The MMO was measured as the distance between the incisal edges of the upper and lower central incisors. Pain level on function was determined by asking the patients how much pain they felt when chewing an ordinary meal. In addition, the patients were asked to bite 2 pieces of wooden tongue depressors with their front teeth during the examination. Pain levels at the time of biting and chewing were measured with VAS. Then, average VAS score between chewing and biting was calculated. Of the 57 subjects, 17 had otologic symptoms such as otalgia, tinnitus, vertigo, and hearing loss. Otalgia was the major complaint among these patients. In the past, they had been referred to ear, nose, and throat, or audiology departments, yet the cause of their otologic symptoms could not be determined. Patients with otologic causes were not included in the present study. Written consent forms were obtained from patients before the procedure. All patients were scheduled for arthrocentesis. Arthrocentesis was performed using a technique described by Nitzan, in which 2-gauge needles are inserted into the superior joint space of the TMJ under local anesthesia.16 Through 1 needle, at least 100 mL of Ringer lactate solution is injected into the superior joint space; at the same time, the second needle acts as an outflow portal, which allows lavage of the joint cavity. All the measurements were then repeated 1 month after treatment. The pre-operative and postoperative results were analyzed statistically. All continuous variables were subjected to the t test, and discrete variables were
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subjected to the x2 test. Variables were analyzed using SAS (SPSS20.0, Chicago, IL).
RESULTS Of the 57 patients with TMJ CL, 49 were female and 8 were male: they were aged 17 to 60 years (mean, 36.5 years). Before arthrocentesis and lavage, the mean MMO was 24.67 4.61 mm. Following TMJ arthrocentesis and lavage, the mean MMO was 39.81 4.56 mm after a follow-up period of 1 month. This increase in MMO following arthrocentesis and lavage was found to be statistically significant (P < 0.0001). On the VAS, the mean tenderness score before TMJ arthrocentesis was 7.02 1.09. One month after lavage, the mean tenderness score was 2.37 0.65. This indicates a significant reduction in tenderness in the affected joint as a result of TMJ arthrocentesis and lavage, and the difference was found to be statistically significant (P < 0.0001). On the VAS, the average score for pain on function was 6.86 1.31 before TMJ arthrocentesis. On follow-up, the average score was 2.45 0.69. This also represents a significant improvement in pain on function and chewing ability as a result of treatment, and this difference was also found to be statistically significant (P < 0.0001). Both pre-treatment and post-treatment, mean scores of TMD symptoms, t and P values are shown in Table 1. Forty patients (70.18%) stated they had no otologic complaints, 17 (29.82%) patients reported at least 1 otologic complaint, 17 (29.82%) patients reported otalgia, and 8 (14.04%) patients reported tinnitus. Vertigo was noted in 5 (8.77%) patients. All patients with tinnitus had also otalgia, and all patients with vertigo also had both otalgia and tinnitus. Complaints of hearing loss were not noted among any of the patients. On follow-up, 14 patients no longer complained of otalgia, 5 patients no longer complained of tinnitus, and 2 patients no longer complained of vertigo. These differences also represent a significant improvement after treatment, especially in patients with otalgia (P < 0.0006). The number of patients that reported tinnitus and vertigo after TMJ arthrocentesis and lavage was less, but this difference was not statistically significant (Table 2). On a separate note, temporary facial paresis or paralysis caused by the use of a local anesthetic, or swelling of the neighboring tissues caused by perfusion of Ringer solution, occurred during arthrocentesis. However, these effects were transient and disappeared within a few hours.
DISCUSSION Several studies have been proposed in the past to explain the otologic symptoms reported by TMD patients. The reported prevalence of otologic complaints in TMD patients varies in literature.1,4,17–20 Tuz et al4 investigated the prevalence of otologic complaints in 200 TMD patients. In their study, 22.5% of the patients had no otologic TABLE 1. Pre-treatment and 1 Month After Arthrocentesis Average Scores of TMD Symptoms, t and P values TMD Symptoms
Pre-treatment
Average MMO 24.67 4.61 mm Average tenderness 7.02 1.09 score Average score for 6.86 1.31 pain in function
After Arthrocentesis— Follow-up First Month 39.81 4.56 mm 2.37 0.65 2.45 0.69
t
17.61 0.0001 27.51 0.0001
22.49 0.0001
MMO, maximum mouth opening; TMD, temporomandibular disorder.
Significant difference.
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TABLE 2. Distribution of Patients With Otological Symptoms (Pre-treatment and After Artrocentesis, Follow-up First Month), x2 and P Values Otologic Symptoms Otalgia Tinnitus Vertigo Loss of hearing
Number of Patients (Pre-treatment)
Number of Patients (After Arthrocentesis— Follow-up First Month)
17 (29.82%) 8 (14.04%) 5 (8.77%) 0
3 (5.26%) 3 (5.26%) 3 (5.26%) 0
x2
P
11.89 2.52 0.54
0.0006 0.11 0.46
Significant difference.
complaints; 77.5% reported at least 1 complaint; 50% reported earache; and 45.5% reported tinnitus. Vertigo and loss of hearing were noted in 72 (36%) and 47 (23.5%) patients, respectively. Mota et al1 searched the signs and symptoms associated with otalgia in TMJ dysfunction in 21 patients. They reported tinnitus in 81%, vertigo in 26.8%, and difficulty in hearing in 14.3% of subjects in their study.1 Pekkan et al20 reported that the most prominent ear symptom in TMD patients with otologic complaints was otalgia, followed by tinnitus, ear fullness, vertigo, and subjective hearing loss. Williamson8 investigated the interrelationship of internal derangements of the TMJ, headache, vertigo, and tinnitus in 25 patients. He reported that none of them had an otologic disorder when examined by specialists. In our study, we investigated the prevalence of otologic complaints in patients with TMJ CL, and it was found to be 29.82%. The most prominent ear symptom in our patients was found to be otalgia (29.82%), followed by tinnitus (14.04%) and vertigo (8.77%). None of the patients reported hearing loss. Ear, nose, and throat consultants failed to find any pathologic conditions that could explain the ear symptoms. This is consistent with the results of Williamson’s study. In the current literature, there is not a strong explanation that TMJ CL directly causes otologic complaints. Costen21, who pointed out that the condyle may cause aural symptoms by compressing the Eustachian tube or the greater auricular nerve, aroused the most interest in this regard. Subsequently, however, his theory was proved to be false.22 We think that TMJ inflammation may be related to such symptoms because of the close anatomical relationship between the TMJ and ear. Pain may be related to the reflective pain originated from the temporomandibular joint. Mandibular condyle is in contact with the retrodiscal tissue rather than with the disc in TMJ CL. Injury of the retrodiscal tissue may cause pain. In addition, disk displacement may result from a failure of the lubricant system that is initiated by free radicals.23 Free radicals damage important molecules of the articular tissues and it contributes to inflammation and related pain.5 Arthrocentesis is a clinically effective and minimally invasive treatment modality for TMJ CL.9 –11 It has been reported to reduce pain and tenderness on function, thereby improving function in patients with TMJ CL.9,10,14 Lavage of the upper compartment of the TMJ forces the flexible disc away from the fossa, washes away degraded particles and inflammatory components, and decreases intra-articular pressure. This injection of fluid under pressure is useful in breaking joint adherences that are responsible for reduced translatory movements of the condyle, thus resulting in an immediate improvement in mouth opening.24,25 In our study, the mean MMO improved (before arthrocentesis, it was 24.67 4.61 mm; after arthrocentesis, 39.81 4.56 mm). The mean tenderness and pain on function also decreased (tenderness: from 7.02 1.09 to 2.37 0.65; pain: from 6.86 1.31 to 2.45 0.69). These findings are consistent with those of previous studies.9,10,14 We could not find any research regarding the effectiveness of arthrocentesis in TMD patients with otologic symptoms. Therefore, #
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in our study, we investigated otologic symptoms including otalgia, tinnitus, vertigo, and loss of hearing alongside the effectiveness of arthrocentesis in TMJ CL patients. Otalgia was present in 17 patients, but disappeared in 14 (82.35%) of them after arthrocentesis. Tinnitus was present in 8 patients, but disappeared in 5 (62.5%) of them after arthrocentesis. Similarly, complaints of vertigo decreased by 40% after arthrocentesis, as they were present in 5 patients initially and disappeared in 2. As we expected, a significant improvement in otologic symptoms occurred with treatment. In our opinion, these improvements resulted from a decrease in TMJ inflammation perpetuated by the arthrocentesis. In addition, improvement of disc position and joint movement may reduce pain in the joint. Thus, pain score–related reflected pain on ear region may reduce. In otolaryngology clinics, tinnitus and vertigo in patients with otologic pathologies are often treated with lidocaine injections. Fradis et al26 found that intratympanic injection of lidocaine caused an 82% improvement in vertigo, as well as a 67.8% improvement in tinnitus. Moreover, Sakata et al27 investigated the efficacy of lidocaine infusions in the treatment of tinnitus. They found it to have an overall efficacy of 81%. Another method utilizes steroid injection to the tympanic cavity. Sakata et al28 performed intratympanic dexamethasone infusion to treat tinnitus and reported its efficacy to be 71%. In arthrocentesis, local anesthetics are used for a painless procedure. Steroids may also be injected into the upper joint space. The antiinflammatory effects of intra-articular corticosteroids on synovial tissues have been well documented.29 However, this was not applied routenely due to its side effects, like destruction of articular cartilage. Instead, a local anesthetic such as mepivacaine would be an alternative. Another alternative would be sodium hyaluronate due to its faster and longer effect on pain relief.29 Since the TMJ and tympanic structures share a close anatomic relationship, anesthetic may also be injected in arthrocentesis procedures to reduce ear symptoms, as reported by Sakata and Fradis.26,27 In conclusion, otologic complaints are common in patients with TMJ CL. After ruling out primary otalgia, patients with secondary otalgia should be referred to an oral surgeon to rule out TMD causing aural symptoms. Thus, unnecessary visits to the physician and the resultant treatment costs can be avoided. Arthrocentesis procedures have been proved to be effective in reducing not only TMD symptoms, but also otologic complaints. However, further studies are required to evaluate the efficacy of arthrocentesis in the treatment of other TMJ disorders.
REFERENCES 1. Mota LAA, Albuquerque KMG, Santos MHP, et al. Signs and symptoms associated to otalgia in temporomandibular joint dysfunction. Int Arch Otorhinolaryngol 2007;11:411–415 2. Dworkin SF, Huggins KH, Leresche L, et al. Epidemiology of symptoms in temporomandibular disorders: clinical signs in cases and controls. J Am Dent Assoc 1990;120:273–281 3. Keersmaekers K, De Boever JA, Van Den Berghe I. Otalgia in patients with temporomandibular disorders. J Prosthet Dent 1996;75:72–76 4. Tuz HH, Onder EM, Kisnisci RS. Prevalence of otologic complaints in patients with temporomandibular disorder. Am J Orthod Dentofacial Orthop 2003;123:620–623 5. Laskin DM, Greene CS, Hylander WL. Temporomandibular disorders: an evidence-based approach to diagnosis and treatment Singapore: Quintessence; 2006:249–254. 6. Lam DK, Lawrence HP, Tenenbaum HC. Aural symptoms in temporomandibular disorders patients attending a craniofacial pain unit. J Orofac Pain 2001;15:146–157
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7. Bruto LH, Ko´s AOA, Amado SM, et al. Alteraco`es otolo´gicas nas desordens temporomandibulares. Rev Bras Otorrinolaringol 2000;66:327–332 8. Williamson EH. The interrelationship of internal derangement of the temporomandibular joint, headache, vertigo and tinnitus: a survey of 25 patients. J Craniomandib Pract 1990;8:301–306 9. Vasconcelos BCE, Nogueira RVB, Rocha NS. Temporomandibular joint arthrocententesis: evaluation of results and review of the literature. Rev Bras Otorrinolaringol 2006;72:634–638 10. Dimitroulis G, Dolwick MF, Martinez A. Temporomandibular joint arthrocentesis and lavage for the treatment of closed lock: a follow-up study. Br J Oral Maxillofacial Surg 1995;33:23–27 11. Nitzan DW. Arthrocentesis-incentives for using this minimally invasive approach for temporomandibular disorders. Oral Maxillofac Surg Clin North Am 2006;18:311–328 12. McCain JP. Principles and Practice of Temporomandibular Joint Arthroscopy. St Louis: Mosby; 1996:12–360. 13. Alpaslan GH, Alpaslan C. Efficacy of temporomandibular joint arthrocentesis with and without injection of sodium hyaluronate intreatment of internal derangements. J Oral Maxillofac Surg 2001;59:613–618 ¨ nder ME, Tu¨z HH, Koc¸yig˘it D, et al. Long-term results of 14. O arthrocentesis in degenerative temporomandibular disorders. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107:e1–e5 15. Wilkes CH. Internal derangements of the temporomandibular joint. Pathological variations. Arch Otolaryngol Head Neck Surg 1989;115:469–477 16. Nitzan DW, Dolwick MF, Martinez GA. Temporomandibular joint arthrocentesis: a simplified treatment for severe, limited mouth opening. J Oral Maxillofac Surg 1991;49:1163–1167 17. Parker WS, Chole RA. Tinnitus, vertigo, and temporomandibular disorders. Am J Orthod Dentofacial Orthop 1995;107:153–158 18. Cooper BC, Cooper DL. Recognizing otolaryngologic symptoms in patients with temporomandibular disorders. Cranio 1993;11:260– 267 19. Rubinstein B, Axelsson A, Carlsson GE. Prevalence of signs and symptoms of cra-niomandibular disorders in tinnitus patients. J Craniomandib Disord 1990;4:186–192 20. Pekkan G, Aksoy S, Hekimog˘lu C, et al. Comparative audiometric evaluation of temporomandibular disorder patients with otological symptoms. J Craniomaxillofac Surg 2010;38:231–234 21. Costen J. A syndrome of ear and sinus symptoms dependent upon disturbed function of the temporomandibular joint. Ann Otol Rhinol Laryngol 1934;43:1–5 22. Vernon J, Griest S, Press L. Attributes of tinnitus associated with the temporomandibular joint syndrome. Eur Arch Otorhinolaryngol 1992;249:93–94 23. Guven O, Tozoglu S, Tekin U, et al. Comparative audiometric evaluation of temporomandibular disorder patients with otological symptoms. J Craniofac Surg 2010;38:231–234 24. Dolwick MF. Temporomandibular joint surgery for internal derangement. Dent Clin North Am 2007;51:195–208 25. Guarda-Nardini L, Manfredini D, Ferronato G. Arthrocentesis of the temporomandibular joint: a proposal for a single-needle technique. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106:483– 486 26. Fradis M, Podoshin L, Ben-David J, et al. Treatment of Meniere’s disease by intratympanic injection with lidocaine. Arch Otolaryngol 1985;111:491–493 27. Sakata H, Kojima Y, Koyama S, et al. Treatment of cochlear tinnitus with transtympanic infusion of 4% lidocaine into the tympanic cavity. Int Tinnitus J 2001;7:46–50 28. Sakata E, Itoh A, Itoh Y. Treatment of cochlear-tinnitus with dexamethasone infusion into the tympanic cavity. Int Tinnitus J 1996;2:129–135 29. Tozoglu S, Al-Belasy FA, Dolwick MF. A review of techniques of lysis and lavage of the TMJ. Br J Oral Maxillofac Surg 2011;49: 302–309
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The main distinguishing feature between the 2 is endothelial cells that are normal in KD but large and atypical in ALHE. In addition, ALHE is more common in middle-aged, white females and develops in the subcutis and dermis without lymph node involvement.17 On computed tomography scans, either well defined nodular masses or ill-defined plaque-like infiltrative masses in the subcutaneous tissue associated with lymphadenopathy are reported as typical findings.18 The attenuation of the masses varies from iso- to hyperattenuated.14 On magnetic resonance images, the masses are reported to show variable signal intensity, that is, low-to-high signal intensity on T1- and T2-weighted images.14,18,19 On postcontrast computed tomography and magnetic resonance imaging, enhancement patterns vary from mild to intense and from homogeneous to heterogeneous. This variability in the degree of enhancement is thought to be attributed to the different degrees of vascular proliferation and fibrosis.14 Standard treatment of KD is not yet well established. Therapeutic options include conservative management such as intralesional and/or systemic steroids and surgical excision. In 2002, cyclosporine has also been used with good results.20 Surgical excision is the preferred method of initial treatment and also permits proper tissue diagnosis. The role of fine needle aspiration and biopsy procedures is limited in diagnosing KD,21 making surgical resection likely necessary to make the final diagnosis because the histologic features of the tumor are nonspecific and can be found in many other disease entities including reactive processes. Moreover, small biopsy specimens might not demonstrate the lobulated architecture of the whole histologic picture of this tumor. Because recurrence rates are as high as 25% after surgery,22 complete surgical excision is the treatment of choice for solitary lesions, as in our case. Kimura disease is an unusual cause of lesions in the orbit and eyelid. Although it is a rare entity in Western countries, it is important to correctly diagnose this condition because it is more common in Asian populations, and a benign process that carries a good prognosis. In conclusion, despite its rarity, it is important to understand that KD can affect all races and almost all age groups, and should be suspected when a subcutaneous mass of the head or neck including an eyelid mass is associated with eosinophilia.
REFERENCES 1. Kim HT, Szeto C. Eosinophilic hyperplastic lymphogranuloma, comparison with Mikulicz’s disease. Chin Med J 1937;23:699–700 2. Kimura TYS, Ishikawa E. On the unusual granulation combined with hyperplastic changes of lymphatic tissues. Trans Soc Pathol Jpn 1948:37 3. Li TJ, Chen XM, Wang SZ, et al. Kimura’s disease: a clinicopathologic study of 54 Chinese patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:549–555 4. Sun QF, Xu DZ, Pan SH, et al. Kimura disease: review of the literature. Intern Med J 2008;38:668–672 5. Muller-Richter UD, Moralis A, Reuther T, et al. Kimura’s disease in a white man. Head Neck 2011;33:138–140 6. Prabhakaran VC, Sachdev A, Cheung D, et al. Kimura disease of the eyelid: a clinicopathologic study with electron microscopic observations. Ophthal Plast Reconstr Surg 2006;22:495–498 7. Hidayat AA, Cameron JD, Font RL, et al. Angiolymphoid hyperplasia with eosinophilia (Kimura’s disease) of the orbit and ocular adnexa. Am J Ophthalmol 1983;96:176–189 8. Kawata R, Yoshimura K, Ichihara T, et al. Kimura’s disease of the epiglottis: resection by a lateral pharyngotomy approach. Otolaryngol Head Neck Surg 2010;142:148–149 9. Buggage RR, Spraul CW, Wojno TH, et al. Kimura disease of the orbit and ocular adnexa. Surv Ophthalmol 1999;44:79–91
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10. Yoganathan P, Meyer DR, Farber MG. Bilateral lacrimal gland involvement with Kimura disease in an African American male. Arch Ophthalmol 2004;122:917–919 11. Goldenberg D, Gatot A, Barki Y, et al. Computerized tomographic and ultrasonographic features of Kimura’s disease. J Laryngol Otol 1997;111:389–391 12. Atar S, Oberman AS, Ben-Izhak O, et al. Recurrent nephrotic syndrome associated with Kimura’s disease in a young non-Oriental male. Nephron 1994;68:259–261 13. Chen H, Thompson LD, Aguilera NS, et al. Kimura disease: a clinicopathologic study of 21 cases. Am J Surg Pathol 2004;28: 505–513 14. Takahashi S, Ueda J, Furukawa T, et al. Kimura disease: CT and MR findings. AJNR Am J Neuroradiol 1996;17:382–385 15. Sakamoto M, Komura A, Nishimura S. Hematoserological analysis of Kimura’s disease for optimal treatment. Otolaryngol Head Neck Surg 2005;132:159–160 16. Ohta N, Okazaki S, Fukase S, et al. Serum concentrations of eosinophil cationic protein and eosinophils of patients with Kimura’s disease. Allergol Int 2007;56:45–49 17. Lee JK, Almousa R, Thamboo TP, et al. Kimura disease of the eyelid in an Indian man. Clin Exp Ophthalmol 2009;37:412–414 18. Som PM, Biller HF. Kimura disease involving parotid gland and cervical nodes: CT and MR findings. J Comput Assist Tomogr 1992;16:320–322 19. Oguz KK, Ozturk A, Cila A. Magnetic resonance imaging findings in Kimura’s disease. Neuroradiology 2004;46:855–858 20. Shetty AK, Beaty MW, McGuirt WF Jr et al. Kimura’s disease: a diagnostic challenge. Pediatrics 2002;110:e39 21. Kapoor NS, O’Neill JP, Katabi N, et al. Kimura disease: diagnostic challenges and clinical management. Am J Otolaryngol 2012;33:259– 262 22. Yuen HW, Goh YH, Low WK, et al. Kimura’s disease: a diagnostic and therapeutic challenge. Singapore Med J 2005;46:179–183
Outcome of Otologic Symptoms after Temporomandibular Joint Arthrocentesis S. Tozoglu, PhD, DDS, Z. Bayramoglu, DDS,y and O. Ozkan, MDz Abstract: The objectives of this study were to determine the prevalence of otologic complaints in patients with temporomandibular joint (TMJ) closed lock (CL), and to evaluate the efficacy of arthrocentesis in temporomandibular disorder (TMD) patients with otologic symptoms. Fifty-seven patients with TMJ CL were From the Department of Oral and Maxillofacial Surgery, Akdeniz University, Faculty of Dentistry, Antalya; yDepartment of Oral and Maxillofacial Surgery; and zDepartment of ENT, Faculty of Dentistry, Ataturk University, Erzurum, Turkey, Erzincan University, Medical Faculty, Erzincan Turkey. Received October 10, 2014. Accepted for publication February 17, 2015. Address correspondence and reprint requests to Sinan Tozoglu, PhD, DDS, Associated Professor, Department of Oral and Maxillofacial Surgery, Akdeniz University, Faculty of Dentistry, Antalya, Turkey; E-mail: [email protected] The authors have no conflicts of interest to report. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001808 #
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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included in this study. The pre-treatment evaluations included assessment of the maximum mouth opening (MMO); pain level in palpation of the affected TMJ; pain level with function; and otologic complaints, including otalgia, tinnitus, vertigo, and hearing loss. Arthrocentesis treatment was performed for all the patients, and post-treatment data were recorded 1 month later. Before arthrocentesis and lavage, the mean MMO was 24.67 4.61 mm; the mean tenderness score was 7.02 1.09; and the mean score for pain in function was 6.86 1.31. Following TMJ arthrocentesis and lavage, the mean MMO was 39.81 mm 4.56 mm; the mean tenderness score was 2.37 0.65; and the mean score for pain in function was 2.45 0.69. Seventeen (29.82%) patients reported at least 1 otologic complaint, 17 (29.82%) patients reported otalgia, and 8 (14.04%) patients reported tinnitus. Vertigo was noted in 5 (8.77%) patients. Complaints of hearing loss were not noted in any of the patients. After treatment, 14 patients no longer complained of otalgia, 5 patients no longer complained of tinnitus, and 2 patients no longer complained of vertigo. This represented a significant improvement in the patients’ condition, especially in patients with otalgia (P < 0.0006). As evident from the results of this study, arthrocentesis procedures reduce both TMD symptoms and otologic complaints. Key Words: TMJ, arthrocentesis, closed lock, otalgia
O
talgia may arise from otologic causes such as middle or external ear otitis, or mastoiditis, as well as from non-otologic causes such as dental conditions, tonsillitis, neoplasms, neuralgia, and temporomandibular articulation disorders.1 Temporomandibular disorders (TMDs) such as osteoarthritis, closed lock (CL), and myofascial dysfunction are the most common non-otologic causes of ear pain.2– 4 In temporomandibular joint (TMJ) CL, the patient’s main complaints originated from the TMJ rather than the muscle.5 The intra-articular disc is located even further forward and the condyle is unable to pass over the posterior band on attempted mouth opening. The main complaint of patients with TMJ CL is a sudden inability to open the mouth wide, which is associated with localized pain in the TMJ that increases with attempted mouth opening and chewing. The patient generally also experiences joint tenderness on lateral and intrameatal palpation. In unilateral cases, the mandible will deviate to the affected side with attempted mouth opening.5 Such patients may also have otologic complaints, such as otalgia, tinnitus, vertigo, and hearing loss,1,4,6,7 although they have no pathologic conditions of the ear. Such patients generally consult otolaryngologists or oral surgeons for treatment of their symptoms.4,8 To solve the otologic complaints, it might be wise to focus on the joint problem itself in TMJ CL patients. Arthrocentesis has been used in the past to treat patients with TMJ CL (CL: anterior disk displacement without reduction).9–13 After lysis and lavage of the upper joint space of the TMJ, all patients show improvement in symptoms such as palpation, pain, limited mouth opening, and pain during function.9,10,14 In addition, an improvement in otologic symptoms is also noticed after such treatment. Although there is some available research about otologic complaints in patients with TMD, none of it investigates otologic complaints in patients with TMJ CL. Additionally, there is no available research regarding the effectiveness of arthrocentesis in TMD patients with otologic symptoms. #
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Therefore, the aim of this study is to ascertain the prevalence of otologic symptoms in TMJ CL patients, and investigate the role of arthrocentesis in the elimination of such symptoms.
MATERIAL AND METHODS This study investigated 57 TMJs of 57 patients (49 female and 8 male patients), all of whom had signs and symptoms of TMJ CL and accompanying otologic complaints. None of the patients had a history of macrotrauma. The patients ranged in age from 17 to 60 years. All the patients were clinically examined to diagnose their TMD problems. Pre-treatment data collected included medical and dental history, history of the TMD problems, and evaluation of clinical signs or symptoms. We classified the patients according to Wilkes staging.15 Patients with Wilkes stages 3, 4, and 5 were included in the study: Stage III (intermediate stage)—multiple episodes of pain, joint tenderness, temporal headaches, locking, CLs, restriction of motion, painful chewing, anterior disk displacement, moderate to marked disk thickening, normal osseous contour; stage IV (intermediate-late stage)—chronic and episodic pain, headaches, variable restriction of motion, anterior disk displacement, marked disk thickening, and abnormal bone contours; stage V (late stage)—crepitus on examination, variable and episodic pain, anterior disk displacement with disk perforation and gross deformity, and degenerative osseous changes, chronic restriction of motion, difficulty to function. The patients were also questioned about their otologic complaints, including otalgia, tinnitus, vertigo, and hearing loss. In the past, patients had received nonsurgical treatment for their TMJ problems, but mentioned that they did not perceive any benefit from this. The patients complained of limited mouth opening and pain in the affected TMJ. Histories of painful locking and limited mouth opening (15–33 mm) ranged from 2 days to 2 years. In cases in which diagnosis could not be confirmed, further investigations were done with MRI scans. All the details were recorded in a questionnaire by the examiner. Pain level was estimated using a visual analog scale (VAS) (0–10), where 0 indicated no pain, and 10, severe pain. Clinical examinations included evaluations of maximum mouth opening (MMO), pain level in palpation of the affected TMJ, and pain level on function. The MMO was measured as the distance between the incisal edges of the upper and lower central incisors. Pain level on function was determined by asking the patients how much pain they felt when chewing an ordinary meal. In addition, the patients were asked to bite 2 pieces of wooden tongue depressors with their front teeth during the examination. Pain levels at the time of biting and chewing were measured with VAS. Then, average VAS score between chewing and biting was calculated. Of the 57 subjects, 17 had otologic symptoms such as otalgia, tinnitus, vertigo, and hearing loss. Otalgia was the major complaint among these patients. In the past, they had been referred to ear, nose, and throat, or audiology departments, yet the cause of their otologic symptoms could not be determined. Patients with otologic causes were not included in the present study. Written consent forms were obtained from patients before the procedure. All patients were scheduled for arthrocentesis. Arthrocentesis was performed using a technique described by Nitzan, in which 2-gauge needles are inserted into the superior joint space of the TMJ under local anesthesia.16 Through 1 needle, at least 100 mL of Ringer lactate solution is injected into the superior joint space; at the same time, the second needle acts as an outflow portal, which allows lavage of the joint cavity. All the measurements were then repeated 1 month after treatment. The pre-operative and postoperative results were analyzed statistically. All continuous variables were subjected to the t test, and discrete variables were
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subjected to the x2 test. Variables were analyzed using SAS (SPSS20.0, Chicago, IL).
RESULTS Of the 57 patients with TMJ CL, 49 were female and 8 were male: they were aged 17 to 60 years (mean, 36.5 years). Before arthrocentesis and lavage, the mean MMO was 24.67 4.61 mm. Following TMJ arthrocentesis and lavage, the mean MMO was 39.81 4.56 mm after a follow-up period of 1 month. This increase in MMO following arthrocentesis and lavage was found to be statistically significant (P < 0.0001). On the VAS, the mean tenderness score before TMJ arthrocentesis was 7.02 1.09. One month after lavage, the mean tenderness score was 2.37 0.65. This indicates a significant reduction in tenderness in the affected joint as a result of TMJ arthrocentesis and lavage, and the difference was found to be statistically significant (P < 0.0001). On the VAS, the average score for pain on function was 6.86 1.31 before TMJ arthrocentesis. On follow-up, the average score was 2.45 0.69. This also represents a significant improvement in pain on function and chewing ability as a result of treatment, and this difference was also found to be statistically significant (P < 0.0001). Both pre-treatment and post-treatment, mean scores of TMD symptoms, t and P values are shown in Table 1. Forty patients (70.18%) stated they had no otologic complaints, 17 (29.82%) patients reported at least 1 otologic complaint, 17 (29.82%) patients reported otalgia, and 8 (14.04%) patients reported tinnitus. Vertigo was noted in 5 (8.77%) patients. All patients with tinnitus had also otalgia, and all patients with vertigo also had both otalgia and tinnitus. Complaints of hearing loss were not noted among any of the patients. On follow-up, 14 patients no longer complained of otalgia, 5 patients no longer complained of tinnitus, and 2 patients no longer complained of vertigo. These differences also represent a significant improvement after treatment, especially in patients with otalgia (P < 0.0006). The number of patients that reported tinnitus and vertigo after TMJ arthrocentesis and lavage was less, but this difference was not statistically significant (Table 2). On a separate note, temporary facial paresis or paralysis caused by the use of a local anesthetic, or swelling of the neighboring tissues caused by perfusion of Ringer solution, occurred during arthrocentesis. However, these effects were transient and disappeared within a few hours.
DISCUSSION Several studies have been proposed in the past to explain the otologic symptoms reported by TMD patients. The reported prevalence of otologic complaints in TMD patients varies in literature.1,4,17–20 Tuz et al4 investigated the prevalence of otologic complaints in 200 TMD patients. In their study, 22.5% of the patients had no otologic TABLE 1. Pre-treatment and 1 Month After Arthrocentesis Average Scores of TMD Symptoms, t and P values TMD Symptoms
Pre-treatment
Average MMO 24.67 4.61 mm Average tenderness 7.02 1.09 score Average score for 6.86 1.31 pain in function
After Arthrocentesis— Follow-up First Month 39.81 4.56 mm 2.37 0.65 2.45 0.69
t
17.61 0.0001 27.51 0.0001
22.49 0.0001
MMO, maximum mouth opening; TMD, temporomandibular disorder.
Significant difference.
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P
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TABLE 2. Distribution of Patients With Otological Symptoms (Pre-treatment and After Artrocentesis, Follow-up First Month), x2 and P Values Otologic Symptoms Otalgia Tinnitus Vertigo Loss of hearing
Number of Patients (Pre-treatment)
Number of Patients (After Arthrocentesis— Follow-up First Month)
17 (29.82%) 8 (14.04%) 5 (8.77%) 0
3 (5.26%) 3 (5.26%) 3 (5.26%) 0
x2
P
11.89 2.52 0.54
0.0006 0.11 0.46
Significant difference.
complaints; 77.5% reported at least 1 complaint; 50% reported earache; and 45.5% reported tinnitus. Vertigo and loss of hearing were noted in 72 (36%) and 47 (23.5%) patients, respectively. Mota et al1 searched the signs and symptoms associated with otalgia in TMJ dysfunction in 21 patients. They reported tinnitus in 81%, vertigo in 26.8%, and difficulty in hearing in 14.3% of subjects in their study.1 Pekkan et al20 reported that the most prominent ear symptom in TMD patients with otologic complaints was otalgia, followed by tinnitus, ear fullness, vertigo, and subjective hearing loss. Williamson8 investigated the interrelationship of internal derangements of the TMJ, headache, vertigo, and tinnitus in 25 patients. He reported that none of them had an otologic disorder when examined by specialists. In our study, we investigated the prevalence of otologic complaints in patients with TMJ CL, and it was found to be 29.82%. The most prominent ear symptom in our patients was found to be otalgia (29.82%), followed by tinnitus (14.04%) and vertigo (8.77%). None of the patients reported hearing loss. Ear, nose, and throat consultants failed to find any pathologic conditions that could explain the ear symptoms. This is consistent with the results of Williamson’s study. In the current literature, there is not a strong explanation that TMJ CL directly causes otologic complaints. Costen21, who pointed out that the condyle may cause aural symptoms by compressing the Eustachian tube or the greater auricular nerve, aroused the most interest in this regard. Subsequently, however, his theory was proved to be false.22 We think that TMJ inflammation may be related to such symptoms because of the close anatomical relationship between the TMJ and ear. Pain may be related to the reflective pain originated from the temporomandibular joint. Mandibular condyle is in contact with the retrodiscal tissue rather than with the disc in TMJ CL. Injury of the retrodiscal tissue may cause pain. In addition, disk displacement may result from a failure of the lubricant system that is initiated by free radicals.23 Free radicals damage important molecules of the articular tissues and it contributes to inflammation and related pain.5 Arthrocentesis is a clinically effective and minimally invasive treatment modality for TMJ CL.9 –11 It has been reported to reduce pain and tenderness on function, thereby improving function in patients with TMJ CL.9,10,14 Lavage of the upper compartment of the TMJ forces the flexible disc away from the fossa, washes away degraded particles and inflammatory components, and decreases intra-articular pressure. This injection of fluid under pressure is useful in breaking joint adherences that are responsible for reduced translatory movements of the condyle, thus resulting in an immediate improvement in mouth opening.24,25 In our study, the mean MMO improved (before arthrocentesis, it was 24.67 4.61 mm; after arthrocentesis, 39.81 4.56 mm). The mean tenderness and pain on function also decreased (tenderness: from 7.02 1.09 to 2.37 0.65; pain: from 6.86 1.31 to 2.45 0.69). These findings are consistent with those of previous studies.9,10,14 We could not find any research regarding the effectiveness of arthrocentesis in TMD patients with otologic symptoms. Therefore, #
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Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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in our study, we investigated otologic symptoms including otalgia, tinnitus, vertigo, and loss of hearing alongside the effectiveness of arthrocentesis in TMJ CL patients. Otalgia was present in 17 patients, but disappeared in 14 (82.35%) of them after arthrocentesis. Tinnitus was present in 8 patients, but disappeared in 5 (62.5%) of them after arthrocentesis. Similarly, complaints of vertigo decreased by 40% after arthrocentesis, as they were present in 5 patients initially and disappeared in 2. As we expected, a significant improvement in otologic symptoms occurred with treatment. In our opinion, these improvements resulted from a decrease in TMJ inflammation perpetuated by the arthrocentesis. In addition, improvement of disc position and joint movement may reduce pain in the joint. Thus, pain score–related reflected pain on ear region may reduce. In otolaryngology clinics, tinnitus and vertigo in patients with otologic pathologies are often treated with lidocaine injections. Fradis et al26 found that intratympanic injection of lidocaine caused an 82% improvement in vertigo, as well as a 67.8% improvement in tinnitus. Moreover, Sakata et al27 investigated the efficacy of lidocaine infusions in the treatment of tinnitus. They found it to have an overall efficacy of 81%. Another method utilizes steroid injection to the tympanic cavity. Sakata et al28 performed intratympanic dexamethasone infusion to treat tinnitus and reported its efficacy to be 71%. In arthrocentesis, local anesthetics are used for a painless procedure. Steroids may also be injected into the upper joint space. The antiinflammatory effects of intra-articular corticosteroids on synovial tissues have been well documented.29 However, this was not applied routenely due to its side effects, like destruction of articular cartilage. Instead, a local anesthetic such as mepivacaine would be an alternative. Another alternative would be sodium hyaluronate due to its faster and longer effect on pain relief.29 Since the TMJ and tympanic structures share a close anatomic relationship, anesthetic may also be injected in arthrocentesis procedures to reduce ear symptoms, as reported by Sakata and Fradis.26,27 In conclusion, otologic complaints are common in patients with TMJ CL. After ruling out primary otalgia, patients with secondary otalgia should be referred to an oral surgeon to rule out TMD causing aural symptoms. Thus, unnecessary visits to the physician and the resultant treatment costs can be avoided. Arthrocentesis procedures have been proved to be effective in reducing not only TMD symptoms, but also otologic complaints. However, further studies are required to evaluate the efficacy of arthrocentesis in the treatment of other TMJ disorders.
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7. Bruto LH, Ko´s AOA, Amado SM, et al. Alteraco`es otolo´gicas nas desordens temporomandibulares. Rev Bras Otorrinolaringol 2000;66:327–332 8. Williamson EH. The interrelationship of internal derangement of the temporomandibular joint, headache, vertigo and tinnitus: a survey of 25 patients. J Craniomandib Pract 1990;8:301–306 9. Vasconcelos BCE, Nogueira RVB, Rocha NS. Temporomandibular joint arthrocententesis: evaluation of results and review of the literature. Rev Bras Otorrinolaringol 2006;72:634–638 10. Dimitroulis G, Dolwick MF, Martinez A. Temporomandibular joint arthrocentesis and lavage for the treatment of closed lock: a follow-up study. Br J Oral Maxillofacial Surg 1995;33:23–27 11. Nitzan DW. Arthrocentesis-incentives for using this minimally invasive approach for temporomandibular disorders. Oral Maxillofac Surg Clin North Am 2006;18:311–328 12. McCain JP. Principles and Practice of Temporomandibular Joint Arthroscopy. St Louis: Mosby; 1996:12–360. 13. Alpaslan GH, Alpaslan C. Efficacy of temporomandibular joint arthrocentesis with and without injection of sodium hyaluronate intreatment of internal derangements. J Oral Maxillofac Surg 2001;59:613–618 ¨ nder ME, Tu¨z HH, Koc¸yig˘it D, et al. Long-term results of 14. O arthrocentesis in degenerative temporomandibular disorders. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107:e1–e5 15. Wilkes CH. Internal derangements of the temporomandibular joint. Pathological variations. Arch Otolaryngol Head Neck Surg 1989;115:469–477 16. Nitzan DW, Dolwick MF, Martinez GA. Temporomandibular joint arthrocentesis: a simplified treatment for severe, limited mouth opening. J Oral Maxillofac Surg 1991;49:1163–1167 17. Parker WS, Chole RA. Tinnitus, vertigo, and temporomandibular disorders. Am J Orthod Dentofacial Orthop 1995;107:153–158 18. Cooper BC, Cooper DL. Recognizing otolaryngologic symptoms in patients with temporomandibular disorders. Cranio 1993;11:260– 267 19. Rubinstein B, Axelsson A, Carlsson GE. Prevalence of signs and symptoms of cra-niomandibular disorders in tinnitus patients. J Craniomandib Disord 1990;4:186–192 20. Pekkan G, Aksoy S, Hekimog˘lu C, et al. Comparative audiometric evaluation of temporomandibular disorder patients with otological symptoms. J Craniomaxillofac Surg 2010;38:231–234 21. Costen J. A syndrome of ear and sinus symptoms dependent upon disturbed function of the temporomandibular joint. Ann Otol Rhinol Laryngol 1934;43:1–5 22. Vernon J, Griest S, Press L. Attributes of tinnitus associated with the temporomandibular joint syndrome. Eur Arch Otorhinolaryngol 1992;249:93–94 23. Guven O, Tozoglu S, Tekin U, et al. Comparative audiometric evaluation of temporomandibular disorder patients with otological symptoms. J Craniofac Surg 2010;38:231–234 24. Dolwick MF. Temporomandibular joint surgery for internal derangement. Dent Clin North Am 2007;51:195–208 25. Guarda-Nardini L, Manfredini D, Ferronato G. Arthrocentesis of the temporomandibular joint: a proposal for a single-needle technique. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106:483– 486 26. Fradis M, Podoshin L, Ben-David J, et al. Treatment of Meniere’s disease by intratympanic injection with lidocaine. Arch Otolaryngol 1985;111:491–493 27. Sakata H, Kojima Y, Koyama S, et al. Treatment of cochlear tinnitus with transtympanic infusion of 4% lidocaine into the tympanic cavity. Int Tinnitus J 2001;7:46–50 28. Sakata E, Itoh A, Itoh Y. Treatment of cochlear-tinnitus with dexamethasone infusion into the tympanic cavity. Int Tinnitus J 1996;2:129–135 29. Tozoglu S, Al-Belasy FA, Dolwick MF. A review of techniques of lysis and lavage of the TMJ. Br J Oral Maxillofac Surg 2011;49: 302–309
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