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Case report
Septic arthritis of the temporomandibular joint in an unvaccinated adolescent
  1. Alexander Sachs,
  2. Erik Ziegler and
  3. Raymond Patrick Shupak
  1. Department of Oral and Maxillofacial Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
  1. Correspondence to Dr Raymond Patrick Shupak; rpshupak{at}gmail.com

Abstract

Septic arthritis of the temporomandibular joint (TMJ) is a rare condition, particularly in the paediatric population. Our case involves a 15-year-old unvaccinated Amish man with acute pain and trismus of the TMJ. The diagnosis was reached after history, clinical examination, radiographic and laboratory examinations were performed. The patient improved after a minimally invasive surgical procedure and medical therapy. Failure to recognise and treat septic arthritis in a timely fashion can result in serious sequalae. Infectious aetiologies should be kept on the differential for any patient with acute TMJ pain.

  • ear, nose and throat/otolaryngology
  • infectious diseases
  • head and neck surgery
  • oral and maxillofacial surgery
  • orthopaedics
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Background

Septic arthritis of the temporomandibular joint (SATMJ) is a rare condition, even more so in the paediatric population.1 Various pathophysiological routes have been investigated such as local spread from TMJ joint surgery, distant spread from odontogenic, middle ear or other head and neck infections and haematogenous spread. Multiple organisms have been isolated as the main aetiological agents of TMJ septic arthritis with Staphylococcus aureus being the most common.2

Despite a lack of consensus on how to treat the condition, good results can be obtained when following sound surgical principles. Management includes urgent decompression and drainage followed by medical management with antibiotic therapy.3 Early management of the condition is important in preventing long-term issues such as fibrosis, ankylosis and destruction of the TMJ. This is particularly important in the paediatric patient where the mandibular condyle is one of the main drivers of growth and development of the mandible and lower face.4

Case presentation

Our patient was a 15-year-old unvaccinated Amish man who presented to UPMC Children’s Hospital with worsening trismus and fever for 3 days. His medical history was insignificant. He had no history of immunodeficiency or other risk factors. The patient reported that he had sustained two lacerations over the previous 2 weeks. One laceration was noted on his hand sustained while butchering a pig, and the other was sustained to the nasal bridge during a fall. After both injuries, the patient failed to properly clean and dress the wounds.

On arrival to the emergency department at UPMC Children’s Hospital, the patient was noted to be haemodynamically stable with a normal WBC count of 8.1×109/L (reference range 4.5–13×109/L), elevated temperature of 38.3°C and elevated CRP of 5.83 mg/dL (reference range 0.04–0.079 mg/dL). On physical examination, the patient displayed no oedema or erythema overlying the right preauricular region. It was noted that the patient had leftward deviation of the mandibular dental midline as well as a right-sided apertognathia. He was also noted to have limited mouth opening (10–15 mm) as well as right-sided facial pain with tenderness to palpation overlying the lateral pole of the TMJ.

The patient was admitted and the infectious disease team was consulted. Their differential diagnosis included clostridium tetani infection given his history of contaminated wounds, trismus and his unvaccinated status. Therefore, the patient was transferred to the paediatric intensive care unit for airway monitoring and administered 500 units of tetanus immunoglobulin IM (Intramuscular) as well as vancomycin, cefepime and metronidazole by the infectious disease team. Subsequently, the oral and maxillofacial surgery service was consulted for evaluation.

Investigations

A CT of the neck with contrast was obtained upon arrival to the emergency room. The CT scan revealed a right TMJ effusion without any deformation to the condylar head or glenoid fossa (figures 1–3). A contrasted TMJ MRI was subsequently ordered to better characterise the joint effusion and surrounding soft tissues. T2-weighted imaging demonstrated an effusion of the right TMJ with surrounding mild myositis and evidence of pachymeningitis (figure 4).

Figure 1

Axial section of a CT of the neck with contrast demonstrating a 22×27.5 mm joint effusion in the right temporomandibular joint.

Figure 2

Sagittal section of a CT of the neck with contrast demonstrating a superior and inferior joint space effusion of the right temporomandibular joint.

Figure 3

Coronal section of a CT of the neck with contrast demonstrating a joint space effusion of the right temporomandibular joint.

Figure 4

Sagittal section of a T2-weighted MRI with contrast demonstrating a large superior and inferior joint space effusion of the right temporomandibular joint.

Differential diagnosis

After clinical and radiological examination, a differential diagnosis was created. This included septic arthritis, rheumatoid arthritis, psoriatic arthritis, parotitis, traumatic effusion, osteomyelitis and neoplasia.2 5 In addition, tetanus was a concern although following a comprehensive examination it was of low concern since only the right TMJ was involved.

Treatment

The patient was taken to the operating room the following day for diagnostic and therapeutic aspiration and lavage of the right TMJ. The patient was intubated, prepped and draped in a sterile fashion. Anatomic landmarks were identified and the Holmlund-Hellsing line was drawn with the classic 10/2 mm, 20/10 mm markings (figure 5). An 18-gauge needle was then inserted into the posterior joint space and used to aspirate the contents of the right TMJ. The aspirate yielded a cloudy seropurulent exudate (figure 6). The aspirate was then sent for cell count, gram stain, aerobic and anaerobic culture and sensitivity. Additional studies were unable to be sent for due to the limited volume of aspirate.

Figure 5

Intraoperative picture of the aspiration and lavage procedure. Note: Holmlund-Hellsing line drawn with insertion of the inflow and outflow at the 10/2 mm, 20/10 mm position.

Figure 6

Aspirate from the right temporomandibular joint prior to the lavage procedure.

The posterior joint space 18-guage needle was then kept in place to be used as an inflow port for arthrocentesis and lavage. A second 18-gauge needle was then inserted for an anterior outflow port. Approximately 150 mL of normal saline solution with gentle manual pressure was used to lavage the joint space.6 The lavage continued until the outflow fluid was clear. No antibiotic or steroid solution was injected directly into the joint space for risk of introducing new microbes into the space.

Outcome and follow-up

Following the procedure, the patient was monitored in the paediatric intensive care unit. After returning from the operating room, the patient’s antibiotic therapy was deescalated based on blood culture results and intraoperative findings. He was maintained on intravenous cefazolin while hospitalised. He was transferred to the floor on postoperative day 1 at which time there was significant clinical improvement in pain and jaw function. His maximal incisal opening returned to 30–35 mm unassisted with a resolution of his mandibular deviation. The cell count returned 98 900 WBC/cumm, 15 250 RBC/cumm, 99% neutrophils/1%lymphocytes with evidence of intracellular bacteria. The cultures resulted in growth of pan-sensitive S. aureus. A repeat CRP was drawn on postoperative day 1 resulting in a down trending value of 4.44 mg/dL. The infectious disease team held additional lab draws as the patient showed rapid clinical improvement. The patient was discharged home on postoperative day 2 with a 4-week course of oral cephalexin as well as TMJ physical therapy instructions. The patient was evaluated 1 month after his hospital admission with complete resolution of symptoms associated with septic arthritis.

Discussion

SATMJ is an extremely rare but serious condition with an estimated incidence of 2–10 cases per 100 000 in the general population.7 Septic arthritis can afflict both adults and children.3 4 Paediatric SATMJ is rare with currently less than 40 cases reported in the literature.1 8 The aetiology and pathophysiology of SATMJ have been postulated. Some common reported routes of spread include local odontogenic infections, middle ear infections or tonsillar infections.8–11 The most commonly reported spread involves the haematogenous route owing to the lack of basement membrane and high permeability of the joint synovial membrane.3 The causative organisms in SATMJ include S. aureus, streptococcus spp, Neisseria spp and Haemophilus influenzae and rarely Raoultella ornithinolytica.12–14 The microbiological findings in the jaw joint are constant with what is reported in the orthopaedic literature involving knee and hip joints.15

Currently, there is no universally accepted treatment algorithm for the management of adult or paediatric SATMJ. Procedures ranging from aspiration to open joint procedures have been described.16 Cai et al suggested a protocol following their review of 40 cases of adult TMJ septic arthritis at their institution. The authors argue for aspiration and joint lavage as the first-line treatment.3 Others argue that arthroscopic lysis and lavage should be used as first-line treatment owing to greater visualisation of the joint space ensuring complete washout.2 Unfortunately, the equipment and proper training in TMJ arthroscopy are not universal available. Medical management of septic TMJ arthritis includes targeted antibiotic therapy following aspiration, which is sent for culture and sensitivity.3 Most authors also argue for early mobilisation of the joint following any surgical procedure to prevent formation of adhesions and eventual fibrosis.2

Our patient underwent a diagnostic aspiration and lavage during the same anaesthetic. Our aspirate needle was subsequently used for the inflow port in order to limit the number of punctures and trauma to the TMJ capsule. Operative time was under 20 min. Arthroscopy and open arthrotomy were reserved for treatment failure, as both procedures are more time-consuming and traumatic to the TMJ complex. This methodology is similar to the algorithm employed in paediatric orthopaedic surgery involving septic arthritis of the hip.17

Early and aggressive treatment of suspected SATMJ is vitally important to prevent both short-term and long-term morbidity. Failure to treat SATMJ can lead to local spread to critical anatomical regions. Specifically, untreated SATMJ can lead to acute sequela including erosion of the skull base and formation of epidural abscesses.5 Additional sequela of SATMJ includes fibrosis, ankylosis and bony destruction of the condyle. This has been reported to occur in as little as 7–10 days if the joint space is not properly decompressed.14 Furthermore, failure to diagnosis and treat SATMJ may lead to ankylosis in the future. Some authors suggest that as many as 68% of ankylotic TMJs may have had an initial infectious aetiology.4 18 The authors recommend urgent consultation by trained maxillofacial surgeons when a patient presents with pain, trismus, mandibular deviation and signs and symptoms of infection of the TMJ. We also recommend appropriate contrasted CT and MRI in the initial workup of these patients. Finally, prompt surgical intervention with a minimally invasive procedure (aspiration with lavage) is recommended as first-line treatment. The lavage procedure is quick and requires less training and equipment than other procedures. Arthroscopy and open arthrotomy can be reserved for treatment failure. Close coordination with the microbiology lab, infectious disease team and physical therapy is also suggested.

Learning points

  • Paediatric temporomandibular joint septic arthritis cases are exceedingly rare, but if misdiagnosed, can lead to permanent dysfunction or continued spread beyond the joint capsule.

  • Surgical decompression and initiation of broad-spectrum antibiotics is imperative when suspecting septic arthritis of the TMJ.

  • Long-term antibiotics combined with physical therapy are used to complete treatment after the joint has been decompressed.

References

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Footnotes

  • Contributors RPS, EZ and AS all contributed to the conception, review and manuscript preparation as well as literature review.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Parental/guardian consent obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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