Extravasation of irrigant to the parapharyngeal space during temporomandibular joint (TMJ) arthroscopy requiring prolonged intubation: a case report and review of the literature

Background: Temporomandibular joint (TMJ) arthroscopy is a common modality for the diagnosis and treatment of temporomandibular joint disease (TMD). Complications of TMJ arthroscopy are uncommon, but can include extravasation of irrigation fluid to the parapharyngeal space. The parapharyngeal space is a complex space with communication to the submandibular space and exam findings can also include edema of the sublingual and submandibular spaces. Extravasation of irrigant to the parapharyngeal space will result in airway edema and, if unnoticed, could result in unsuccessful extubation. Case Description: This case report describes two cases of extravasation of irrigant to the parapharyngeal space during TMJ arthroscopy. The first case involved a 19-year-old female with bilateral TMJ pain and disc abnormality who failed non-surgical treatment. Treatment included bilateral TMJ arthroscopy that involved release of the lateral pterygoid muscle with synovial biopsy. Our second patient was a 63-year-old female with an unilateral ankylosing process that presented with an infection of the joint. Treatment included unilateral TMJ arthroscopy that involved a second port for synovial biopsy. Extravasation of irrigant to the parapharyngeal space was diagnosed with direct laryngoscopy for the first patient and with video assisted laryngoscopy for the second patient. Both patients remained intubated on transfer from the operating room and both were safely extubated on post-operative day 1. Rapid resolution of the airway edema over a 24-hour period was observed. Conclusions: Extravasation of irrigant to the parapharyngeal space during TMJ arthroscopy is an uncommon, but known complication. Edema of the parapharyngeal space due to extravasation of irrigant can complicate extubation and result in upper airway obstruction. We discuss our experience with the diagnosis and management of this complication and propose an anatomic pathway for its occurrence. Extravasation of irrigant can occur to experienced arthroscopic surgeons and we have hypothesized that operative maneuvers such as avoiding over insufflation of the superior joint space prior to insertion of the arthroscope and maintaining a patent irrigation system during arthroscopy can help prevent extravasation. An understanding of this uncommon, but known, complication of TMJ arthroscopy is important for safe intraoperative and postoperative management of the airway and timely extubation.