Manual of Surgery Volume Second: Extremities—Head—Neck. Sixth Edition.

by Alexis Thomson; Alexander Miles

The non-suppurative form is usually due to gonorrhœal infection, and as a rule is bilateral. The patient complains of neuralgic pains shooting towards the ears and temples, and of pain in the joint on movement. The jaw is therefore kept fixed, usually with the mouth slightly open and the chin protruded. Mastication is impossible, and the speech is indistinct. There is effusion into the joint, and a swelling may be detected in front of the ear. The inflammation may subside and movement restored, or fibrous ankylosis may ensue.

The suppurative form may be due either to direct spread of infection from adjacent parts, as, for example, in middle ear disease, suppurative parotitis, or pyogenic affections of the mandible, or it may be part of a general pyæmic infection, as sometimes occurs after exanthematous fevers and in gonorrhœa. The clinical features are similar to those of the non-suppurative form, but the signs referable to the joint are often masked by those of the primary lesion. When the pus originates in the joint, it may point either towards the skin or into the external auditory meatus through the petro-tympanic (Glaserian) fissure. The joint is usually completely disorganised and ankylosis results.

Tuberculous arthritis is rare, and is usually secondary to disease of the mandible, the temporal bone, or the middle ear. It leads to destruction of the joint and ankylosis. It is treated by incision and scraping, or by excision of the condyle.

Arthritis deformans is a comparatively common affection, and is generally bilateral. In the earlier stages the condyle is usually hypertrophied and distorted, and the glenoid cavity is correspondingly broadened and flattened, and in time may be filled up by new bone. Osteophytic outgrowths form around the joint and lead to fixation or locking. The enlarged condyle may be felt in front of the ear, and there is pain and cracking on movement; the pain is worst at night and in wet weather. The jaw is usually depressed and the chin protruded. The disease runs a chronic course, with occasional acute exacerbations. Excision of the condyle may be advisable when non-operative measures have failed to give relief. In the later stages, the condyle, together with the meniscus, may be worn away and completely disappear.

Closure or Fixation of the Mandible.—Temporary fixation is due to spasmodic contraction of the muscles of mastication, particularly the masseter. This may be symptomatic of some inflammatory condition in the vicinity, such as a pyogenic affection of the lower jaw—for example, that associated with a carious root or an unerupted wisdom tooth, or with parotitis or tonsillitis. In such cases the spasm passes off on the removal of the cause. It is occasionally a manifestation of hysteria. The administration of a general anæsthetic and the introduction of a wedge or separator is usually necessary to confirm the diagnosis and, it may be, to permit of operative measures, such as the extraction of a wisdom tooth.

Muscular fixation may be due to rheumatic or syphilitic myositis, and this is sometimes followed by fibroid degeneration of the muscles, rendering the fixation permanent.

Permanent fixation may be due to a variety of causes. Fibroid degeneration of muscles following myositis has already been mentioned. Much more frequently it results from cicatricial contraction of the soft parts of the face or mouth following such conditions as cancrum oris, ulceration, or burns. Fixation following upon prolonged immobilisation after fracture or dislocation, or any of the forms of arthritis or suppurative or tuberculous disease of the adjacent portions of the mandible, is also met with. The ankylosis may be fibrous or osseous, and may be intra- or extra-articular.

The clinical features vary with the degree of separation of the jaws. There is always some deformity, and more or less interference with mastication and speech. The patient usually feeds himself by pushing small portions of bread or meat with the fingers through some gap between the badly opposed and badly formed and preserved teeth. As the patient is unable to keep the mouth clean, particles of food lodge and decompose there, causing irritation of the mucous membrane, caries of the teeth, and fœtor of the saliva and breath. When osseous ankylosis occurs in childhood, it leads to arrest of development of the mandible, which is small and markedly receding, so that the teeth do not oppose those of the maxilla ([Fig. 256]).