A 41-year-old female patient with a history of type 2 diabetes mellitus treated pharmacologically.
She was admitted to the otorhinolaryngology service of San Juan de Dios Hospital due to a 3-month history of right earache of insidious onset, which increased progressively/10 at the moment of the Visual Scale.
Upon examination, the patient was afflicted with purulent effusion, hypoacusis and increased ipsilateral preauricular volume.
The diagnosis of necrotizing external otitis is based on the study of the clinical picture.
Initial management consisted of hospitalization and antibiotic treatment with an empirical scheme focused on the otic process with ceftazidime plus intravenous clindamycin and topical ciprofloxacin.
The degree of compromise is objectified in the images of the computerized axial tomography (CAT) that shows a clear zone of erosion of the right mandibular condylar bone surface, with loss of cortical layer and destruction to the bone marrow.
Maxillofacial surgery was consulted.
The examination showed an increase in right preauricular volume of diffuse limits, firm consistency, with increased local temperature and associated erythema.
The functional examination revealed a considerable reduction in opening of approximately 20 mm, with preserved laterality movements, due to arthralgia exacerbated by function.
On examination there is absence of multiple posterior teeth both upper and lower.
Magnetic resonance imaging (MRI) shows degenerative changes and erosion at the cortical level of the anterior aspect of the mandibular condyle in addition to a temporal inflammatory process of the same disseminated intraosseous space on the masticator side.
With the clinical and imaging findings, the diagnostic hypothesis of infectious arthritis of the TMJ by continuity is proposed.
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After establishing the diagnosis of necrotizing and mastoiditis, the ENT team entered the pavilion to perform a modified radical mastoidectomy.
Subsequently, an intra-articular puncture was performed to study the content, where it was observed that the fluid content was cloudy and seropurulent and sent to bacteriological culture, which was negative at 72 h of remission.
A double-needle arthroscentesis of the TMJ was performed according to the technique of Nitzan et al., performing a profuse lavage of the joint with saline solution.
The patient after these interventions improves her general condition, being discharged with a clear decrease in symptoms, increase in volume and an improvement in mouth opening reaching 40 mm.
After one month of follow-up, the patient is asymptomatic.
However, the presence of articular noise in the opening and closing process is observed, which progresses to a certainty in the following controls.
The patient was referred to proband treatment to improve occlusal stability and thus reduce joint overload.
A control CT scan was requested 2 months later which confirmed a partial regeneration of the condylar cortical bone.
Currently, four years later, she is asymptomatic, with preserved mandibular dynamics.
However, as a consequence of persistent medial and posterior mastoiditis, there are auditory alterations due to the perception of severe noise, in addition to the presence of right TMJ cryptium due to irreversible tissue damage.
