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Título

Rotational dislocation C1–C2 after otoplasty under local anesthesia

Introdução

Nontraumatic rotational atlantoaxial subluxation (NTARS) is an uncommon condition in clinical practice. It is mainly observed after infection of the upper respiratory tract, called Grisel, being responsible for 48% of nontraumatic atlantoaxial rotational dislocation. Head-and-neck surgery is the second cause, and adenotonsillectomy is responsible for 31% of NTARS. Although rare, NTARS was reported in the literature after otoplasty and only four reports of patients were found in the researched literature: Dubrana et al., Kelly et al., Durst et al. (2012), and Macheboeuf et al. (2019). Each author reported one patient with NTARS after otoplasty. All reported patients underwent surgery under general anesthesia.

The goal is to report a rare case of NTARS after bilateral otoplasty, the performed treatment, and follow-up.

Relato de caso

A 15-year-old woman presented with head deformity 10 days after bilateral otoplasty under local anesthesia. She presented with a painful torticollis; the head was rotated to the right and tilted to the left side. Computed tomography (CT) showed NTARS [Figure 1].

Reduction was achieved under anesthesia by transoral palpation of the dislocated C1 articular facet associated with manual head traction, followed by cervical halter traction. The anatomical relationship of C1–C2 was confirmed by CT [Figure 2].

Two recurrence of the dislocation was observed after two attempts of closed reduction under anesthesia followed by cervical traction and hard collar immobilization. Open reduction and posterior atlantoaxial fixation with C1–C2 sublaminar wire and autologous iliac bone graft was performed, followed by hard cervical collar immobilization for 3 months [Figure 3].

There was neither intraoperative nor postoperative complication. The patient remained neurologically intact, radiographic evidence of bone fusion was observed after 1 year follow-up, and the patient returned to normal activities [Figure 4].

Conclusão

Considering the instability of C1–C2 joint and recurrence of dislocation, we performed an open posterior reduction and C1–C2 arthrodesis using just wire cerclage. Wire cerclage was the option considering that this procedure can be performed with less exposure of posterior vertebral elements, less dissection, less muscle detachment, and less complications. During follow-up, there was no complication regarding arthrodesis, bone graft healing, and implants. The clinical and radiological outcomes were satisfactory, and after 1 year follow-up, the patient had a normal life and returned to all previous activity.

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