A 53-year-old Caucasian female presented to the Oral Medicine Department at the hospital of the University of Pennsylvania for consultation regarding facial pain. A panoramic radiograph revealed multilocular radiolucencies in the right articular eminence. A CT scan was then performed, and the radiolucencies were determined to be pneumatization of the articular eminence

Mupparapu, Muralidhar

Pinto, Andres A

Sollecito, Thomas P

Stanton, David C

Stoopler, Eric T

English

ScholarlyCommons@Penn

University of Pennsylvania ScholarlyCommons Departmental Papers (Dental) Penn Dental Medicine 2003 Extensive Pneumatization of the Temporal Bone and Articular Eminence: An Incidental Finding in a Patient With Facial Pain. Case Report and Review of Literature Eric T. Stoopler University of Pennsylvania, ets@dental.upenn.edu Andres A. Pinto University of Pennsylvania, apinto@upenn.edu David C. Stanton University of Pennsylvania, david.stanton@uphs.upenn.edu Muralidhar Mupparapu University of Pennsylvania, mmd@dental.upenn.edu Thomas P. Sollecito University of Pennsylvania, tps@pobox.upenn.edu Follow this and additional works at: https://repository.upenn.edu/dental_papers  Part of the Dentistry Commons, Medical Pathology Commons, Musculoskeletal Diseases Commons, Pathological Conditions, Signs and Symptoms Commons, and the Radiology Commons Recommended Citation Stoopler, E. T., Pinto, A. A., Stanton, D. C., Mupparapu, M., & Sollecito, T. P. (2003). Extensive Pneumatization of the Temporal Bone and Articular Eminence: An Incidental Finding in a Patient With Facial Pain. Case Report and Review of Literature. Quintessence International, 34 (3), 211-214. Retrieved from https://repository.upenn.edu/dental_papers/41 This paper is posted at ScholarlyCommons. https://repository.upenn.edu/dental_papers/41 For more information, please contact repository@pobox.upenn.edu. Extensive Pneumatization of the Temporal Bone and Articular Eminence: An Incidental Finding in a Patient With Facial Pain. Case Report and Review of Literature Abstract A 53-year-old Caucasian female presented to the Oral Medicine Department at the hospital of the University of Pennsylvania for consultation regarding facial pain. A panoramic radiograph revealed multilocular radiolucencies in the right articular eminence. A CT scan was then performed, and the radiolucencies were determined to be pneumatization of the articular eminence. Keywords articular eminence, CT scan, panoramic radiograph, pneumatization, temporal bone Disciplines Dentistry | Medical Pathology | Musculoskeletal Diseases | Pathological Conditions, Signs and Symptoms | Radiology This journal article is available at ScholarlyCommons: https://repository.upenn.edu/dental_papers/41 , .. Pathology f---extensive pneumatization of the temporal bone and articular eminence: An incidental finding in a p·atient with facial pain. case report and review of literature Eric T. Stoopler, DMD1/Andres Pinto, DMD2/David C. Stanton, MD, DMD'/ Muralidhar Mupparapu, DMD4/Thomas P. Sollecito, DMD2 A 53·year-old Caucasian female presented to the Oral Medicine Department at the hospital of the University of Pennsylvania for consultation regarding facial pain. A panoramic radiograph revealed multi-locular radiolucencies in the right articular eminence. ACT scan was then performed, and the radiolucen-cies were determined to be pneumatization of the articular eminence. (Quintessence lnt 2003;34: 211-214) Key words: articular eminence, CT scan, panoramic radiograph, pneumatization, temporal bone Pneumatization of the articular eminence of the temporal bone is a relatively uncommon incidental finding in dental practice. Often, patients presenting with facial pain are evaluated via a complete history and physical examination, which includes obtaining proper radiographic images. The most common imag-ing modality used is the panoramic radiograph, which should be thoroughly evaluated for pathology by the dentist. The following article details a case report of a patient with facial pain, who was found to have a pneumatized articular eminence but ultimately ruled out for intrabony pathology. A review of the current literature regarding this phenomenon also is presented. 1Fellow, Department of Oral Medicine, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania. 2Assistant Professor, Department of Oral Medicine, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania. 3Assistant Professor of Oral and Maxillofacial Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania. 4Assistant Professor of Radiology, Department of Oral Medicine, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania Reprint requests: Dr Thomas P. Sollecito, Department of Oral Medicine, University of Pennsylvania School of Dental Medicine, 400i Spruce Street, Philadelphia, Pennsylvania 19104. E-mail: tps@pobox.upenn.edu Quintessence International CASE REPORT A 53-year·old Caucasian female presented to the Hospital of the University of Pennsylvania, Department of Oral Medicine,· complaining of facial pain. By the patient's report, the original pain was di· agnosed as muscular soreness secondary to occlusal discrepancy and treated with orthodontic and prosthodontic therapy. The symptoms started to recur multiple years ago, but were intermittent and infre· quent with minimal severity. Three months prior to her presentation, the pain returned as a dull, some· times throbbing ache extending from the right tempo-ral region into the right neck and right face. She ad· mitted suffering trauma to the right side of her face, one month prior to the onset of her recent symptoms. The pain was worsened with mastication, while non· steroidal anti·inflammatory drugs provided some re-lief. Her symptoms did not change with positional change, stooping, or with the valsalva maneuver. The patient's medical history included rheumatoid arthritis and asthma, as well as a history of recurrent urethral blockage. Her medications were estrogen re· placement therapy, celecoxib (100 mg twice daily) and mometasone spray as needed. She was allergic to ery· thromycin and penicillin. A detailed review of systems 211 -- Stoopler et al --------------------------------------Fig 1 Cropped, magnified, panoramic radiograph of the patient showing the right condyle, glenoid fossa, and pneumatization of the temporal bone extending into the articular eminence (arrows). revealed occasional bilateral tinnitus associated with significant sinus congestion. Other noted symptoms included mild blurry vision (followed by her ophthal-mologist), shortness of breath with exertion, and inter-mittent urinary retention. Her family history was sig-nificant only for lung cancer (father) and her social history was noncontributory. Physical examination revealed normal range of jaw motion with no pain. The patient was noted to have a right "S" shape deviation on opening. Auscultation of the temporomandibular joint area revealed crepitation over the left condylar area as well as an opening non-reciprocal click of the right temporomandibular joint, both of which were not associated with any pain. Palpation of the pretragus and intra-auricular areas did not reproduce the painful symptoms. The patient's closing muscles of mastication were, however, mild to moderately tender, bilaterally, but notably more severe on the right side. The salivary glands were free flowing and had no palpable masses. Palpation over the area of distribution of the temporal artery was negative. The patient's cranial nerves II through XII were grossly intact. Mild thyromegaly was detected, but no lymph node enlargement was noted. Her occlusion was physiologic. Since the right zygomatic arch area was painful, a computer tomographic scan (CT) of the maxillofacial region was obtained to rule out bony pathology such as a giant cell lesion, central hemangioma, traumatic bone cyst, aneurysmal bone cyst, myxoma, and metas-tasis. Axial CT scan images revealed extensive pneumatization of the right temporal bone with the pneumatization extending into the right zygomatic arch including the articular eminence (Fig 2). On the left side, no such extensive pneumatization was no-ticed. The area was observed on reformatted sagittal 212 Fi_g 2 Axial. CT s.can from a high spe~d CT scan~ing protocol w1th bone w1ndow1ng shows the extens1ve pneumatization Within the temporal bone and Involvement of the right zygomatic arch (arrows). Note the absence of pneumatization of the left articular eminence. and coronal images which confirmed the findings from the panoramic radiograph regarding the exten-sion into the articular eminence. The bone and the surrounding structures appeared normal in both the bone windows and soft tissue windows. It was con-cluded that the radiographic changes were simply an incidental finding of extensive pneumatization of the temporal bone. A panoramic film revealed pneumatization of the right zygomatic arch (Fig 1). The patient was given a provisional diagnosis of myofascial pain of the muscles of mastication, as well as the aforementioned pneuma-tization of the right zygomatic arch. Other incidental changes observed in the radiographic exam were con-sistent with arthritic changes of the left condyle. A treatment plan was formulated, including passive stretching exercises together with local heat/ cold ther-apy. Because of the anatomic localization of the pain, an erythrocyte sedimentation rate (ESR) was also ob-tained to rule out temporal arteritis. The ESR was not elevated. She was advised to continue using the anti· inflammatory agent ( celecoxib) as initial therapy. At two subsequent visits, her symptoms were greatly reduced with the prescribed conservative treat-ment for muscular pain. A follow-up at 8 weeks re-vealed 98% relief in a verbal scale with only mild myalgia in the masseter muscle, bilaterally. LITERATURE REVIEW Prior to reviewing the current published literature re-garding pneumatized articular eminence, a brief re-view of the anatomy of the temporal bone and perti-nent aspects of the temporomandibular joint (TMJ) area would be appropriate. The temporal bones of the Volume 34, Number 3, 2003 ~---------------------------------- Stoopler et al --~oil contribute to the lower lateral aspects of the cra-$,1 1 vault and the cranial base. The temporal bone ar-~ ~lates with tbe occipital bone, the parietal bone, the ·~eater wing and body of the sphenoid bone, and the ~:'gomatic bone. There are three portions of the tem-~y ral bone: the squamous portion which includes the pogomatic process and the articular eminence; the ~~trousmastoid portion which separates the middle Pnd posterior cranial fossa within the skull and houses ;he compone~ts of t?e middl~ ear chamber; and the tympaniC portion whtch contnbutes to the structure of the external ~uditory meatus .. ' . . ·.The TMJ ts a complex articulatwn of the mandtbu-lar condyle and the mandibular fossa of the temporal bone. The fossa is bordered laterally by the root of the zygomatic process, medially by the spine of the sphe-noid bone, anteriorly by the articular eminence, poste--jjoilY by the squamotympanic and petrotympanic fis-sures, and superiorly by a thin plate of bone that separates the mandibular fossa from the middle cra-nial fossa. 1 The masseter muscle, both superficial and deep portions, originates from the zygomatic arch, and the fibers of the temporalis muscle pass downward deep to the zygomatic arch, to insert into the coronoid process and ramus of the mandible.' The pneumatized articular eminence of the tempo-ral bone is an air cell cavity that is similar to air cells in the mastoid process and ethmoid bone.3 One of the first reports of air cells in the temporal bone was by Tremble' in 1934, who was curious about the anatomic basis for the spread of infections within the temporal bone. The cause of pneumatization of the ar-ticular eminence is unknown but may be similar to other pneumatized areas of bone within the body, such as the mastoid process. The most popular theory to explain pneumatization of the mastoid process is resorption of diploic bone by an active invasion of tympanic epitheliums Pneumatization of the mastoid process is almost complete when a patient reaches age 5, but air cells may continue to develop through adult-hood.' Pneumatization of the zygomatic process of the maxilla does not begin until the patient is at least 9 years old, although it is unknown at what age air cells within the articular eminence begin to develop. 6 Several articles have been published regarding the prevalence of pneumatization of the articular emi-nence. Tyndall and Matteson' studied panoramic radiographs of 1,061 patients and reported that 28 pa-tients or 2.6% of the study population had pneuma-tized articular eminences. Kaugers et al6 reviewed 784 panoramic films and reported only eight patients or 1.0% of the study population to have pneumatization of the articular eminence. In a more recent study, Groell and Fleischmann' reviewed 100 high-resolution axial CT scans of the base of the skull and found only Quintessence International 12 patients with pneumatized articular eminences. Pneumatization is usually symmetrical, as reported in the literature, but asymmetry can occasionally be ob-served.18 In additon, the studies demonstrated no gen-der predilection for pneumatization of the articular eminence and the mean ages of patients with this phe-nomena ranged from 32.4 years to 45.9 years. 3 •6 Tyndall and Matteson' attempted to classify the radio-graphic types of pneumatized articular eminences into three types: unilocular, multilocular, and trabecular variant of multilocular type. Subsequent studies re-ported difficulty in classifying pneumatized articular eminences because of the overlap in radiographic ap-pearance between the different types: Overall, the inci-dence of pneumatization of the articular eminence is relatively low in the general population; however, clin-icians must be aware of this phenomenon to accu-rately assess radiographs and their patients. A panoramic radiograph is a useful technique to display the pneumatized articular eminence of the temporal bone. In a symptomatic patient, high resolu-tion CT of the base of the skull represents the method of choice in the evaluation of bony structures allowing exact delineation of bony structures.3•9•10 The astute clinician, when observing variations in nortnal anatomy, will use a differential diagnosis to ar-rive at a specific diagnosis for the patient. The well-corticated multilocular radiolucencies in the articular eminence of the temporal bone may elicit a differential diagnosis consisting of giant cell lesion, central heman-gioma, traumatic bone cyst, aneurysmal bone cyst, myxoma, metastasis, and of course, variation of normal anatomy. The pneumatized articular eminence is dis-tinguished from these tumors by a Jack of clinical signs or symptoms, as these pathologic lesions have been re-ported to be characterized by painful enlargement of the cheek, and seen radiographically as expansile, de-structive lesions, which is best characterized by CT.3 The pneumatized articular eminence is an impor-tant finding due to its potential for causing complica-tions. In one study, CT scans revealed that due to pneumatization, there was approximately less then 1 mm of bone between the glenoid fossa and the middle cranial fossa. 8 This could be an important implication in the event of maxillofacial trauma. Fractures of the base of the skull frequently extend throughout the pneumatic spaces of the temporal bone and may re-lease air into the glenoid fossa. 7 One study conducted demonstrated that air occurred in the TMJ fossa in 37% of temporal bone fractures, and in 12%, these air collections represented the only sign of fracture11 Dehiscence of the middle wall of the glenoid fossa may allow herniation of the soft tissue contents into the middle ear. 12 This herniation could result in acute middle ear and mastoid effusion. In addition, temporal 213 ~ -- Stoopler etal -----'----------------------------------- I air spaces are potential paths for the spread of infec-tion and other disease processes. There are wide variations in temporal bone aera-tion, and air cells in the articular eminence may pre-sent as an incidental finding to the clinician. Knowledge of this phenomenon may be helpful in the interpretation of radiographs and other imaging stud-ies. In our case, as in most others, the articular emi-nence pneumatization was an incidental finding unre-lated to the patient's signs or symptoms. REFERENCES 1. Liebgott B. The skull. In: Liebgott B (ed). The Anatomical Basis of Dentistry. Toronto: .B.C. Decker, 1986: 202-204, 1289. 2. Liebgott B. The head by regions. In: Liebgott B (ed). The Anatomical Basis of Dentistry. Toronto: B.C. Decker, 1986: 296-298. 3. Tyndall D, Matteson S. Radiographic appearance and popu-lation distribution of the pneumatized articular eminence of the temporal bone. J Oral Max Snrg 1985;43:493-497. 4. Tremble GE. Pneumatization of the temporal bone. Arch Otolaryngol1934;19:172-182. 5. Mawson SR. Prenatal and postnatal development of the ea In: Mawson SR (ed). Diseases of the Ear, ed 3. Baltin1 r. William and Wilkins, 1974:7,12-13. ore: I 6. Kaugers G, Mercuri L, Laskin D, Pneumatization of the ticular eminence of the temporal bone: Prevalence, devel:r- 1 ment, and the surgical treatment. J Am Dent Assoe 19S~: 113:55-57. , 7. Groell R, Fleisch~ann ~- The pneumatic spaces. of the tem. poral bone: Relatronshtp to the tcmporomandtbular joint Dentomaxillofac Radiol1999;28:69-72. · 8. Hasnaini M, Ng SY. Extensive temporal bone pneutnatiza, tion: Incidental finding in a patient with TMJ' dysfunction Dent Update 2000;27:187-189. · 9. Swartz JD, Harnsberger HR. The middle ear and mastoid In: Swartz JD, Harnsberger HR (eds). Imaging of th; Temporal Bone, ed 2. New York: Thieme, 1992:55-60. 10. Virapongse C, Sarwar M, Bhimani S, Sasaki C, Shapiro R, Computed tomography of temporal bone pneumatization: 2. Pctrosquamal suture and septum. AJNR 1985;6:561-568. 11. Betz BW, Wiener MD. Air in the temporomandibular joint fossa: CT sign of temporal bone fracture. Radiology 1991; 180:463-466. 12. Weismann JL, Hirsch BE, Chan K, Tabor EK, Curtin HD, Dehiscent temporomandibular joint. Radiology 1991;180: 211-213. Herstellung~ und Vertriebsgesellschaft · Richter & Hoffmann HARVARD Dental GmbH Babelsberger Stra.Be 42, 10716 Berlin, Tel. ++49 (0) 30 82 00 99-0, Fax: ++49 (0) 30 822 8146 214 Volume 34, Number 3, 2003 

Extensive Pneumatization of the Temporal Bone and Articular Eminence: An Incidental Finding in a Patient With Facial Pain. Case Report and Review of Literature

Kosmopolis

University of Pennsylvania 
ScholarlyCommons 
Departmental Papers (Dental) Penn Dental Medicine 
2003 
Extensive Pneumatization of the Temporal Bone and Articular 
Eminence: An Incidental Finding in a Patient With Facial Pain. 
Case Report and Review of Literature 
Eric T. Stoopler 
University of Pennsylvania, ets@dental.upenn.edu 
Andres A. Pinto 
University of Pennsylvania, apinto@upenn.edu 
David C. Stanton 
University of Pennsylvania, david.stanton@uphs.upenn.edu 
Muralidhar Mupparapu 
University of Pennsylvania, mmd@dental.upenn.edu 
Thomas P. Sollecito 
University of Pennsylvania, tps@pobox.upenn.edu 
Follow this and additional works at: https://repository.upenn.edu/dental_papers 
 Part of the Dentistry Commons, Medical Pathology Commons, Musculoskeletal Diseases Commons, 
Pathological Conditions, Signs and Symptoms Commons, and the Radiology Commons 
Recommended Citation 
Stoopler, E. T., Pinto, A. A., Stanton, D. C., Mupparapu, M., & Sollecito, T. P. (2003). Extensive 
Pneumatization of the Temporal Bone and Articular Eminence: An Incidental Finding in a Patient With 
Facial Pain. Case Report and Review of Literature. Quintessence International, 34 (3), 211-214. Retrieved 
from https://repository.upenn.edu/dental_papers/41 
This paper is posted at ScholarlyCommons. https://repository.upenn.edu/dental_papers/41 
For more information, please contact repository@pobox.upenn.edu. 
Extensive Pneumatization of the Temporal Bone and Articular Eminence: An 
Incidental Finding in a Patient With Facial Pain. Case Report and Review of 
Literature 
Abstract 
A 53-year-old Caucasian female presented to the Oral Medicine Department at the hospital of the 
University of Pennsylvania for consultation regarding facial pain. A panoramic radiograph revealed 
multilocular radiolucencies in the right articular eminence. A CT scan was then performed, and the 
radiolucencies were determined to be pneumatization of the articular eminence. 
Keywords 
articular eminence, CT scan, panoramic radiograph, pneumatization, temporal bone 
Disciplines 
Dentistry | Medical Pathology | Musculoskeletal Diseases | Pathological Conditions, Signs and Symptoms 
| Radiology 
This journal article is available at ScholarlyCommons: https://repository.upenn.edu/dental_papers/41 
, .. 
Pathology f---
extensive pneumatization of the temporal bone and articular 
eminence: An incidental finding in a p·atient with facial pain. 
case report and review of literature 
Eric T. Stoopler, DMD1/Andres Pinto, DMD2/David C. Stanton, MD, DMD'/ 
Muralidhar Mupparapu, DMD4/Thomas P. Sollecito, DMD2 
A 53·year-old Caucasian female presented to the Oral Medicine Department at the hospital of the 
University of Pennsylvania for consultation regarding facial pain. A panoramic radiograph revealed multi-
locular radiolucencies in the right articular eminence. ACT scan was then performed, and the radiolucen-
cies were determined to be pneumatization of the articular eminence. (Quintessence lnt 2003;34: 
211-214) 
Key words: articular eminence, CT scan, panoramic radiograph, pneumatization, temporal bone 
Pneumatization of the articular eminence of the temporal bone is a relatively uncommon incidental 
finding in dental practice. Often, patients presenting 
with facial pain are evaluated via a complete history 
and physical examination, which includes obtaining 
proper radiographic images. The most common imag-
ing modality used is the panoramic radiograph, which 
should be thoroughly evaluated for pathology by the 
dentist. The following article details a case report of a 
patient with facial pain, who was found to have a 
pneumatized articular eminence but ultimately ruled 
out for intrabony pathology. A review of the current 
literature regarding this phenomenon also is presented. 
1Fellow, Department of Oral Medicine, University of Pennsylvania School of 
Dental Medicine, Philadelphia, Pennsylvania. 
2Assistant Professor, Department of Oral Medicine, University of 
Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania. 
3Assistant Professor of Oral and Maxillofacial Surgery, Hospital of the 
University of Pennsylvania, Philadelphia, Pennsylvania. 
4Assistant Professor of Radiology, Department of Oral Medicine, University 
of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania 
Reprint requests: Dr Thomas P. Sollecito, Department of Oral Medicine, 
University of Pennsylvania School of Dental Medicine, 400i Spruce Street, 
Philadelphia, Pennsylvania 19104. E-mail: tps@pobox.upenn.edu 
Quintessence International 
CASE REPORT 
A 53-year·old Caucasian female presented to the 
Hospital of the University of Pennsylvania, 
Department of Oral Medicine,· complaining of facial 
pain. By the patient's report, the original pain was di· 
agnosed as muscular soreness secondary to occlusal 
discrepancy and treated with orthodontic and 
prosthodontic therapy. The symptoms started to recur 
multiple years ago, but were intermittent and infre· 
quent with minimal severity. Three months prior to 
her presentation, the pain returned as a dull, some· 
times throbbing ache extending from the right tempo-
ral region into the right neck and right face. She ad· 
mitted suffering trauma to the right side of her face, 
one month prior to the onset of her recent symptoms. 
The pain was worsened with mastication, while non· 
steroidal anti·inflammatory drugs provided some re-
lief. Her symptoms did not change with positional 
change, stooping, or with the valsalva maneuver. 
The patient's medical history included rheumatoid 
arthritis and asthma, as well as a history of recurrent 
urethral blockage. Her medications were estrogen re· 
placement therapy, celecoxib (100 mg twice daily) and 
mometasone spray as needed. She was allergic to ery· 
thromycin and penicillin. A detailed review of systems 
211 
-- Stoopler et al --------------------------------------
Fig 1 Cropped, magnified, panoramic radiograph of the patient 
showing the right condyle, glenoid fossa, and pneumatization of 
the temporal bone extending into the articular eminence (arrows). 
revealed occasional bilateral tinnitus associated with 
significant sinus congestion. Other noted symptoms 
included mild blurry vision (followed by her ophthal-
mologist), shortness of breath with exertion, and inter-
mittent urinary retention. Her family history was sig-
nificant only for lung cancer (father) and her social 
history was noncontributory. 
Physical examination revealed normal range of jaw 
motion with no pain. The patient was noted to have a 
right "S" shape deviation on opening. Auscultation of 
the temporomandibular joint area revealed crepitation 
over the left condylar area as well as an opening non-
reciprocal click of the right temporomandibular joint, 
both of which were not associated with any pain. 
Palpation of the pretragus and intra-auricular areas 
did not reproduce the painful symptoms. The patient's 
closing muscles of mastication were, however, mild to 
moderately tender, bilaterally, but notably more severe 
on the right side. The salivary glands were free flowing 
and had no palpable masses. Palpation over the area 
of distribution of the temporal artery was negative. 
The patient's cranial nerves II through XII were 
grossly intact. Mild thyromegaly was detected, but no 
lymph node enlargement was noted. Her occlusion 
was physiologic. 
Since the right zygomatic arch area was painful, a 
computer tomographic scan (CT) of the maxillofacial 
region was obtained to rule out bony pathology such 
as a giant cell lesion, central hemangioma, traumatic 
bone cyst, aneurysmal bone cyst, myxoma, and metas-
tasis. Axial CT scan images revealed extensive 
pneumatization of the right temporal bone with the 
pneumatization extending into the right zygomatic 
arch including the articular eminence (Fig 2). On the 
left side, no such extensive pneumatization was no-
ticed. The area was observed on reformatted sagittal 
212 
Fi_g 2 Axial. CT s.can from a high spe~d CT scan~ing protocol 
w1th bone w1ndow1ng shows the extens1ve pneumatization Within 
the temporal bone and Involvement of the right zygomatic arch 
(arrows). Note the absence of pneumatization of the left articular 
eminence. 
and coronal images which confirmed the findings 
from the panoramic radiograph regarding the exten-
sion into the articular eminence. The bone and the 
surrounding structures appeared normal in both the 
bone windows and soft tissue windows. It was con-
cluded that the radiographic changes were simply an 
incidental finding of extensive pneumatization of the 
temporal bone. 
A panoramic film revealed pneumatization of the 
right zygomatic arch (Fig 1). The patient was given a 
provisional diagnosis of myofascial pain of the muscles 
of mastication, as well as the aforementioned pneuma-
tization of the right zygomatic arch. Other incidental 
changes observed in the radiographic exam were con-
sistent with arthritic changes of the left condyle. 
A treatment plan was formulated, including passive 
stretching exercises together with local heat/ cold ther-
apy. Because of the anatomic localization of the pain, 
an erythrocyte sedimentation rate (ESR) was also ob-
tained to rule out temporal arteritis. The ESR was not 
elevated. She was advised to continue using the anti· 
inflammatory agent ( celecoxib) as initial therapy. 
At two subsequent visits, her symptoms were 
greatly reduced with the prescribed conservative treat-
ment for muscular pain. A follow-up at 8 weeks re-
vealed 98% relief in a verbal scale with only mild 
myalgia in the masseter muscle, bilaterally. 
LITERATURE REVIEW 
Prior to reviewing the current published literature re-
garding pneumatized articular eminence, a brief re-
view of the anatomy of the temporal bone and perti-
nent aspects of the temporomandibular joint (TMJ) 
area would be appropriate. The temporal bones of the 
Volume 34, Number 3, 2003 
~---------------------------------- Stoopler et al --
~oil contribute to the lower lateral aspects of the cra-
$,1 1 vault and the cranial base. The temporal bone ar-~ ~lates with tbe occipital bone, the parietal bone, the 
·~eater wing and body of the sphenoid bone, and the 
~:'gomatic bone. There are three portions of the tem-
~y ral bone: the squamous portion which includes the 
pogomatic process and the articular eminence; the 
~~trousmastoid portion which separates the middle 
Pnd posterior cranial fossa within the skull and houses 
;he compone~ts of t?e middl~ ear chamber; and the 
tympaniC portion whtch contnbutes to the structure of 
the external ~uditory meatus .. ' . . 
·.The TMJ ts a complex articulatwn of the mandtbu-
lar condyle and the mandibular fossa of the temporal 
bone. The fossa is bordered laterally by the root of the 
zygomatic process, medially by the spine of the sphe-
noid bone, anteriorly by the articular eminence, poste-
-jjoilY by the squamotympanic and petrotympanic fis-
sures, and superiorly by a thin plate of bone that 
separates the mandibular fossa from the middle cra-
nial fossa. 1 The masseter muscle, both superficial and 
deep portions, originates from the zygomatic arch, and 
the fibers of the temporalis muscle pass downward 
deep to the zygomatic arch, to insert into the coronoid 
process and ramus of the mandible.' 
The pneumatized articular eminence of the tempo-
ral bone is an air cell cavity that is similar to air cells 
in the mastoid process and ethmoid bone.3 One of the 
first reports of air cells in the temporal bone was by 
Tremble' in 1934, who was curious about the 
anatomic basis for the spread of infections within the 
temporal bone. The cause of pneumatization of the ar-
ticular eminence is unknown but may be similar to 
other pneumatized areas of bone within the body, 
such as the mastoid process. The most popular theory 
to explain pneumatization of the mastoid process is 
resorption of diploic bone by an active invasion of 
tympanic epitheliums Pneumatization of the mastoid 
process is almost complete when a patient reaches age 
5, but air cells may continue to develop through adult-
hood.' Pneumatization of the zygomatic process of the 
maxilla does not begin until the patient is at least 9 
years old, although it is unknown at what age air cells 
within the articular eminence begin to develop. 6 
Several articles have been published regarding the 
prevalence of pneumatization of the articular emi-
nence. Tyndall and Matteson' studied panoramic 
radiographs of 1,061 patients and reported that 28 pa-
tients or 2.6% of the study population had pneuma-
tized articular eminences. Kaugers et al6 reviewed 784 
panoramic films and reported only eight patients or 
1.0% of the study population to have pneumatization 
of the articular eminence. In a more recent study, 
Groell and Fleischmann' reviewed 100 high-resolution 
axial CT scans of the base of the skull and found only 
Quintessence International 
12 patients with pneumatized articular eminences. 
Pneumatization is usually symmetrical, as reported in 
the literature, but asymmetry can occasionally be ob-
served.18 In additon, the studies demonstrated no gen-
der predilection for pneumatization of the articular 
eminence and the mean ages of patients with this phe-
nomena ranged from 32.4 years to 45.9 years. 3 •6 
Tyndall and Matteson' attempted to classify the radio-
graphic types of pneumatized articular eminences into 
three types: unilocular, multilocular, and trabecular 
variant of multilocular type. Subsequent studies re-
ported difficulty in classifying pneumatized articular 
eminences because of the overlap in radiographic ap-
pearance between the different types: Overall, the inci-
dence of pneumatization of the articular eminence is 
relatively low in the general population; however, clin-
icians must be aware of this phenomenon to accu-
rately assess radiographs and their patients. 
A panoramic radiograph is a useful technique to 
display the pneumatized articular eminence of the 
temporal bone. In a symptomatic patient, high resolu-
tion CT of the base of the skull represents the method 
of choice in the evaluation of bony structures allowing 
exact delineation of bony structures.3•9•10 
The astute clinician, when observing variations in 
nortnal anatomy, will use a differential diagnosis to ar-
rive at a specific diagnosis for the patient. The well-
corticated multilocular radiolucencies in the articular 
eminence of the temporal bone may elicit a differential 
diagnosis consisting of giant cell lesion, central heman-
gioma, traumatic bone cyst, aneurysmal bone cyst, 
myxoma, metastasis, and of course, variation of normal 
anatomy. The pneumatized articular eminence is dis-
tinguished from these tumors by a Jack of clinical signs 
or symptoms, as these pathologic lesions have been re-
ported to be characterized by painful enlargement of 
the cheek, and seen radiographically as expansile, de-
structive lesions, which is best characterized by CT.3 
The pneumatized articular eminence is an impor-
tant finding due to its potential for causing complica-
tions. In one study, CT scans revealed that due to 
pneumatization, there was approximately less then 1 
mm of bone between the glenoid fossa and the middle 
cranial fossa. 8 This could be an important implication 
in the event of maxillofacial trauma. Fractures of the 
base of the skull frequently extend throughout the 
pneumatic spaces of the temporal bone and may re-
lease air into the glenoid fossa. 7 One study conducted 
demonstrated that air occurred in the TMJ fossa in 
37% of temporal bone fractures, and in 12%, these air 
collections represented the only sign of fracture11 
Dehiscence of the middle wall of the glenoid fossa 
may allow herniation of the soft tissue contents into 
the middle ear. 12 This herniation could result in acute 
middle ear and mastoid effusion. In addition, temporal 
213 
~ 
-- Stoopler etal -----'----------------------------------- I 
air spaces are potential paths for the spread of infec-
tion and other disease processes. 
There are wide variations in temporal bone aera-
tion, and air cells in the articular eminence may pre-
sent as an incidental finding to the clinician. 
Knowledge of this phenomenon may be helpful in the 
interpretation of radiographs and other imaging stud-
ies. In our case, as in most others, the articular emi-
nence pneumatization was an incidental finding unre-
lated to the patient's signs or symptoms. 
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2. Liebgott B. The head by regions. In: Liebgott B (ed). The 
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3. Tyndall D, Matteson S. Radiographic appearance and popu-
lation distribution of the pneumatized articular eminence of 
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6. Kaugers G, Mercuri L, Laskin D, Pneumatization of the 
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7. Groell R, Fleisch~ann ~- The pneumatic spaces. of the tem. 
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9. Swartz JD, Harnsberger HR. The middle ear and mastoid 
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Herstellung~ und Vertriebsgesellschaft · Richter & Hoffmann HARVARD Dental GmbH 
Babelsberger Stra.Be 42, 10716 Berlin, Tel. ++49 (0) 30 82 00 99-0, Fax: ++49 (0) 30 822 8146 
214 Volume 34, Number 3, 2003 


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Extensive Pneumatization of the Temporal Bone and Articular Eminence: An Incidental Finding in a Patient With Facial Pain. Case Report and Review of Literature

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