Dom, M

Guffens, F

Vanhoenacker, Filip

English

Ghent University Academic Bibliography

Case 13176 Case report: Primary synovial chondromatosis of the rightTMJ.F. GuffensM. DomF.M. VanhoenackerUniversity Hospital Antwerp, Department of Radiology, University Hospital Antwerp;Wilrijkstraat, 10 2650 Antwerp, AZ Sint-Maarten Mechelen/Duffel Belgium, University of Ghent;Email:filip.vanhoenacker@telenet.be University Hospital Antwerp  Head & Neck Imaging Section: 2015, Dec. 23 Published: 59 year(s), femalePatient:Clinical HistoryA 59-year-old woman was referred to the Otorhinolaryngology Department with a painless swellingin the right preauricular area. No history of trauma or limitation of mandibular movement wasreported. No intracapsular sounds on jaw opening. The patient had no relevant medical history.Imaging FindingsCT scan showed widening of the right temporomandibular joint (TMJ) containing multiple smallround cartilaginous nodules of uniform size. The joint surface was well-delineated, with absence ofirregularity or sclerosis of the glenoid fossa or the mandibular condyle.MRI of the TMJ was subsequently performed. Techniques included pre-contrast axial and coronalfat saturated T2-weighted sequences and sagittal fat saturated T1 spin-echo sequence before andafter gadolinium contrast administration.MRI revealed an hour-glass like soft-tissue lesion at the right TMJ. On T2W, multiple low signalintensity foci were present within the joint surrounded by fluid. On post-contrast images there wassubtle enhancement of the slightly thickened synovium.Based on the imaging findings, the diagnosis of primary synovial chrondromatosis was made. Anarthrotomy with subsequent histopathological examination showed subsynovial cartilagemetaplasia, and the presence of multiple similar-sized round cartilaginous nodules, thus confirmingour diagnosis.DiscussionSynovial chondromatosis (SC) is a rare, benign, chronic condition characterized by progressivemetaplasia in which hyaline cartilage is formed in the synovial membranes of joints, which canbecome detached producing loose bodies in the joint space.The knee is the most frequently affected articulation. Other commonly involved joints are the hip,elbow, shoulder, and ankle. The temporomandibular joint (TMJ) is less commonly involved withonly about 150 cases described to date. (1-3)The mean age of patients with SC of the TMJ is 46.3 years. Females are affected almost three timesmore than males. Two forms of SC are described in the literature. Primary SC is defined by subsynovial cartilagemetaplasia, synovial hyperplasia, and production of similar-sized round cartilaginous nodules. (5)The secondary form occurs as part of a pre-existing joint disease, such as arthritis or trauma. In thesecondary form, formation of nodules in the joint space is caused by the dislodgement of bony orcartilaginous tissue. These loose bodies undergo concentric layering of synovial cells, by whichnourishment is provided. These nodules are more irregular and are often larger compared to nodulesof primary origin. (1-4)A staging system (5), proposed by Milgram for the subacromial bursa, consists of three stages: 1) Initial stage: intrasynovial active disease without loose bodies; 2) Transitional stage: both intrasynovial active disease and the formation of loose bodies; 3) Advanced stage: only detached particles varying from 1 mm to 10 mm are present in the jointspace, with burned-out intrasynovial disease.The three primary symptoms of SC of the TMJ are pain in the preauricular area, swelling and facialasymmetry and joint deformity. Less frequent symptoms consist of occlusal changes, joint sounds,trismus, headache and facial nerve palsy, caused by intracranial extension. (3)Radiological diagnosis of SC in TMJ can be made by panoramic radiography, CT or MRI.Radiographic features of primary SC in the TMJ are widening of the joint space, limitation ofmotion, irregularity of the joint surface and the presence of calcified loose nodules of uniform size.(6). In secondary SC, there is typically narrowing of the joint space with nodules of different size.CT imaging is superior for detailed evaluation of the joint margins and local extent of calcified SC.(7)MRI is useful in demonstrating synovial origin, depicting the nodules in the early stages offormation before ossification, internal derangement of TMJ and more precise assessment of thelesion's extent. (8)Final DiagnosisPrimary synovial chondromatosis of the right TMJ.Differential Diagnosis Listosteoarthritis, chondrocalcinosis, osteochondroma, pigmented villonodular synovitis ,osteochrondritis dissecansFiguresFigure 1 Axial CT soft tissue windowAxial CT(soft tissue window) shows multiple soft tissue calcifications (red circle) at the rightTMJ. © Vanhoenacker F.M., Department of Radiology, AZ Sint-Maarten, Mechelen-Duffel, Belgium Area of Interest: Head and neck;  Imaging Technique: CT;  Procedure: Diagnostic procedure;  Special Focus: Arthritides; Figure 2 Coronal and sagittal CT (bone window)Coronal and sagittal CT (bone window) show multiple calcified loose bodies of uniform sizeand widening of the right TMJ (red circle). © Vanhoenacker F.M., Department of Radiology, AZ Sint-Maarten, Mechelen-Duffel, Belgium Area of Interest: Head and neck;  Imaging Technique: CT;  Procedure: Diagnostic procedure;  Special Focus: Arthritides; Figure 3 Axial and coronal FS T2-WIMRI revealed an hour-glass like soft-tissue lesion. Axial and coronal fatsuppressed T2weighted images show multiple loose bodies in the joint, most of which are of low signalintensity (red circle). © Vanhoenacker F.M., Department of Radiology, AZ Sint-Maarten, Mechelen-Duffel, Belgium Area of Interest: Head and neck;  Imaging Technique: MR;  Procedure: Diagnostic procedure;  Special Focus: Arthritides; Figure 4 Sagittal FS T1WI after contrastSagittal post contrast T1W images of the right TMJ show peripheral wall enhancementrepresenting slightly thickened synovium(red circle). © Vanhoenacker F.M., Department of Radiology, AZ Sint-Maarten, Mechelen-Duffel, Belgium Area of Interest: Head and neck;  Imaging Technique: MR;  Procedure: Diagnostic procedure;  Special Focus: Arthritides; References[1] Reddy PK, Vannemreddy PS, Gonzalez E, Nanda A. (2000) Synovial chondromatosis of thetemporomandibular joint with intracranial extension J Clin Neurosci 7(4):332-4[2] Murphey MD, Vidal JA, Fanburg-smith JC, Gajewski DA. (2007) Imaging of synovialchondromatosis with radiologic-pathologic correlation Radiographics 27(5):1465-88[3] Guarda-nardini L, Piccotti F, Ferronato G, Manfredini D. (2010) Synovial chondromatosis ofthe temporomandibular joint: a case description with systematic literature review Int J OralMaxillofac Surg. 39(8):745-55[4] Deboise A, Roche Y. (1991) Synovial chondromatosis of the temporomandibular joint possiblysecondary to trauma. A case report Int J Oral Maxillofac Surg 20(2):90-2[5] Milgram JW, Hadesman WM. (1988) Synovial osteochondromatosis in the subacromial bursaClin Orthop Relat Res (236):154-9[6] Noyek AM, Holgate RC, Fireman SM, Rosen P, Pritzker KP (1977) The radiologic findings insynovial chondromatosis (chondrometaplasia) of the temporomandibular joint Otolaryngol Suppl1977;3:45-8[7] Yu Q, Yang J, Wang P, Shi H, Luo J. (2004) CT features of synovial chondromatosis in thetemporomandibular joint Oral Surg Oral Med Oral Pathol Oral Radiol Endod 97(4):524-8[8] Wong WC, Cheng PW, Chan FL. (2001) . MRI appearance of synovial chondromatosis in thetemporomandibular joint Clin Radiol 56(9):773-4CitationF. GuffensM. DomF.M. VanhoenackerUniversity Hospital Antwerp, Department of Radiology, University Hospital Antwerp;Wilrijkstraat, 10 2650 Antwerp, AZ Sint-Maarten Mechelen/Duffel Belgium, University of Ghent;Email:filip.vanhoenacker@telenet.be (2015, Dec. 23)  Case report: Primary synovial chondromatosis of the right TMJ. {Online}URL: http://www.eurorad.org/case.php?id=13176

Case report: primary osteochondromatosis of the right TMJ

https://biblio.ugent.be/publication/7079179/file/7079180

Case report: primary osteochondromatosis of the right TMJ

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