Synovial chondromatosis of the temporomandibular joint diagnosed by magnetic resonance imaging: report of a case

A Multidisciplinary Approach to Synovial Chondromatosis of the Temporomandibular Joint With Cranial Base Involvement: A Brief Review of the Literature and Case Report

Synovial chondromatosis (SC) is an infrequent, benign condition of unknown etiology affecting the synovium within articular joints. Often considered a metaplastic process, multiple cartilaginous nodules develop in the confines of the synovial membrane. In time, these cartilage nodules develop into fragments, sometimes detaching from the synovium and, thus, become loose in an adjacent synovial cavity. The temporomandibular joint (TMJ) is an unusual site of involvement, with the extracapsular compromise of the cranial base exceedingly rare. A 68-year-old woman presented with a tender mass to the left TMJ that later proved to be SC. Computed tomography illustrated a rare extension of the lesion into the middle cranial fossa. The multidisciplinary effort to remove the mass in its entirety included both oral and maxillofacial surgical and neurosurgical teams. We have reviewed the presentation, diagnosis, surgical treatment, and outcomes of the present case, with diagnostic images and photomicrographs of the lesion included. We also briefly reviewed the reported studies.

Diagnostic accuracy of synovial chondromatosis of the temporomandibular joint on magnetic resonance imaging

The purpose of this study was to evaluate the diagnostic accuracy of magnetic resonance imaging (MRI) for synovial chondromatosis (SC) of the temporomandibular joint (TMJ). In this study, 1415 patients (2109 joints) with temporomandibular joint disorders were collected between January 2012 and January 2017. All patients had a preoperative MRI examination and were treated by either arthroscopy or open surgery. On reviewing all MRI images, the number of "positive", "suspicious", and "negative" cases was collected afterwards, then the number of reported SC cases in operative data was recorded. The SPSS software was used to process all collected data. The kappa coefficient and ROC curve (AUC-index) with sensitivity and specificity were calculated to evaluate the consistency between MRI and arthroscopy/open surgery. Compared to 156 joints with SC detected by arthroscopy and open surgery, the results of MRI examination showed "positive" in 117 joints, and "negative" in 1938 joints. The number of "true positive", and "true negative" cases was 95, and 1897 respectively. The AUC-index was 0.86 (0.82-0.90) with a kappa coefficient of 0.74 (P < 0.05). In conclusion, the incidence of synovial chondromatosis diagnosed on MRI was in accordance with the arthroscopic and open surgery. Therefore, being a relatively non-invasive tool, MRI could be recommended as an effective diagnostic modality for SC.

Innovative Surgical Management of the Synovial Chondromatosis of Temporo-Mandibular Joints: Highly Conservative Surgical Technique

Synovial chondromatosis (SC) is an uncommon disease characterized by a benign nodular cartilaginous proliferation arising from the joint synovium, bursae, or tendon sheaths. Although the temporomandibular joint is rarely affected by neoplastic lesions, SC is the most common neoplastic lesion of this joint. The treatment of this disease consists in the extraoral surgery with a wide removal of the lesion; in this study, the authors described a more conservative intraoral surgical approach. Patient with SC of temporomandibular joint typically refer a limitation in the mouth opening, together with a persistent not physiological mandibular protrusion and an appearance of a neoformation located at the right preauricular region: the authors reported 1 scholar patient. After biopsy of the neoformation, confirming the synovial chondromatosis, the patient underwent thus to the surgical excision of the tumor, via authors' conservative transoral approach, to facilitate the enucleation of the neoformation. The mass fully involved the pterygo-maxillary fossa with involvement of the parotid lodge and of the right TMJ: this multifocal extension suggested for a trans-oral surgical procedure, in the light of the suspicion of a possible malignant nature of the neoplasm. Our intraoral conservative approach to surgery is aimed to reduce the presence of unaesthetic scars in preauricular and facial regions, with surgical results undoubtedly comparable to the traditional surgical techniques much more aggressive. Our technique could be a valid, alternative, and safe approach to treat this rare and complex kind of oncological disease.

A rare case of synovial chondromatosis of the inferior TMJ compartment. Diagnosis and treatment aspect

AIM

Synovial Chondromatosis (SC) is a rare, benign non neoplastic arthopathy characterized by the metaplastic development of cartilaginous nodules within the synovial membrane. In only 3% of all cases does it affect the temporomandibular joint (TMJ) and cases that arise from the lower compartment are rarely found in literature. The aim of this paper is to report a new case of SC of the inferior TMJ compartment with the description of the clinical, therapeutic and histopathological findings.

CASE REPORT

This article presents a 68-year-old woman with preauricular swelling on the right side, pain, crepitus and limited joint motion. This patient was evaluated by preoperative clinical manifestation, CT scan and MR images. Both showed multiple, calcified loose bodies in the inferior compartment. Based on these images as well as the patient's signs and symptoms, a surgical intervention was performed. A good functional recovery with no signs of recurrence at 36 months of follow up was obtained.

CONCLUSION

Among cases of synovial chondromatosis in literature, only twelve originating in the lower compartment have been reported, this one included. In all the cases treated for SC in the lower compartment, both in literature and in our case report, surgical treatment led to healing.

Synovial chondromatosis of the temporomandibular joint: MRI findings with pathological comparison

OBJECTIVES

The aim of this retrospective study was to characterize MRI findings of synovial chondromatosis in the temporomandibular joint (TMJ) by correlation with their pathological findings.

METHODS

22 patients with synovial chondromatosis in unilateral TMJ were referred for plain MRI prior to surgical management and pathological examinations. Parasagittal and coronal proton density-weighted imaging and T₂ weighted imaging were performed for each case.

RESULTS

MRI demonstrated multiple chondroid nodules and joint effusion in all patients (100%) and amorphous iso-intensity signal tissues within expanded joint space and capsule in 19 patients (86.4%). On T₂ weighted imaging, signs of low signal nodules within amorphous iso-intensity signal tissues were used to determine the presence of attached cartilaginous nodules in pathology, resulting in 100% sensitivity, 60% specificity and 90.9% accuracy. Signs of low and intermediate signal nodules within joint fluids were used to detect loose cartilaginous nodules and resulted in 80% sensitivity, 42.9% specificity and 68.2% accuracy.

CONCLUSIONS

MRI of synovial chondromatosis in TMJ was characterized by multiple chondroid nodules, joint effusion and amorphous iso-intensity signal tissues within the expanded space and capsule. The attached cartilaginous nodules in pathology were better recognized than the loose ones on MRI. Plain MRI was useful for clinical diagnosis of the disorder.

Synovial chondromatosis in the inferior compartment of the temporomandibular joint: different stages with different treatments

PURPOSE

To discuss a new classification and the treatment principles of synovial chondromatosis (SC) in the inferior compartment of the temporomandibular joint (TMJ).

PATIENTS AND METHODS

Five cases of SC in the inferior compartment were treated in an open manner between January 2008 and May 2011. Each case had different clinical and radiologic aspects and was treated with different surgical therapies. SC in the inferior compartment of the TMJ is classified into 3 stages. All patients were evaluated by computed tomography, magnetic resonance imaging, and clinical manifestations preoperatively and postoperatively.

RESULTS

There were 3 kinds of manifestation modes from radiologic findings. Case 1 was in stage 1, in which multiple loose bodies are noted without bony erosion. This patient was treated by removal of loose bodies and affected synovium. Case 2 was in stage 2, in which multiple calcified nodules were conglutinated to the condyle; the condyle was enlarged with pressure erosions. This patient was treated by condylectomy and reconstruction with costochondral graft. Case 3, case 4, and case 5 were all in stage 3, in which the condyle was destroyed as a result of pressure erosions or by direct bony invasion of the mass and the inferior surface of the disc was involved. These patients were treated by condylectomy together with discectomy, as well as reconstruction with costochondral graft and pedicled deep temporal fascial fat flap. No recurrence occurred. The height of the ramus and the occlusion were maintained in the same condition as preoperatively.

CONCLUSIONS

Our new classification of SC in the inferior compartment of the TMJ can better guide clinical treatment.

Synovial chondromatosis of the temporomandibular joint with condylar extension

Synovial chondromatosis is a benign disease that rarely affects the temporomandibular joint (TMJ). It can be seen commonly in the superior joint space and presents with various signs and symptoms according to the stage of progression. Sometimes it presents as a large swelling in the preauricular area with or without cranial extension, and the clinical and radiographic findings may be misdiagnosed as other benign or malignant diseases of TMJ. Therefore, we report an uncommon case of synovial chondromatosis presenting as a large preauricular mass arising from the inferior joint space of the TMJ with bony resorption of the mandibular condyle, which mimicked osteochondroma.

Synchronous occurrence of ipsilateral synovial chondromatosis of the temporomandibular joint and pleomorphic adenoma of the parotid gland

We present a unique case characterized by true coexistence of synovial chondromatosis (SC) of the temporomandibular joint (TMJ) with a salivary gland tumor, specifically pleomorphic adenoma, of the ipsilateral parotid gland. The possibility that the condition was the result of a single pathologic entity, ie, SC with extracapsular involvement or pleomorphic adenoma affecting the TMJ, received strong consideration. Nonetheless, careful assessment of the clinical, radiographic, MRI, and surgical findings strongly suggested the synchronous occurrence of 2 separate pathologic processes, despite their close proximity. Further, histopathologic examination confirmed the presence of both SC of the TMJ and pleomorphic adenoma of the superficial lobe of the ipsilateral parotid gland. Previous reports have pointed out the possibility of misdiagnosing extracapsular spread of SC as a salivary gland tumor. Vice versa, it has been noted that parotid gland tumors, especially malignant, may cause TMJ symptoms similar to those of SC. However, to the best of our knowledge, this is the first time that true synchronous occurrence of ipsilateral SC and pleomorphic adenoma, or parotid tumor of any kind, is reported.

CT features of synovial chondromatosis in the temporomandibular joint

OBJECTIVE

The purpose of this study was to determine the characteristic computed tomography (CT) findings of synovial chondromatosis of the temporomandibular joint (TMJ).

STUDY DESIGN

Eight subjects with synovial chondromatosis were examined with axial and coronal CT scans. All lesions were histopathologically confirmed either through an arthroscopic punch biopsy or surgery. CT appearances of the lesions were reviewed and classified.

RESULTS

Among the 8 subjects, 7 (87.5%) demonstrated soft tissue swelling, 7 (87.5%) showed loose calcified bodies, and 6 (75%) had bony changes of the articular surfaces. Patterns of the skull base changes as well as intracranial extension of the disease were identified.

CONCLUSIONS

Based on the CT findings, synovial chondromatosis of the TMJ is characterized by soft tissue swelling, loose calcified bodies, and bony changes of the skull base. The latter may lead to destruction of the central skull base and intracranial extension.

Synovial chondromatosis of the temporomandibular joint: clinical, diagnostic, and histomorphologic findings

Objective. The primary diagnosis of synovial chondromatosis of the temporomandibular joint is extremely rare. Often many months, or even years pass before the diagnosis is confirmed. Study Design. Eight patients with synovial chondromatosis were treated by arthrotomy. In addition to the definitive diagnosis, histologic classification according to the stages proposed by Milgram was undertaken and confirmed with the literature. Results. The predominant symptoms of synovial chondromatosis, including pain, swelling, restricted movement of the mandible, and crepitation, were evaluated. Nevertheless, more than 80% of the patients were previously primarily treated on the basis of other tentative diagnoses. Conclusion. Synovial chondromatosis of the temporomandibular joint should be included in the differential diagnosis of chronic swelling and pain in the preauricular region, and the patient should be sent for appropriate diagnostics and therapy at an early stage.

Tc-99m HMPAO brain perfusion SPECT in drug-free obsessive-compulsive patients without depression

The aim of this study was to confirm prior results of brain-imaging studies on obsessive-compulsive disorder (OCD) in a sample of Turkish patients, as a cross-cultural study. Tc-99m HMPAO brain perfusion SPECT imaging was performed in nine drug-free OCD patients without depression and six controls. The patients' Hamilton Depression Rating Scale scores were <16. The severity of obsessive-compulsive symptoms was rated with the Yale-Brown Obsessive-Compulsive Rating Scale (YBOCS). Quantitative evaluation of regional cerebral blood flow revealed that right thalamus, left frontotemporal cortex and bilateral orbitofrontal cortex showed significant hyperperfusion in patients with OCD compared with controls. YBOCS scores did not show any correlation with hyperperfusion in regional cerebral blood flow in these areas. Results of this cross-cultural study may support orbitofrontal and thalamic dysfunction in OCD in a sample of Turkish patients.

Synovial chondromatosis of the temporomandibular joint with intracranial extension

An unusual case of synovial chondromatosis of the temporomandibular joint with intracranial extension, which resulted in complete dehiscence of the floor of the middle cranial fossa, is reported. An overview of the current literature and a discussion of the diagnosis and surgical management of synovial chondromatosis are presented.

A case report. Chondromatosis of the temporomandibular joint

Synovial chondromatosis is a rare pathological condition that usually affects large joints but can affect the temporomandibular joint. The disease typically manifests itself with signs and symptoms similar to internal derangement. The disease is characterized by free-floating or attached cartilaginous bodies in the joint space. In this article, the authors present a case of synovial chondromatosis and discuss its pathological process. They also discuss diagnostic approaches and current treatment.

[Synovial chondromatosis (chondrometaplasia). Contribution to the differential diagnosis of temporomandibular joint diseases]

A rare case of synovial chondromatosis of the temporomandibular joint with unspecific symptoms is presented. This causes difficulties in classifying the different clinically and technically acquired features at differential diagnosis. The concept of chondrometaplasia as being triphasic and self-limiting is strongly supported and extreme care should be taken during therapy in order to avoid any unnecessary destruction and mutilation. This case seems to indicate that chronic parafunctional overload was the initiating stimulus for this reactive metaplastic process. Nonphysiologic overstrain of any cause should be diagnosed and corrected.

Loose bodies in the temporomandibular joint. The advantages of arthroscopy

Loose bodies are a rare cause of temporomandibular joint symptoms. Their main source is synovial chondromatosis. We report on clinical findings, diagnostic methods, treatment choices and outcome following the removal of loose bodies in 10 patients. Seven patients were evaluated and treated by means of arthroscopy, while in three patients open arthrotomy was performed. In five patients, no diagnostic imaging technique had demonstrated the presence of loose bodies prior to arthroscopy. In six patients, histology revealed synovial chondromatosis. In four patients, osteochondral fragments alone were found. Until now, the recommended treatment of choice for the removal of all loose bodies and of affected synovial tissue required open arthrotomy. We conclude that the advantages of arthroscopy consist in locating loose bodies that are not detectable radiologically and in reducing operative trauma.

Arthroscopic punch for definitive diagnosis of synovial chondromatosis of the temporomandibular joint. Case report and pathology review

Synovial chondromatosis is characterized as a benign monoarticular condition with metaplastic cartilaginous nodules that develop within the synovial membrane of articulating joints. In addition to a pathology literature review, this article describes an unusual case of temporomandibular synovial chondromatosis that was sufficiently expansile to displace the condyle, which created not only a posterior occlusal apertognathia, but unusual articular bony fossa and eminentia erosions. An arthroscopic approach for definitive diagnostic punch biopsy and surgical approach is described and presented along with preoperative computerized tomograph, magnetic resonance imaging, and tomographic diagnostic images, as well as 3-year follow-up clinical and radiographic findings. Most interestingly, the arthroscopic examination and biopsy proved to be the most useful method to establish a definitive diagnosis of synovial membrane chondromatosis within the temporomandibular joint region for this patient.

Radiologic case study. MRI in the diagnosis of synovial disease

Fourteen patients with various synovial diseases were imaged using conventional radiographic techniques and MRI. We had five patients with synovial tumors, including two each with PVNS and synovial osteochondromatosis. We had five patients with infections and four patients with various other forms of arthritis. Although MRI was found to be a useful means to visualize the synovium, the findings were nonspecific except in the case of PVNS.

Synovial chondromatosis with cranial extension

Synovial chondromatosis is a benign arthropathy characterized by metaplasia in synovial membranes that can produce detached particles of cartilage. It occurs most often in the knee, hip, and elbow but has been reported in the temporomandibular joint. This is a rare presentation of synovial chondromatosis with glenoid fossa erosion and cranial extension.

Synovial chondromatosis of the temporomandibular joint. Report of a case

A case of synovial chondromatosis of the temporomandibular joint is reported in which initial clinical and radiographic data indicated disk derangement. Magnetic resonance imaging revealed distention and thickening of the lateral capsule but could not delineate the numerous loose bodies found at arthrotomy. The literature is reviewed, and diagnosis and surgical therapy are discussed.

Asymptomatic, radiologically detected chondrometaplasia in the temporomandibular joint

Asymptomatic loose bodies were detected in the temporomandibular joint of a 62-year-old woman during an examination before comprehensive dental care. The radiologic interpretation was synovial chondrometaplasia (synovial osteochondromatosis). A histologic diagnosis was not obtained, because surgery was unwarranted in view of the lack of symptoms and the benign differential diagnosis. Review of the literature revealed 62 reported cases of temporomandibular joint chondrometaplasia, all of which included one or more of the following: swelling, pain, joint noise, and limited mandibular movement. These reports have described this entity as a rare lesion, but the rate of reports has increased, perhaps because of greater practitioner awareness and increased sensitivity of diagnostic tests.

Synovial chondromatosis of the temporomandibular joint possibly secondary to trauma. A case report

A histologically confirmed case of synovial chondromatosis of the temporomandibular joint associated with a glenoid fossa callus is described. The lesion appeared 6 years after trauma to the chin. Conservative surgical treatment without excision of the synovial membrane or meniscus but including arthroplasty of both the eminence and the lateral side of the glenoid fossa was successful. The possible role of trauma in the etiology of synovial chondromatosis is discussed.

The diagnostic value of computed tomography in temporomandibular joint synovial chondromatosis

Synovial chondromatosis of the temporomandibular joint was diagnosed and location of dens particles was assessed by means of computed tomography. Based upon the data collected, the joint was operated conservatively and most of the calcifications were removed leaving the patient symptom free. The importance of an accurate preoperative diagnosis of synovial chondromatosis by use of CT scan is stressed in view of numerous unnecessary condylectomies and parotidectomies reported in the literature.