Bilateral spontaneous symptomatic temporomandibular joint herniation into the external auditory canal: A case report and literature review

Finding the Silver Bullet for Persistent Foramen Hushke

We report a case of persistent foramen Hushke and embark on a literature search from 1990 to 2021. The search was done using electronic databases of PubMed and Google Scholar using the MESH words 'TMJ herniation', 'persistent foramen Hushke', 'TMJ prolapse', 'EAC dehiscence', and 'ear canal mass'. A total of 37 other case reports were included after excluding duplicates and non-English publications. The most common presentations, treatment modalities, complications, and outcomes were discussed. Common presentations include otalgia, tinnitus, otorrhea, and aural fullness. Surgical intervention shows a good outcome, whereas conservative treatment shows a mixed response. Despite the overwhelming success of surgical interventions in treating symptomatic persistent foramen of Hushke, it is still early to establish a guideline to manage these patients, as this condition is rare and presents with variable symptoms. More high-quality studies and a long-term follow-up of the patients may be essential to observe and compare the outcome and recurrence rate of temporomandibular joint (TMJ) herniation.

Persistent foramen of Huschke: Clinical manifestations and complications, systematic review

BACKGROUND

Foramen of Huschke is a bone defect with wide clinical symptoms which ca can be responsible for severe complications. Clinical history and imaging are unspecific, it is therefore essential to recognize and treat the pathology related to the persistence of this foramen, to avoid destruction of the TMJ, chronic pain or OBJECTIVE: The aim of this review was to summarise the clinical manifestations and complications of persistent foramen of Huschke in adult patients, through a review of the cases reported in the literature.

METHODS & MATERIALS

A literature search of the PubMed, Cochrane Library, ScienceDirect and Embase databases was conducted for all articles published up to November 2022 to identify studies and case reports concerning clinical manifestations and complications of persistent foramen of Huschke in adult patients, with the key words "foramen of Huschke" or "foramen tympanicum".

RESULTS

74 papers where firstly identify, and 21 were selected. This correspond to 46 patients with the additional case from our department. Symptoms mostly reported consisted of otitis (63%, 29/46), otorrhea (28.26%, 13/46), and masticatory tinnitus (19.57%, 9/46). Diagnosis was priority made by CT-scan (95.65%, 44/46). Surgery was the most performed treatment (28.26%, 13/46). In our case, the use of FLUOBEAM® NIR camera was help-full for TMJ surgery.

CONCLUSION

Persistent foramen of Huschke should be suspected in the presence of otitis, otorrhea and masticatory tinnitus. Knowledge of this anatomical variation could help to treat certain pathology like TMJ disorders or TMJ septic arthritis.

Persistent foramen of Huschke: Presentation, evaluation, and management

OBJECTIVE

Describe the presentation and management strategy for patients with symptomatic foramen of Huschke (FH).

PATIENTS

Adults with persistent FH confirmed on imaging.

INTERVENTIONS

Diagnosis and management of symptomatic persistent FH.

MAIN OUTCOME MEASURE

Resolution of otologic symptoms.

RESULTS

A total of four patients with symptomatic, radiographically-confirmed persistent FH were included. The majority of patients endorsed otalgia (n = 4) and otorrhea (n = 3), and only one patient was noted to have a conductive hearing loss. All patients were noted to have dynamic movement of an external auditory canal mass with mandible manipulation on examination, and all patients had an identifiable fistula on imaging. Patients underwent surgical intervention, including both preauricular (n = 2) and transcanal (n = 2) approaches, and all endorsed symptomatic resolution after convalescence.

CONCLUSIONS

Persistent FH remains an uncommon and potentially underrecognized cause of otologic symptoms. Diagnosis requires a high index of suspicion, and one must rely on both key examination findings and imaging to confirm this diagnosis. In appropriately selected patients, surgical intervention can provide durable symptomatic resolution.

LEVEL OF EVIDENCE

IV.

Otoscopy and imaging features of spontaneous temporomandibular joint herniation into the external auditory canal

Objective:

To explore the otoscopy, CT and MRI features of spontaneous temporomandibular joint(TMJ）herniation(STMJH) into the external auditory canal (EAC) through the persistent foramen of Huschke (PFH).

Methods:

15 cases diagnosed STMJH were collected. The otoscopy, CT data of 15 cases and MRI data of 6 cases were retrospectively reviewed.

Results:

Otoscopy revealed a mass located in the anterior wall of the bony EAC that moved forwards and backwards during mouth opening and closing, respectively. CT showed a soft mass with bony defect in the anterior wall of the EAC, with no enhancement; the bony defect margin was well defined in all cases. The bone adjacent to the PFH was pressed and partially wrapped around the soft mass, as if “holding a ball,” in seven cases. Pseudobone shell around the soft mass was observed in eight cases. Six cases included MRI scans, which showed TMJ soft tissue herniated into the EAC.

Conclusion:

STMJHs have unique otoscopic, CT and MRI features. The examination strategy recommended is dynamic otoscopy and conventional CT, MRI can be chosen when the herniation is complicated by infection or otitis externa or when the patient has TMJ dysfunction; conservative management and follow-up observations are the main treatment strategy recommended.

Advances in knowledge:

Mechanical stress of TMJ on the EAC is thought to cause herniation and the special CT features, the location and size of the PFH, especially the location, are the major risk factors for TMJ herniation in patients with FH.

Temporomandibular joint herniation into the middle ear: A rare cause of mastication-induced tinnitus

A 75-year-old patient complained of mastication-induced clicking tinnitus on the left side, and otoendoscopic examination revealed that the left tympanic membraneTM was outwardly bulged by clenching her teeth. Temporal bone computed tomography demonstrated that the posteromedial bony wall of the glenoid was partially dehiscent, allowing herniation of soft tissue contents of temporomandibular joint into the middle ear. Increased middle ear pressure due to soft tissue herniation can induce left tympanic membrane bulging and accompanying clicking tinnitus. Herniation of temporomandibular joint soft tissue into the middle ear should be considered as a differential diagnosis when clicking tinnitus is evoked by mastication.

Temporomandibular Joint Herniation: Review of the Literature

OBJECTIVE

To define clear clinical characteristics and management strategies of herniation of temporomandibular joint (TMJ) into the external auditory canal (EAC).

DATA SOURCE

MEDLINE, PubMed, and EMBASE databases.

STUDY SELECTION

A search was conducted using the keywords "temporomandibular joint" and "herniation" with all of their synonyms. Literature selection criteria included articles published in English, and articles dating back no further than 1970.

RESULTS

Forty articles regarding 51 cases were eligible for critical appraisal. According to the previously published papers, TMJ herniation has following characteristics; symptoms are nonspecific, but a distinguishable feature is a protruding mass into the EAC that can be seen to appear and disappear as the mouth opens and closes. High-resolution computed tomography scans are sensitive to the bony defect and are helpful in diagnosing TMJ herniation. In the surgical treatment of TMJ herniation, wall reconstruction rather than simple mass excision could be a safe and long-lasting strategy.

CONCLUSIONS

Herniation of TMJ into the EAC is a rare condition, but can be encountered in the clinic at any time. This literature review could be helpful in the diagnosis and treatment of TMJ herniation into the EAC.

Bilateral spontaneous temporomandibular joint herniation: A case report and literature review

In this article we report the case of a 41-year-old man with bilateral aural fullness and hearing loss. On examination he was found to have bilateral, dehiscent anterior canal walls with herniation of the mandibular condyle. This herniation partially obstructed the canals and contributed to his symptoms. To the best of our knowledge, this is only the third reported case of bilateral spontaneous temporomandibular joint herniation, and only 28 cases of unilateral spontaneous herniation can be found in the English language literature. While it is a rare phenomenon, it should be considered when evaluating a patient with fluctuating ear symptoms.