Arthroscopic management of intra-articular pigmented villonodular synovitis of temporomandibular joint

The hue of temporomandibular joint arthroscopy under local versus general anaesthesia

BACKGROUND

Temporomandibular joint arthroscopy (TMJA) is often performed under general anaesthesia (GA) worldwide on an inpatient basis, whereas local anaesthesia (LA) is not equally considered as the standard procedure.

OBJECTIVES

To compare the efficacy between LA and GA when performing TMJA.

METHODS

This study retrospectively reviewed a total of 182 patients in LA group and 91 patients in GA group who underwent TMJA for the management of disc displacement. Patients were divided into two groups based on type of anaesthesia used for surgery; LA group and GA group. Comparisons were made based on operative time, intubation and extubation time (for GA only), hospital stay duration, total cost and post-operative clinical and radiological outcomes.

RESULTS

The demographics and pre-operative clinical assessments were matched in both groups. No post-operative significant difference was found in outcomes when performing TMJA under LA compared to GA in terms of pain reduction (p = .016) and improvement in mouth opening (p = .866). The median operative time and hospital stay duration for LA group were significantly less compared to GA group (p < .001). GA group required an additional intubation and extubation time, whereas LA group patients were waived from it. TMJA for LA group was performed in the minor procedure setup, which reduced the costs for surgery (p < .001). Post-operative disc position was excellent and good with an overall success rate of 95%.

CONCLUSION

The use of LA performing TMJA reduces operating time, costs, hospital stay and recovery room time than GA group. Furthermore, TMJA performed under LA shared similar post-operative clinical and radiological outcomes with those performed under GA.

Management of tenosynovial giant cell tumour of the temporomandibular joint: a systematic review

Diffuse type tenosynovial giant cell tumour of the temporomandibular joint (D-TGCT-TMJ) is a rare proliferative disorder. The aim of this study was to perform a systematic review of the literature to summarize D-TGCT-TMJ management regimes and recurrence rates with at least 12 months of follow-up. Our secondary aim was to propose a minimum period of post-operative follow-up. A medline search for any D-TGCT-TMJ case detailing treatment, follow-up of at least 12 months, and presence of recurrence was undertaken. The following variables were extracted from the studies: patient's age and sex, presence of middle cranial fossa invasion, treatment undertaken, total length of follow-up, and presence of recurrence. All studies were assessed for bias as per the Joanna Briggs Institute systematic reviews appraisal tool. There were 63 cases reviewed and were predominantly managed with total resection (60.3%). Other modalities included: arthroplasty, subtotal resection with or without postoperative radiotherapy, medical therapy and surveillance. The recurrence rate was 9.52% and the longest follow-up period where recurrence was observed was at 60 months. Total resection and arthroplasty are common D-TGCT-TMJ management regimes. Patients with D-TGCT-TMJ should be followed up annually for at least 5 years postoperatively to assess for recurrence.

Clinical and immunohistochemical analysis of diffuse tenosynovial giant cell tumour of the temporomandibular joint

The objective of this study was to summarize diagnostic points and treatment strategies for diffuse tenosynovial giant cell tumours (D-TSGCTs) of the temporomandibular joint (TMJ), and to evaluate the expression of proteins related to bone destruction and recurrence. The clinical and histopathological characteristics of 24 cases were analysed retrospectively. TRAP staining and immunohistochemical staining for MMP-9, MMP-13, and Ki-67 were performed. The median age of the patients was 45.5 years; the female to male ratio was 1.7:1. In 11 cases (45.8%), skull base destruction seen on computed tomography was confirmed by surgery. Computer-assisted navigation was performed in six cases. Four patients received adjuvant radiotherapy after first surgery. Five patients had recurrent lesions. Multinucleated giant cells were positive for TRAP, MMP-9, and MMP-13. The average Ki-67 index of the recurrent cases was significantly higher than that of the non-recurrent ones (P<0.05). This study demonstrates the aggressive and recurrent nature of D-TSGCT occurring in the TMJ. Computer-assisted navigation is helpful to protect vital structures and determine margins. Adjuvant postoperative radiotherapy is recommended for local control of residual or recurrent tumour. In conclusion, MMP-9 and MMP-13 may play a role in bone destruction of D-TSGCT, and the Ki-67 index has predictive significance for recurrence.

Pigmented Villonodular Synovitis Presenting as Unilateral Hearing Loss: Review of the Literature and Case Report

BACKGROUND/AIMS

To review the existing literature on pigmented villonodular synovitis (PVNS) of the temporomandibular joint (TMJ) and report a rare case of PVNS of the TMJ presenting with unilateral hearing loss.

METHODS

Review of the existing literature and a description of personal experience with PVNS of the TMJ presenting with unilateral hearing loss.

RESULTS

Review of the existing literature revealed 76 reported cases of PVNS of the TMJ. The most common presenting symptom was of a slowly enlarging mass or swelling of the preauricular area, with dysfunctional TMJ also frequently reported. All patients underwent surgical excision with some pursuing radiation as adjuvant therapy. Presented Patient: A 46-year-old man presented with several months of unilateral subjective hearing loss and aural fullness. Imaging revealed a mass centered along the superior TMJ with expansion through the squamous temporal bone and extra-axial intracranial extension into the middle cranial fossa. Imaging characteristics and fine-needle aspiration biopsy were consistent with PVNS.

INTERVENTION

The patient underwent near-total excision of the mass via frontotemporal craniectomy and lateral temporal bone resection.

FOLLOW-UP

At the 16-month follow-up there was no evidence of disease recurrence.

CONCLUSION

PVNS of the TMJ represents a rare entity that can present with a variety of symptoms including unilateral hearing loss.

Nodular Tenosynovitis of the Temporomandibular Joint: An Entity Not Yet Described

Nodular tenosynovitis usually affects the hands and it represents a benign pathology with locally aggressive behavior. Its etiology could be related to chronic inflammatory processes such as trauma, metabolic disturbance, and joint diseases. Histopathological analysis is required for a diagnosis of certainty and surgery represents the treatment of choice. There are no cases in the literature that describe a nodular tenosynovitis affecting the temporomandibular joint (TMJ) The main aim of the present report therefore, is to describe this unusual case and to show the utility of arthroscopic procedures in managing intra-articular tumors of the TMJ.

Arthroscopic approach for treating a pigmented villonodular sinovitis of TMJ. A case report

The present report describes the case of a 29-year-old man referred to our service for TMJ pain and progressive reduction of the mouth opening. Differential diagnostics included rheumatologic diseases, monoarthritis and intraarticular lumps. In this line, a face CT scan and a MRI of TMJ were carried out in order to ensure a proper diagnosis. These tests showed a solid lesion into the joint cavity. In view of that, we decided to perform a diagnostic and therapeutic arthroscopy of TMJ. Histopathological studies confirmed the diagnosis of pigmented villonodular synovitis. The main aim of this report is to describe this rare syndrome with the goal of proposing suitable treatments. Moreover, we highlight the benefits of using arthroscopic procedures in the cases which the tumor is still confined to the joint. As far as we are aware, scientific literature documents only a single case of pigmented villonodular synovitis of TMJ treated with arthroscopic approach. Key words:Arthroscopic approach, pigmented villonodular synovitis, TMJ, mouth opening.

Pigmented villonodular synovitis of the temporomandibular joint with intracranial extension

Pigmented villonodular synovitis is an uncommon benign tumor-like proliferative lesion with an undetermined origin. Involvement of the temporomandibular joint is uncommon. Although pigmented villonodular synovitis is a benign lesion, it can grow with an aggressive pattern, and it extends extra-articularly in most of the reported cases, about one-third of them exhibiting intracranial involvement. The authors reported an additional case of a 47-year-old woman with intracranial extension, who had a history of joint pain and trismus. The preoperative diagnosis was made with arthroscopy. The lesion was completely excised via preauricular approach and condylotomy. The bone defect was covered by the pedicled temporalis myofascial fat flap. The patient has been symptom-free for 40 months postoperatively.

Pigmented villonodular synovitis of the temporomandibular joint with intracranial extension: A case series and systematic review

BACKGROUND

Pigmented villonodular synovitis (PVNS) is a rare proliferative disorder of the synovial membrane. PVNS generally affects large joints but occasionally involves the temporomandibular joint (TMJ), with occasional extension into the middle cranial fossa. The purpose of this study was to report our experience with PVNS along with a focused literature review.

METHODS

Patients with PVNS of the TMJ treated at the University of California - San Francisco from 2007 to 2013 were reviewed. A PubMed search was performed to identify additional cases.

RESULTS

Five patients underwent surgical resection, with 1 recurrence at 61 months. A literature review identified 58 patients, 19 of which had intracranial involvement. Interestingly, intracranial extension was more common in men. Intracranial extension was not associated with an increased rate of recurrence.

CONCLUSION

PVNS of the TMJ is a rare entity associated with excellent outcomes, even with intracranial extension. Management should consist of maximal resection, with radiotherapy reserved for extensive or recurrent lesions.

Pigmented villonodular synovitis of the temporomandibular joint: CT imaging findings

OBJECTIVE

The purpose of this study was to determine the characteristic computed tomography (CT) findings of pigmented villonodular synovitis (PVNS) of the temporomandibular joint (TMJ).

STUDY DESIGN

Eight subjects with PVNS were examined with both pre and post contrast CT scans. All lesions were histopathologically confirmed through surgery. CT appearances of the lesions were reviewed.

RESULTS

Among the eight subjects, 8 (100%) demonstrated soft tissue mass and enhancement after contrast administration, 6 (75%) appeared as all or focal areas of noncontrast hyperdensity, 6 (75%) had widening of the joint spaces. Bony erosion of the mandibular condyles and articular surfaces were found in 7 (87.5%) and 6 (75%) subjects, respectively.

CONCLUSIONS

Based on the CT findings, PVNS of the TMJ is characterized by hyperdensity soft tissue mass and further increase in density after contrast administration, bony destruction of the mandibular condyles and skull base, and intracranial extension.