Benign Temporomandibular Joint Lesions Presenting as Masses in the External Auditory Canal

A case report of an unusual temporomandibular joint mass: Nodular fasciitis

Nodular fasciitis (NF) is a benign myofibroblastic proliferation that grows very rapidly, mimicking a sarcoma on imaging. It is treated by local excision, and recurrence has been reported in only a few cases, even when excised incompletely. The most prevalent diagnoses of temporomandibular joint (TMJ) masses include synovial chondromatosis, pigmented villonodular synovitis, and sarcomas. Cases of NF in the TMJ are extremely rare, and only 3 cases have been reported to date. Due to its destructive features and rarity, NF has often been misdiagnosed as a more aggressive lesion, which could expose patients to unnecessary and invasive treatment approaches beyond repair. This report presents a case of NF in the TMJ, focusing on various imaging features, along with a literature review aiming to determine the hallmark features of NF in the TMJ and highlight the diagnostic challenges.

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.

Determining the existence of the foramen of Huschke in patients with temporomandibular joint disorders using cone beam computed tomography: retrospective cohort study

Background

Foramen of Huschke has been presented as an unusual developmental defect in anteroinferior aspect of external auditory canal. It can be associated with significant otologic complications. The purpose of this study was to determine the association between existence of foramen of Huschke and temporomandibular joint disorders in Cone Beam Computed Tomography (CBCT) images.

Methods

Of an initial sample of 465 patients, we retrospectively evaluated the CBCT images of 118 individuals with clinical signs and symptoms of temporomandibular joint disorders as case group and 256 individuals as control group. The presence, size and localization of foramen of Huschke were assessed in the axial and corrected sagittal images. The sex and age distribution were determined. Fisher’s exact test, T-test and Pearson’s Chi-square were applied to assess the relationship between foramen of Huschke and temporomandibular joint disorders in the case and control groups considering age and sex.

Results

The foramen of Huschke prevalence was slightly higher in patients with temporomandibular joint disorders (3.4%) than patients without temporomandibular joint disorders (0.8%). However, the difference was not statistically significant (P = 0.082). foramen of Huschke was found in five females and one male. There was no significant difference between case and control groups considering the age of patients with foramen of Huschke (P = 0.683). There was no significant difference between the case and control groups, considering the right and left ears in distribution of foramen of Huschke (P = 0.099) (P = 0.183).

Conclusions

Higher prevalence of foramen of Huschke in patients with temporomandibular joint disorders may suggest possible mechanism for temporomandibular joint disorders development that can be affected by presence of foramen of Huschke.

Two case reports of intra-articular nodular fasciitis of the knee confirmed by MYH9-USP6 gene fusion expression

AIM

To describe two cases of intra-articular nodular fasciitis (NF) which developed within the knee joint and were associated with the expression of the MYH9-USP6 gene fusion.

PATIENTS AND METHODS

Two women, 30 and 56 years of age, with no history of joint disease or knee joint trauma, are presented in our cases. We report these cases describing the clinical presentation, assessment, histopathological examination, gene expression, and clinical management.

RESULTS

Both patients presented with knee pain and limitation in the range of flexion. We diagnosed our two cases as intraarticular nodular fasciitis based on histological findings and by the detection of the MYH9-USP6 gene fusion. The transcript of MYH9-USP6 gene fusion was identified by RT-PCR and direct sequencing in both cases.

CONCLUSION

We report the first cases of intra-articular NF involving the knee joint, with identification of a MYH9-USP6 gene fusion by RT-PCR. NF should be considered in the differential diagnosis of intra-articular lesions.

Reconstruction of the Anterior External Auditory Canal With Mastoid Cortex Autologous Bone Graft

OBJECTIVE

To describe the surgical management of temporomandibular joint (TMJ) herniation with external auditory canal (EAC) reconstruction using autologous bone grafting from the mastoid cortex.

STUDY DESIGN

Retrospective case series.

SETTING

A tertiary university medical center.

PATIENTS

Three patients who presented to our Otolaryngology clinic with evidence of TMJ herniation through an anterior EAC defect, both on otoscopy and computed tomography (CT) imaging.

INTERVENTIONS

Reconstruction of the anterior EAC with mastoid cortex bone grafting using an endaural approach.

MAIN OUTCOME MEASURES

Successful reconstruction of anterior EAC bony defect without recurrence of herniation.

RESULTS

All three patients presented with otalgia, hearing loss, and either tinnitus or a clicking sensation with jaw movement. Etiologies for TMJ herniation included osteoradionecrosis following external beam radiation therapy for head and neck carcinoma and iatrogenic injury following multiple tympanoplasties and canalplasties. A mastoid cortex bone graft was placed and secured anterior to the bony EAC defect through an endaural approach. Two patients wore a dental retainer postoperatively to keep the condyle in an open position. After reconstruction, patients reported an improvement in their presenting symptoms. There was no recurrence of TMJ herniation in all cases after 1, 4, and 9 years.

CONCLUSIONS

Anterior EAC reconstruction with autologous bone grafting can be an effective definitive treatment in TMJ herniation. To our knowledge, this is the first report of the use of bone grafting to reconstruct the canal defect in TMJ herniation.Level of Evidence: V.

Surgical reconstruction of the foramen tympanicum: What is known and how we do it

Defects affecting the anterior wall of the tympanal bone can result from trauma, infection, neoplasm or previous local surgery. An anatomic variation, namely the persistence of the foramen tympanicum, can also be encountered. When symptomatic, surgical reconstruction may be indicated. The aim of this study was to identify the surgical treatments of symptomatic foramen tympanicum found in the literature and detail our innovative reconstruction technique. A bibliographic research was conducted in PubMed database in March 2020, without time limitation. Papers dealing with surgical management of a foramen tympanicum were included. Data collected were the publication date, the number of patients, their age and gender, the symptoms and the surgical treatment performed. We report, in addition, the case of a symptomatic persistent foramen tympanicum in a 30-year-old man with a follow-up of 18-months. A total of 17 studies (n=23 patients) were included for analysis. The main reconstruction techniques were, in equal proportion, cartilage graft (30%) and insertion of a titanium mesh (30%). We carried out an iliac crest bone graft using a preauricular approach on a patient suffering from chronic tinnitus and fullness in the left ear resulting from a persistent foramen tympanicum, confirmed by clinical and radiological examinations. It allowed the complete resolution of symptoms and no complication such as temporomandibular ankylosis occurred. Based on the review of the literature, we believe this technique has the advantage of providing durable reconstruction thanks to osseointegration.

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.

Idiopathic, Infectious and Reactive Lesions of the Ear and Temporal Bone

A number of infectious, inflammatory and idiopathic lesions develop within otologic tissues that may share similar clinical and/or microscopic features. This review first provides a working classification for otitis externa, and then otitis media and includes two recently described entities, eosinophilic otitis media and otitis media with ANCA-associated vasculitis. Next, the microscopic findings of a spectrum of otopathologic conditions are described, including post-inflammatory conditions such as tympanosclerosis and aural polyps, an overview of animate aural foreign body as well as iatrogenic aural foreign body reactions. Finally, a review of fungal disease affecting the ear with a brief synopsis of Candida auris, a recently described and virulent organism, is presented.