Rare Cause of Tinnitus: Spontaneous Temporomandibular Joint Herniation Into the External Auditory Canal

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.

Prevalence of foramen Huschke: evaluation of the association between mastoid pneumatization volume and the existence of foramen Huschke using cone beam computed tomography

PURPOSE

The study examined the association between mastoid pneumatization (MP) volume and the existence of foramen Huschke (FH).

METHODS

Cone beam computed tomography (CBCT) images of 1117 patients (2234 mastoid regions) were analyzed. The prevalence of FH was calculated. The association of MP volume calculated in 83 patients (48 women, 35 men) with sex, side, and the existence of FH analyzed. T test and Pearson's Chi-square test were used for statistical analyses.

RESULTS

FH was observed in 223 (20%) patients. FH was unilateral in 141 (63.7%) patients (74 left-sided, 68 right-sided) and bilateral in 81 (36.3%) patients. Six patients with FH had herniation into the external auditory canal. MP volume was significantly greater in females (p = 0.016). Additionally, MP volume was significantly greater in patients having FH (p = 0.009).

CONCLUSION

It is possible to speculate that the volume of MP, which is in close neighborhood with the external auditory canal, somehow affects the existence of FH located in the tympanic segment.

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.

Relationship between the degree of mastoid pneumatization and the presence of persistent foramen of Huschke

The aim of this study was to determine the relationship between the degree of mastoid pneumatization and the presence of persistent foramen of Huschke (FH). Temporal computed tomography images of 714 patients (1428 ears) who applied to the Otorhinolaryngology Department of Karabuk University Training and Research Hospital between January 2016 and June 2018 were retrospectively analysed. We compared the mastoid pnomatization levels of 95 patients (74 females, 21 males, mean age 53.18±15.09years) who had persistent FH and 135 patients (103 females, 32 males, mean age 54.29±15.82years) with no FH who had similar age and gender. FH was found to be unilateral (right: 23, left: 45) in 68 (71.5%) out of 95 patients with FH, and FH was bilateral in 27 (28.4%) patients. The degree of mastoid pnomatization of the patients with FH was significantly higher than the patients without FH (p=0.015). The degree of pneumatization of the mastoid bone may lead to persistent FH by affecting the ossification process of the tympanic segment, which has a close anatomical relationship with it.

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.