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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 30  |  Issue : 1  |  Page : 73-77

Imaging findings in a case of synovial chondromatosis of temporomandibular joint


Department of Oral Medicine and Radiology, Maulana Azad Institute of Dental Sciences, New Delhi, Delhi, India

Date of Submission16-Sep-2017
Date of Acceptance17-Feb-2018
Date of Web Publication23-Apr-2018

Correspondence Address:
Dr. Khushboo Singh
Department of Oral Medicine and Radiology, Maulana Azad Institute of Dental Sciences, New Delhi - 110 002
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_36_17

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   Abstract 


Synovial chondromatosis (SC) is a benign pathology that usually affects the joints of axial skeleton and being rare in temporomandibular joint region. Clinically, the presentation can be in the form of swelling, pain, clicking sounds, and mouth opening limitation. Imaging is a vital component to distinguish the conditions similar to SC. A case of SC diagnosed with the help of imaging has been discussed in the present paper along with a brief review of differential diagnosis.

Keywords: Imaging findings, synovial chondromatosis, temporomandibular joint


How to cite this article:
Singh K, Ghosh S, Verma M, Gupta S. Imaging findings in a case of synovial chondromatosis of temporomandibular joint. J Indian Acad Oral Med Radiol 2018;30:73-7

How to cite this URL:
Singh K, Ghosh S, Verma M, Gupta S. Imaging findings in a case of synovial chondromatosis of temporomandibular joint. J Indian Acad Oral Med Radiol [serial online] 2018 [cited 2021 Dec 9];30:73-7. Available from: https://www.jiaomr.in/text.asp?2018/30/1/73/230892




   Introduction Top


Synovial chondromatosis (SC) is a rare, benign cartilaginous metaplasia that affects diarthrodial joints predominantly of axial skeleton, typically knee (35%), elbow (22%), wrist (11%), and hip (4%).[1],[2] Both primary as well as secondary form of this entity have been identified. The proposed etiopathogenesis in primary form is cartilaginous metaplasia of synovial tissue and deposition of chondromucin, leading to the formation of fragments of cartilage, i.e., loose bodies, in the synovial membrane of the affected joint. These cartilaginous bodies enlarge and finally detach from the synovial membrane. The secondary form occurs subsequent to preexisting joint disease, such as arthritis, trauma, infection, or articular disease, such as inflammatory and noninflammatory osteochondritis.[3] There is female preponderance more common during fourth and fifth decade of life. Clinical presentation of SC affecting temporomandibular joint (TMJ) typically includes swelling, pain, clicking sounds, crepitation, and limitation of mandibular movement. Because these signs and symptoms overlap with the TMJ disc displacement disorders, therefore vigilant attention should be paid to clinical and radiological assessment. Imaging modalities available include convention plain film radiography, computed tomography (CT), and magnetic resonance imaging (MRI). The present paper describes a typical case of SC with radiographic assessment as well as a review of differential diagnosis.


   Case Report Top


A 59-year-old female reported to the outpatient department (OPD) (referred from ENT dept.) with the complaints of pain in front of right ear for the last 15 days. History revealed patient started having pain in front of right ear which was dull, continuous, and used to aggravate while eating cold things. She consulted in ENT department and was advised tab. Nimesulide, three times a day and ultrasonic therapy for 2 months and was relieved from the same. But pain was on and off in nature for which she used to take tab. Nimesulide on her own. There was increased pain for the last 15 days when she reported to dental OPD after referral from ENT department. There was positive medical history of hypertension and diabetes mellitus type 2 for which she was on medication for the last 13 years. Extraoral examination revealed a round swelling approx. 2 cm × 2 cm in right preauricular region, which was tender and fixed to underlying structures with normal color and texture of overlying skin [Figure 1]. TMJ examination revealed the presence of clicking with respect to (wrt) right TMJ, mouth opening (MO) of 48 mm, and deviation of mandible (3 mm) toward left on MO. Intraoral examination showed no pathological finding. Based on history and clinical examination, differential diagnosis was made as osteoma, chondroma, and chondrosarcoma wrt right TMJ. Laboratory examination revealed raised alkaline phosphatase (153.6 U/l), raised gamma-glutamyl transferase (113.4 U/l), and raised erythrocyte sedimentation rate (49 mm/h). Orthopantomogram showed well-defined, multiple, rounded, radiopacities over the right TMJ region [Figure 2]. Antero-posterior radiographic view of right shoulder and bilateral knee (skyline view) revealed no abnormal findings [Figure 3]. Noncontrast CT revealed multiple, small, uniform, well-defined calcified osteochondral bodies within the right TMJ causing expansion of joint cavity and minimal narrowing of cartilaginous part of right external auditory meatus [Figure 4], [Figure 5], [Figure 6], [Figure 7]. High-resolution T1 and T2-weighted MRI images of TMJ were obtained in different planes in open and closed mouth positions, which revealed evidence of a large ossified loose body posterior to the right mandibular condyle measuring 7.6 mm (oblique AP) × 15.7 mm (oblique transverse) × 14.6 mm (CC) in size [Figure 8]. It showed well-corticated margin with speckled appearance in the form of multiple T1- and T2-hypointensities within. Multiple other small loose calcified bodies were seen in right TMJ superior and posterior to mandibular condyle and also anteriorly below articular eminence. These calcified bodies measured 4–6 mm in size. The articular surface of mandibular condyle was flattened and the condyle was displaced anteriorly not articulating with the glenoid fossa but with the articular eminence. The articular disc was slightly deformed in shape with thin anterior band. Suspicious perforation of the articular disc was seen. These radiographic features were strongly suggestive of SC. Patient was explained about the surgical treatment modality for the lesion. As she was not willing for the surgery, treatment was deferred. Patient is kept under regular follow-up.
Figure 1: Extraoral photograph showing swelling in right preauricular region shown by arrows

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Figure 2: Orthopantomogram radiograph showing multiple, small radiopacities in right TMJ region shown by arrows

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Figure 3: Right shoulder view and bilateral knee (skyline view) showing no abnormal findings

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Figure 4: Coronal CT section shows multiple, well-defined osteochondral bodies in right TMJ joint cavity causing expansion of joint cavity shown by arrows

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Figure 5: Sagittal CT section shows multiple, well-defined osteochondral bodies posterior to right condylar region shown by arrows

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Figure 6: Axial CT section shows multiple, well-defined osteochondral bodies around right condylar area shown by arrows

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Figure 7: Three-dimensional CT view shows a well-defined, rounded, hyperdense lesion in right TMJ area shown by arrows

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Figure 8: T1 and T2-weighted MRI images of TMJ shows evidence of a large ossified loose body posterior to the right mandibular condyle with multiple hypointensities within

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   Discussion Top


SC of extra-gnathic joints is rare, and involvement of the TMJ is even rarer. In 1954, Georg Axhausen first described SC of the TMJ as metaplastic chondrogenesis in the synovial membrane.[4] Various synonyms used for SC are synovial chondrometaplasia, synovial chondrosis, and periarticular tenosynovial chondrometaplasia. Clinical signs and symptoms overlap with other TMJ disorders such as TMJ clicking, locking, crepitus, change in occlusion, functional limitations, usually progressive and of long duration are common to SC as well as other degenerative joint disorders; therefore, careful clinical as well as pertinent diagnostic procedures should be used to arrive at definitive diagnosis. The extension of the lesion from the joint capsule and the involvement of the surrounding tissues may make the diagnosis difficult, causing SC to be confused with parotid, middle ear, or intracranial tumors. Intracranial extension may lead to neurological deficits such as facial nerve paralysis.[5],[6] Imaging modalities that are available for diagnosis of SC include conventional film radiography, CT, MRI, and radionuclide scanning bearing pros and cons of each and every technique. Conventional film radiography can be a basic tool to assess any lesion as it is inexpensive with low radiation exposure, but there is superimposition of anatomical structures as well as image distortion making accurate characterization of the lesion difficult. On the contrary, CT produces excellent details of hard and soft tissue, but at the expense of higher radiation doses to the patient. MRI utilizes nonionizing and produces excellent soft tissue resolution, but is costly with limited availability. Radionuclide scanning is usually used to assess functional/metabolic activity of a lesion. Advanced imaging methods, such as CT and MRI, are proved to be indispensable diagnostic tools as they reveal exact extent and character of the lesion, as well as changes associated with SC, such as temporal bone sclerosis, extension of the lesion through joint capsule to surrounding structures, intracranial extension of the lesion as the images are obtained in multiple planes. On both conventional X-ray and CT, findings associated with SC may include widening of joint space, irregularity of the articular surface, presence of loose calcified nodules, sclerosis of the glenoid fossa, and mandibular condyle.[7],[8] MRI may show distension of lateral capsule of the joint and presence of fluid in the joint. T2-weighted MR images may show the fluid accumulation by way of intense bright signal from the area of the lesion with embedded areas of void signal representing calcified parts of cartilage.[7],[8],[9] There are so many lesions that show loose bodies in the joint [Table 1]. The treatment options for SC are surgery and arthroscopy. Arthroscopy is a less invasive technique, but it is difficult to retrieve the intraarticular loose bodies using arthroscopy.[10] Surgery includes removal of calcifications followed by total or subtotal synovectomy.
Table 1: Radiographic differential diagnosis of loose bodies in temporomandibular joint space

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   Conclusion Top


Any patient reporting with preauricular swelling, pain, and restricted mandibular movements should be thoroughly evaluated. CT is particularly a preferable modality for the diagnosis of SC, as hard tissues, such as calcified cartilaginous bodies, are easily identified and also allow customization of specific protocols to visualize bone or soft tissue.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Lustmann J, Zeltser R. Synovial chondromatosis of the temporomandibular joint. Review of the literature and case report. Int J Oral Maxillofac Surg 1989;18:90-4.  Back to cited text no. 1
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2.
Reddy PK, Vannemreddy PS, Gonzalez E, Nanda A. Synovial chondromatosis of the temporomandibular joint with intracranial extension. J Clin Neurosci 2000;7:332-4.  Back to cited text no. 2
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3.
Hammodeh N, Nasser NA. Synovial chondromatosis of the temporomandibular joint, presenting as parotid mass. J Laryngol Otol 2006;120:1-3.  Back to cited text no. 3
    
4.
Axhausen G. Arthritis deformans of the temporomandibular joint. Dtsch Zahnarztl Z 1954;9:852-9.  Back to cited text no. 4
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5.
McCaffery C, Dodd M, Bekiroglu F, Twohig E. Synovial chondromatosis of the temporomandibular joint with extension into the middle cranial fossa and internal carotid canal. Int J Oral Maxillofac Surg 2017;46:867-70.  Back to cited text no. 5
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Jeyaraj PE, Sharma V. Synovial osteochondromatosis of the temporomandibular joint manifesting as a large infratemporal space occupying lesion. J Maxillofac Oral Surg 2017;16:387-91.  Back to cited text no. 6
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7.
Peyrot H, Montoriol PF, Beziat JL, Barthelemy I. Synovial chondromatosis of the temporomandibular joint: CT and MRI findings. Diagn Interv Imaging 2014;95:613-4.  Back to cited text no. 7
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8.
Varol A, Sencimen M, Gulses A, Altug HA, Dumlu A, Kurt B. Diagnostic importance of MRI and CT scans for synovial osteochondromatosis of the temporomandibular joint. Cranio 2011;29:313-7.  Back to cited text no. 8
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Chen MJ, Yang C, Qiu YT, Jiang Q, Shi HM, Wei WB. Synovial chondromatosis of the temporomandibular joint: Relationship between MRI information and potential aggressive behavior. J Craniomaxillofac Surg 2015;43:349-54.  Back to cited text no. 9
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Lim SW, Jeon SJ, Choi SS, Choi KH. Synovial chondromatosis in the temporomandibular joint: A case with typical imaging features and pathological findings. Br J Radiol 2011;84:e213-6.  Back to cited text no. 10
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
    Tables

  [Table 1]


This article has been cited by
1 Synovial chondromatosis of the temporomandibular joint: a case report
O Barraclough, G Wilson, A Power
The Annals of The Royal College of Surgeons of England. 2020; 102(8): e213
[Pubmed] | [DOI]



 

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