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Ganglion of the temporomandibular joint. Case report and literature survey
British Journal of Oral and Maxillofacial Surgery (1989) 27, 67-70 0 1989 The British Association of Oral and Maxillofacial Surgeons
0266-4356X439/0027-0067/$10.00
GANGLION OF THE TEMPOROMANDIBULAR JOINT. CASE REPORT AND LITERATURE SURVEY M. A. K.
EL-MASSRY,
B. Department
of
M.
W.
Ph.D.,
M.s.,
BAILEY,
M.B.,
F.D.s.,
B.ch.,
B.D.S.
and
F.R.C.S.
Queen Mary’s University Maxillofacial Surgery, Roehampton Lane, London, SW15 SPN
Hospital,
Summary. A case report of a female patient presenting with a painless lump related to the right temporomandibular joint is described. The swelling was surgically excised and the histopathoiogical examination of the specimen showed a very clear resemblance to a ganglion of the synovial membrane. The literature of this rare entity is reviewed.
Introduction A ganglion is a cystic lesion that develops from a synovial membrane. It is filled with viscid fluid and is lined by fibrous or synovial tissue. Often areas of myxomatous degeneration are present in the surrounding tissue (Pitcock, 1971). The three principal sites for a ganglion are the back of the wrist, the dorsum of the foot and the outer aspect of the knee. Of these, the wrist is by far the commonest position (Anderson, 1967). Case report A 33-year-old married woman was referred by her general dental practitioner regarding a painless lump related to the right condylar region. The patient first noticed the lump 6 months before presentation. Generally the patient was perfectly well and healthy. Local examination of the right temporomandibular joint revealed a lump, 1 cm in diameter, soft and freely mobile which moved with the condyle. There was neither limitation of jaw opening nor occlusal abnormalities. Radiographic examination of the right temporomandibular joint did not indicate any pathology related to the condyle and the size of the right temporomandibular joint space was within the normal range and comparable with the left side. Under endotracheal anaesthesia, the right temporomandibular joint was explored via a preauricular approach. After incising the temporal fascia 1 cm above and behind the zygomatic arch, the fascia was elevated off the zygomatic arch together with the periosteum as one layer, thus protecting the temporal branch of the facial nerve. On the lateral aspect of the temporomandibular capsule, there was a 1 cm cystic yellowish swelling (Fig. 1) which tias dissected carefully from the capsule and completely excised, preserving its integrity. Further exploration of the right temporomandibular joint did not reveal any pathological abnormality. After careful haemostasis, the wound was closed in layers, without drainage, and a pressure bandage applied for 48 h. The wound healed with primary intention and the patient made an uneventful recovery. (Received
24 September 1987; accepted 30 November
67
1987)
68
BRITISH
JOURNAL
OF ORAL
& MAXILLOFACIAL
SURGERY
Fig. I Figure l-Showing
the ganglion below the zygomatic arch.
After excision, the cyst was cut in half and found to contain a clear gelatinous material. Microscopic examination of the lesion showed a cyst lined by fibrous tissue, the appearance of which resembled those of a ganglion (Figs. 2 & 3). The histopathology was examined by two different pathologists who both concluded that the lesion bore a very close resemblance to a ganglion of the synovial sheath. Discussion
A ganglion of the temporomandibular joint is a very rare lesion in comparison with other joints such as the wrist or the ankle joints. According to Shiba et al. (1987), only six cases have been reported. Usually a ganglion of the temporomandibular joint is asymptomatic and patients will be aware only of the presence of a lump in the preauricular region. The pathogenesis of a ganglion is still controversial. Lichtenstein (1975) considers that a ganglion develops through myxoid degeneration and cystic softening of the collagenous connective tissue of a joint capsule or tendon sheath. On the other hand, Rosai (1977) explains the pathogenesis of a ganglion as either herniation of the synovium into the surrounding tissues, displacement of synovial tissue during embryogenesis or post-traumatic degeneration of connective tissue. In our case, we think it was due to simple herniation of the synovium into the surrounding tissue through a rent in the capsule which in time completely healed and that is why there was no connection between the ganglion and synovium but it was adherent to the capsule.
GANGLION
OF THE
TEMPOROMANDIBULAR
69
JOINT
Fig. 2 Figure
2-The
cyst wall and the cyst cavity;
Figure
3-Showing
mucoid
degeneration
the lining is formed H&E).
of fibrous
(Low power
x23.5
in the walls of the ganglion. (High power x375 H&E).
(1983) emphasise the fact that the ganglion and joint space. Also these lesions are easily confused with myxomas, especially development. One of these myxomas is the juxta articular accumulation of mutinous material in the juxta articular
Enzinger and Weiss communication between
tissue.
usually
there
is no
they add that some of in the initial stage of myxoma which is an tissues.
70
BRITISH
JOURNAL
OF ORAL
& MAXILLOFACIAL
SURGERY
The diagnosis of a TMJ ganglion may present a clinical problem as it can be mistaken for a parotid tumour.. (Gaisford et al., 1969; Ethel& 1979; Janecka & Conley, 1978). Acknowledgements
The authors would like to thank Dr K. Schafler in the Department of Pathology, Queen Mary’s University Hospital, Roehampton and Dr K. W. Lee, Oral Pathologist at the Eastman Dental Institute for the histopathological reporting. We would also like to thank the Department of Medical Illustration, Queen Mary’s University Hospital for the black and white prints. References
Anderson, W. (1967). Boyd’s Pathology for the Surgeon. 8th Ed., pp. 695. Philadelphia and Lbndon: W. B. Saunders Company. Ethell, A. T. (1979). A rare ‘parotid tumour’. Journal of Laryngology and Ofology, 93, 741. Enzinger, F. M. & Weiss, S. W. (1983). Cartilagenous tumours and tumour-like lesions of soft tissues. In Soft Tissue Turnours. pp. 769-772. St.-Louis, Toronton, London: C. V. Mosby Company. Gaisford. J. C.. Hana. D. C. & Richardson. G. S. (1969). \ , Parotid fumour. Plastic and Reconstructive surgery,
4j,
504.’
Janecka, I. P. & Conley, J. J. (1978). Synovial cyst of temporomandibular joint imitating a parotid tumour. Journal of Maxillofacial Surgery, 6, 154. Lichtenstein, L. (1975). Diseases of Bone Joints. p. 222. St. Louis: C. V. Mosby Company. Pitcock, J. A. (1971). Tumours and tumour-like lesions of somatic tissues. In Campbell’s Operative Orthopaedics. 5th Ed., Vol. II, pp. 1441. St. Louis, London: C. V. Mosby Company. Rosai, J. (1977). In Anderson W. A. D., Kissane, J. M. (eds.) 7th Ed. St. Louis: C. V. Mosby Company, p. 2041. Shiba, R. Suyama, T. & Sakoda, S. (1987). Ganglion of the temporomandibular joint. Journal of Oral and Maxillofacial Surgery,
45, 618.
0266-4356X439/0027-0067/$10.00
GANGLION OF THE TEMPOROMANDIBULAR JOINT. CASE REPORT AND LITERATURE SURVEY M. A. K.
EL-MASSRY,
B. Department
of
M.
W.
Ph.D.,
M.s.,
BAILEY,
M.B.,
F.D.s.,
B.ch.,
B.D.S.
and
F.R.C.S.
Queen Mary’s University Maxillofacial Surgery, Roehampton Lane, London, SW15 SPN
Hospital,
Summary. A case report of a female patient presenting with a painless lump related to the right temporomandibular joint is described. The swelling was surgically excised and the histopathoiogical examination of the specimen showed a very clear resemblance to a ganglion of the synovial membrane. The literature of this rare entity is reviewed.
Introduction A ganglion is a cystic lesion that develops from a synovial membrane. It is filled with viscid fluid and is lined by fibrous or synovial tissue. Often areas of myxomatous degeneration are present in the surrounding tissue (Pitcock, 1971). The three principal sites for a ganglion are the back of the wrist, the dorsum of the foot and the outer aspect of the knee. Of these, the wrist is by far the commonest position (Anderson, 1967). Case report A 33-year-old married woman was referred by her general dental practitioner regarding a painless lump related to the right condylar region. The patient first noticed the lump 6 months before presentation. Generally the patient was perfectly well and healthy. Local examination of the right temporomandibular joint revealed a lump, 1 cm in diameter, soft and freely mobile which moved with the condyle. There was neither limitation of jaw opening nor occlusal abnormalities. Radiographic examination of the right temporomandibular joint did not indicate any pathology related to the condyle and the size of the right temporomandibular joint space was within the normal range and comparable with the left side. Under endotracheal anaesthesia, the right temporomandibular joint was explored via a preauricular approach. After incising the temporal fascia 1 cm above and behind the zygomatic arch, the fascia was elevated off the zygomatic arch together with the periosteum as one layer, thus protecting the temporal branch of the facial nerve. On the lateral aspect of the temporomandibular capsule, there was a 1 cm cystic yellowish swelling (Fig. 1) which tias dissected carefully from the capsule and completely excised, preserving its integrity. Further exploration of the right temporomandibular joint did not reveal any pathological abnormality. After careful haemostasis, the wound was closed in layers, without drainage, and a pressure bandage applied for 48 h. The wound healed with primary intention and the patient made an uneventful recovery. (Received
24 September 1987; accepted 30 November
67
1987)
68
BRITISH
JOURNAL
OF ORAL
& MAXILLOFACIAL
SURGERY
Fig. I Figure l-Showing
the ganglion below the zygomatic arch.
After excision, the cyst was cut in half and found to contain a clear gelatinous material. Microscopic examination of the lesion showed a cyst lined by fibrous tissue, the appearance of which resembled those of a ganglion (Figs. 2 & 3). The histopathology was examined by two different pathologists who both concluded that the lesion bore a very close resemblance to a ganglion of the synovial sheath. Discussion
A ganglion of the temporomandibular joint is a very rare lesion in comparison with other joints such as the wrist or the ankle joints. According to Shiba et al. (1987), only six cases have been reported. Usually a ganglion of the temporomandibular joint is asymptomatic and patients will be aware only of the presence of a lump in the preauricular region. The pathogenesis of a ganglion is still controversial. Lichtenstein (1975) considers that a ganglion develops through myxoid degeneration and cystic softening of the collagenous connective tissue of a joint capsule or tendon sheath. On the other hand, Rosai (1977) explains the pathogenesis of a ganglion as either herniation of the synovium into the surrounding tissues, displacement of synovial tissue during embryogenesis or post-traumatic degeneration of connective tissue. In our case, we think it was due to simple herniation of the synovium into the surrounding tissue through a rent in the capsule which in time completely healed and that is why there was no connection between the ganglion and synovium but it was adherent to the capsule.
GANGLION
OF THE
TEMPOROMANDIBULAR
69
JOINT
Fig. 2 Figure
2-The
cyst wall and the cyst cavity;
Figure
3-Showing
mucoid
degeneration
the lining is formed H&E).
of fibrous
(Low power
x23.5
in the walls of the ganglion. (High power x375 H&E).
(1983) emphasise the fact that the ganglion and joint space. Also these lesions are easily confused with myxomas, especially development. One of these myxomas is the juxta articular accumulation of mutinous material in the juxta articular
Enzinger and Weiss communication between
tissue.
usually
there
is no
they add that some of in the initial stage of myxoma which is an tissues.
70
BRITISH
JOURNAL
OF ORAL
& MAXILLOFACIAL
SURGERY
The diagnosis of a TMJ ganglion may present a clinical problem as it can be mistaken for a parotid tumour.. (Gaisford et al., 1969; Ethel& 1979; Janecka & Conley, 1978). Acknowledgements
The authors would like to thank Dr K. Schafler in the Department of Pathology, Queen Mary’s University Hospital, Roehampton and Dr K. W. Lee, Oral Pathologist at the Eastman Dental Institute for the histopathological reporting. We would also like to thank the Department of Medical Illustration, Queen Mary’s University Hospital for the black and white prints. References
Anderson, W. (1967). Boyd’s Pathology for the Surgeon. 8th Ed., pp. 695. Philadelphia and Lbndon: W. B. Saunders Company. Ethell, A. T. (1979). A rare ‘parotid tumour’. Journal of Laryngology and Ofology, 93, 741. Enzinger, F. M. & Weiss, S. W. (1983). Cartilagenous tumours and tumour-like lesions of soft tissues. In Soft Tissue Turnours. pp. 769-772. St.-Louis, Toronton, London: C. V. Mosby Company. Gaisford. J. C.. Hana. D. C. & Richardson. G. S. (1969). \ , Parotid fumour. Plastic and Reconstructive surgery,
4j,
504.’
Janecka, I. P. & Conley, J. J. (1978). Synovial cyst of temporomandibular joint imitating a parotid tumour. Journal of Maxillofacial Surgery, 6, 154. Lichtenstein, L. (1975). Diseases of Bone Joints. p. 222. St. Louis: C. V. Mosby Company. Pitcock, J. A. (1971). Tumours and tumour-like lesions of somatic tissues. In Campbell’s Operative Orthopaedics. 5th Ed., Vol. II, pp. 1441. St. Louis, London: C. V. Mosby Company. Rosai, J. (1977). In Anderson W. A. D., Kissane, J. M. (eds.) 7th Ed. St. Louis: C. V. Mosby Company, p. 2041. Shiba, R. Suyama, T. & Sakoda, S. (1987). Ganglion of the temporomandibular joint. Journal of Oral and Maxillofacial Surgery,
45, 618.