Middle cerebral artery aneurysm misdiagnosed as a temporomandibular disorder: Report of a case

1 Oral Maxillofac 56: 1346-l 349,

Surg 1998

Middle Cerebral Artery Aneurysm Misdiagnosed as a Temporomandibular Disorder: Report of a Case David

B. Powers, DMD, * and John

patient’s

of synovitis

improved

to the

& Maxillofacial

Surgery,

Wilford

Hall

history showed four one

rare alcohol

cups of coffee to two packs

point

numerous

rent episodes of sinusitis and otitis media. history was signiiicant only for a vasectomy.

of Case

Oral

symptoms

he was pain free. Review of the medical history showed

A 34-year-old man was referred for evaluation in November 1995 with a complaint of headache in the left temporal region for approximately 4 months. The headaches began suddenly with a throbbing pain in the retro-orbital region and were constant in nature for approximately 3 weeks. At the initial examination, the headaches were no longer continuous, but did increase during the day and were aggravated by head movement. Mild phonophobia and photophobia were associated with the headaches, and progression of the pain during the day sometimes lead to nausea. No aura was involved with development of the headache. The patient had been referred for treatment of his “TMJ,” which the referring physician believed was the cause of his headache. The patient was well known to the dental service because he had been evaluated approximately 12 months earlier, 8 months before initiation of the headache, with a chief complaint of a popping left TMJ. At that time the patient reported that the clicking had been present for many years, but was progressively getting louder. The patient had no evidence of osseous changes on the radiographs, could open in excess of 45 mm, and did not have crepitus on function. Sensitivity was confined to the area of the left TMJ. A diagnosis of anterior displacement of the left intraarticular disc with reduction and synovitis was made. The patient was prescribed 500 mg naproxen sodium (Naprosyn; Syntex,

*Resident,

DMDf

Boulder, CO) twice daily for 45 days, with additional recommendations to use warm compresses on the preaurlcular area and eat a soft diet. Surgical intervention was not indicated at that time, and on subsequent follow-up the

We report the case of a middle cerebral artery (MCA) aneurysm detected in a patient with known temporomandibular joint dysfunction and headache, which the referring physician believed was related to his temporomandibular joint (TMJ) problem.

Report

W Morrison,

that

recur-

The surgical The social

use, consumption

of three to

daily, and a positive smoking history of of cigarettes daily for 15 years. Cranial

nerves II through XII were grossly intact, and there was good muscle tone, bulk, and strength. The patient was currently amine

taking

guaifenesin

400

mg

and

phenylpropanol-

HC175 mg (Entex IA; Procter & Gamble, Cincinnati, OH) twice daily, and ketorolac tromethanine 10 mg (Toradol; Syntex) three times daily. Toradol was the only medication that relieved his headache. He had previously failed trials

of sumatriptan

succinate

(Imitrex;

Cerenex,

Triangle Park, NC), seratraline HCl (Zoloft; York, NY), and nortriptylene HCl (Pamelor; Hanover,

NJ). His serum

chemistry

was within

Research

Roerig, New Sandoz, East normal

limits.

The patient had been evaluated by optometry and found to have 20/20 vision. A computed tomography scan of his head showed the presence of thickened maxillary sinus

Medical

Center, Lackland AFB, TX. tDirector, Department of Oral & Maxillofacial Surgery; David Grant Medical Center, Travis AFB, CA formerly: Chairman, Department of OMS, Keesler Medical Center, Keesler APB, MS. The views expressed not necessarily reflect

in this article are those of the authors and do the official policy of the Department of

Defense, the United States Air Force, the United States Government.

or any other

Departments

of

Address correspondence and reprint requests to Dr Powen: Wilford Hall Medical Center, 59 Medical Wing/MRDO, 2200 Bergquist Dr, Suite 1, Lackland AFB, TX 782365300. This is a US government work. There are no restrictions on its use.

FIGURE

0278.2391/98/5611-0016$0.00/0

able

1346

1. Magnetic

aneurysm

resonance in left temporal lobe

imaging (arrow]

(MRI)

scan

showing

prob-

FIGU IRE 2.

Magnetic

resonance

FIGURE 3.

angiography

Conventional

(MRA)

anglogram

scan

showing

showing

presence

the left middle

of left middle

cerebral

artery

cerebral

aneurysm

artery

aneurysm

[arrow).

(arrow).

1348

MIDDLE CEREBRAL ARTERY ANEURYSM

FIGURE 4. Postoperative gram confirming elimination aneurysm. Arrow indicates eurysmal clip.

epithelium, which was being treated with Entex LA. Numerous physical therapy appointments and medical regimens failed to control his headaches. The patient had also been evaluated by a neurologist, who believed his headaches were related to temporomandibular dysfunction (TMD). The patient’s examination was not consistent with TMD or recurrence of synovitis; however, he still complained of an audible click in his left TMJ. The clinical symptoms did not correlate with headache associated with TMD. The patient’s maximum mandibular opening was 43 mm, and there was no evidence of osseous changes in the mandibular condyle or articular fossa on the radiographs. The patient was referred for evaluation by the Keesler AFB Temporomandibular Dysfunction Board. This board is composed of representatives from Oral & Maxillofacial Surgery, General Dentistry, Orthodontics, Physical Therapy, and Neurology. At the recommendation of the board, a magnetic resonance imaging study of the brain was

Onset Frequency Severity Associated symptoms Precipitating factors Relationship to occupation Seasonal relationship Surgical history Allergy Previous medications Data from Diamond

and Dalessio.*

Location Duration Warning signs Sleep habits Emotional factors Family history Medical history Systems review Previous tests for headaches Current medications

angioof the the an-

accomplished (Fig 1). This study showed a suspicious lesion in the left temporal aspect of the brain. Magnetic resonance angiography was performed, which showed a left MC4 aneurysm (Fig 2) which measured 1.0 X 1.5 cm with conventional angiography (Fig 3). Neurosurgery was consulted, and the patient was brought to the operating room in February 1996 for ligation of the left MC4 aneurysm. The operation was successfully accomplished by placing an aneurysm clip and verifying lack of blood flow to the aneurysm. Postoperative angiography confirmed elimination of the lesion (Fig 4). The patient was observed closely after surgery and was noted to have no neurologic deficits. His headache was completely resolved at the Gmonth and l-year follow-up appointments.

Discussion MCA aneurysms account for approximately 20% of all intracranial aneurysms. l MCA aneurysms can generally reach dimensions much larger than aneurysms in other locations without development of symptoms because of the lack of encroachment on vital structures.2 Unt-uptured MCA aneurysms are usually asymptomatic, although, as the lesions grow larger, clinical manifestations such as temporal lobe seizures and transient ischemic attacks due to intraaneurysmal thrombosis and embolism have been reported.2 Certain clinical symptoms suggest a middle cerebral source of aneurysm/bleeding: unilateral temporal region headache, focal neurologic deficits including

1349

SAN0 ET AL

aphagia, and weakness of the contralateral arm or facial hemisphere. Rupture of an MCA aneurysm usually results in symptoms indistinguishable from those associated with subarachnoid hemorrhage due to aneurysmal bleeding from any other location. Several characteristics described by Hiiijk and NorlCn favor the diagnosis of MCA aneurysm.3 Approximately 60% of patients with MCA aneurysm lose consciousnessat the onset of hemorrhage. Roughly 33% of cases with ruptured MCA aneurysm have a unilateral headache, almost always on the side of the aneurysm. Finally, more than 80% of patients with ruptured MCA aneurysm have focal neurologic deficits when first seen. When an awake patient is first seen with severe hemiparesis, the most common source of the bleed is the MCA. Familiarity with the symptoms associatedwith typical headache patterns, vascular disease, myofascial pain and dysfunction, and internal derangement of the TMJ are absolutely essentialwhen evaluating patients

for complaints of headache/TMJ pain. When confronted with identifying the source of headache, a logical history should be taken to help isolate factors that can lead to the correct diagnosis (Table 1). This case shows an example in which close cooperation and good communication between multiple dental/ medical specialties avoided a potentially catastrophic outcome for the patient.

References Youmans JR: Neurological Surgery: A Comprehensive Reference Guide to the Diagnosis and Management of Neurosurgical Problems (ed 4). Philadelphia, PA, Saunders, 1996, p 1292 Wilkins RH, Rengachary SS: Neurosurgery (ed 2). New York, NY, McGraw-Hill, 1996,p 2311 Hc8k 0, NorlCn G: Aneurysms of the middle cerebral artery. Acta Chir Stand 231:1, 1958 (suppl) Diamond S, Dalessio DJ: The Practicing Physician’s Approach to Headache (ed 5). Baltimore, MD, Williams & Wins, 1992, p 11-24

J Oral Maxillofac Surg 56.1349-l 352, 1998

Preauricular Mass Presenting as a Sign of Osteomyelitis of the Temporal Bone Kazuo Sano, DDS, PbD, * Hiroshi Asoh, DDS, f Shin-ichi Yoshida, DDS,f and Tsugio Inokuchi, DDS, PhDJ Osteomyelitis of the temporal bone is a rare disease that generally occurs secondary to malignant external otitis’ or chronic suppurative otitis media.* Furukawa et al3 reported a rare case of osteomyelitis of the temporal bone associated with a focal tonsillar infection. The current report describes a caseof osteomyelitis of the temporal bone secondary to external otitis in which an extracapsular tumor of the temporomandibular joint was originally suspected from the findings on computed tomography (CT) and magnetic resonance imaging (MRI).

Received

from

Surgery,

Nagasaki

*Associate tFormer *Assistant

Department

Assistant

School

of Oral

of Dentistry,

and Maxillofacial Nagasaki,

Japan.

Professor.

Professor. and Chairman. correspondence

and reprint

of Oral and Maxillofacial

School

of Dentistry,

0 1998

Amerlcon

0278.2391,‘98,‘561

Department

University

Professor.

§Professor Address

the Second

1-7-1 Sakamoto,

Association

requests Surgery, Nagasaki

of Oral and Maxillofacial

10017$300/O

to Dr Sano: Second Nagasaki 852-8588, Surgeons

University Japan.

Report of Case A 67-year-oldmanwas referred to the Second Department of Oral and Maxillofacial Surgery, Nagasaki University School of Dentistry, complaining of a tender right-sided preauricular swelling (Fig 1). His medical history included gastric and colon cancer. Two months before examination, the patient took antibiotics for a week after right external otitis was diagnosed by an otolaryngologist. The symptoms of external otitis disappeared after medication, but the preauricular swelling and tenderness remained. On examination, a tender 25 X 15 X s-mm hemispherical, soft swelling was observed. The overlying skin showed no redness, and there was no fluctuation. Trismus was not observed. Radiographic examination showed sclerosis of the right glenoid fossa and zygomatic process of the temporal bone (Fig 2). Hematologic studies and serum chemistry were within normal limits. Technetium-99m (99mTc) scintigraphy showed high accumulation in the right temporal region (Fig 3, but gallium-67 (“Ga) showed no accumulation. The CT scan showed increaseddensity of the right temporal bone, a high-density structure resembling a periosteal reaction on the lateral surface of the right temporal bone, and partial resorption of the right glenoid fossa. It also showed a round, soft tissue density on the lateral aspect of the right condyle (Fig 4). MRI showed a linear, high-intensity signal on the lateral aspect of the right temporal bone. The right temporal bone showed low signal intensity compared with the left temporal bone, suggesting sclerosis of the right