- Email: [email protected]
Myositis ossificans traumatica of the temporal muscle: a case report
Auris Nasus Larynx 28 (2001) 345– 347 www.elsevier.com/locate/anl
Myositis ossificans traumatica of the temporal muscle: a case report E. Mevio a,*, L. Rizzi a, G. Bernasconi b a
Department of Otorhinolaryngology, IRCCS Policlinico San Matteo, Uni6ersity of Pa6ia, Italy b Department of Oral Surgery IRCCS Policlinico San Matteo, Uni6ersity of Pa6ia, Italy
Received 9 November 2000; received in revised form 6 January 2001; accepted 19 January 2001
Abstract Myositis ossificans traumatica (MOT) is a pathological condition characterized by extraskeletal formation of bony tissue, induced by violent or repeated trauma. Reports of this pathology occurring in the region of the head and neck are rare, and even more so in the muscles of mastication. We present the case of patient with MOT of the temporal muscle, the etiology of which seems to be related to traumatic manipulations during dental treatment. A review of the literature is presented and the surgical approach, which resolved this case is discussed. © 2001 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Myositis ossificans traumatica; Temporal muscle
1. Introduction Myositis ossificans is a relatively rare disease characterized by the formation of mature bone in extraskeletal sites. Two distinct anatomo-clinical forms of the disease are distinguished in the following paras. Progressive myositis ossificans or Munchmeyer’s disease is a hereditary form with autosomal dominant transmission. It causes symptoms from early infancy and involves several muscles. The consequent functional limitations are progressive and handicapping. Normally there are associated skeletal malformations, disorders of sexual development and deafness [1,2]. Myositis ossificans traumatica (MOT) is a more circumscribed form, which involves single muscles or muscle groups subjected to violent or repeated trauma. There are many theories on the pathogenesis of MOT and little agreement between the opinions on the exact mechanism involved. According to various authors, the cause of the bone formation within muscle has been attributed to metaplasia of connective tissues cells, os* Corresponding author. Present address: Via Gravellone 37, 27100 Pavia, Italy, Tel.: +39-382-302525. E-mail address: [email protected] (E. Mevio).
sification of a haematoma, or penetration of fragments of periosteum with osteogenic cells into the muscle.
2. Case report In November 1999, a 55 year old lady, KL, was referred to us with considerable trismus; the maximum distance between the edges of the medial incisors was only 6 mm and no movement of the mandible was possible. The patient associated the onset of her symptoms to 18 months earlier when she underwent a series of dental operations with multiple extractions and fitting of dental prostheses. The early trismus was attributed to inflammation and after-effects of the extractions. Subsequently the limited mouth opening became increasingly pronounced and neither medical therapy nor physiotherapy was of any help. Within 2 months, the situation had evolved into the total block of mandibular movements, which we objectively recorded when we first saw the patient (Fig. 1a). Three-dimensional computerized axial tomography showed an area of ossification within the right temporal muscle at the anterior margin, on the internal surface of the muscle belly (Fig. 2). Having made the diagnosis of myositis ossificans traumatica, the management decided on surgery.
0385-8146/01/$ - see front matter © 2001 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 3 8 5 - 8 1 4 6 ( 0 1 ) 0 0 0 5 9 - 1
346
E. Me6io et al. / Auris Nasus Larynx 28 (2001) 345–347
tion was maintained for 3 days using rubber separators. Subsequently the separators were positioned for only a few hours a day and at night in order to allow increasingly long periods of greater comfort and a normal diet. Within 8 days, correct mouth opening had been achieved (Fig. 1b). The patient was then prescribed a cycle of physiotherapy. Radiographic follow-up after 2 months and a clinical examination after 6 months confirmed that the result obtained had been maintained.
3. Discussion
Fig. 1. a) Image at admission. The tight trismus caused by the blocked right temporal muscle is clearly evident, b) The same patient 7 days post-operatively with correct mouth opening.
A right hemicoronal approach was taken using transzygomatic access. Once the coronoid process had been sectioned and removed, it was possible to palpate the bony rope-like neoformation within the temporal muscle. This was resected and removed. It was then possible to force the mouth open and this posi-
MOT in the muscles of mastication is rare; indeed only 22 cases were found in a recent review of the literature [3]. The muscles most frequently affected are the masseters, accounting for two-thirds of cases, and the lateral and medial pterygoid muscles [8]. Reports of the temporal muscle being involved, as in our patient, are extremely rare [4–7]. Dental extractions, local infiltrations of anesthetics, badly performed orthodontic treatment, and orthopedic treatment consequent to cervical trauma are among the possible causes mentioned [6,9–12]. Strains or lacerations of muscle fibers or blood extravasation seem to underlie the tissue alterations, which facilitate the development of osseous metaplasia. In itself, the pathology is benign and self-limiting. However, the degree of disability it causes in the patient is often substantial, as in our patient, and thus once the diagnosis has been established, we believe that early removal of the lesion is the best management. Surgical resection is presently the most appropriate therapeutic strategy. The patient should also be advised to avoid other trauma to the muscle region involved, since recurrence is possible.
Fig. 2. Preoperative CT images. CT sagittal section (left) and 3D CT scan (right) of the ossified lesion (arrows) in the antero-interior part of the right temporal muscle.
E. Me6io et al. / Auris Nasus Larynx 28 (2001) 345–347
References [7] [1] Kaplan FS, McCluskey W, Hahn G, Tabas JA, Muenke M. Genetic transmission of fibrodysplasia ossificans progressiva. Report of a family. J Bone Joint Surg Am 1993;75:1214 – 20. [2] Cushner FD, Morwessel RM. Myositis ossificans in children. Orthopade 1995;18:287 –91. [3] Takahashi K, Sato K. Myositis ossificans traumatica of the medial pterygoid muscle. J Oral Maxillofac Surg 1999;57:451 – 6. [4] Shawkat AH. Myositis ossificans:report of a case. Oral Surg 1967;23:615 – 7. [5] Chomette G, Goudot P, Auriol M. Myosite ossifiante circoscrite faciale. Rev Stomatol Chir Maxillfac 1989;90:1 – 6. [6] Salgarelli A, Magnato R, Carminati R, Barbaglio A, Nocini PF. Miosite ossificante dei muscoli pterigoidei e temporale con inter-
[8] [9] [10] [11]
[12]
347
essamento metacrono controlaterale. Minerva Stomatol 1997;46:259 – 65. El Labban NG, Hopper C, Barber P. Ultrastructural finding of vascular degeneration in fibrodysplasia ossificans progressiva (FOP). J Oral Pathol Med 1995;24:125 – 9. Narang R, Dixon RA. Myositis ossificans: medial pterygoid muscle. A case report. Br J Oral Surg 1974;12:229. Mulherin D, Schow CE. Traumatic myositis ossificans after genioplasty. J Oral Surg 1980;38:786 – 8. Cushner FD, Morwessel RM. Myositis ossificans traumatica. Orthop Rev 1992;21:1319. Parkash H, Goyal M. Myositis ossificans of medial pterygoid muscle. A cause for temporo-mandibular joint ankylosis. Oral Surg Oral Med Oral Pathol 1992;73:27 – 8. Tong KA, Christiansen EL, Heisler W, Hinshaw DB, Hasso AN. Asymptomatic myositis ossificans of the medial pterygoid muscles. A case report. J Orofac Pain 1994;8:223 – 6.
Myositis ossificans traumatica of the temporal muscle: a case report E. Mevio a,*, L. Rizzi a, G. Bernasconi b a
Department of Otorhinolaryngology, IRCCS Policlinico San Matteo, Uni6ersity of Pa6ia, Italy b Department of Oral Surgery IRCCS Policlinico San Matteo, Uni6ersity of Pa6ia, Italy
Received 9 November 2000; received in revised form 6 January 2001; accepted 19 January 2001
Abstract Myositis ossificans traumatica (MOT) is a pathological condition characterized by extraskeletal formation of bony tissue, induced by violent or repeated trauma. Reports of this pathology occurring in the region of the head and neck are rare, and even more so in the muscles of mastication. We present the case of patient with MOT of the temporal muscle, the etiology of which seems to be related to traumatic manipulations during dental treatment. A review of the literature is presented and the surgical approach, which resolved this case is discussed. © 2001 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Myositis ossificans traumatica; Temporal muscle
1. Introduction Myositis ossificans is a relatively rare disease characterized by the formation of mature bone in extraskeletal sites. Two distinct anatomo-clinical forms of the disease are distinguished in the following paras. Progressive myositis ossificans or Munchmeyer’s disease is a hereditary form with autosomal dominant transmission. It causes symptoms from early infancy and involves several muscles. The consequent functional limitations are progressive and handicapping. Normally there are associated skeletal malformations, disorders of sexual development and deafness [1,2]. Myositis ossificans traumatica (MOT) is a more circumscribed form, which involves single muscles or muscle groups subjected to violent or repeated trauma. There are many theories on the pathogenesis of MOT and little agreement between the opinions on the exact mechanism involved. According to various authors, the cause of the bone formation within muscle has been attributed to metaplasia of connective tissues cells, os* Corresponding author. Present address: Via Gravellone 37, 27100 Pavia, Italy, Tel.: +39-382-302525. E-mail address: [email protected] (E. Mevio).
sification of a haematoma, or penetration of fragments of periosteum with osteogenic cells into the muscle.
2. Case report In November 1999, a 55 year old lady, KL, was referred to us with considerable trismus; the maximum distance between the edges of the medial incisors was only 6 mm and no movement of the mandible was possible. The patient associated the onset of her symptoms to 18 months earlier when she underwent a series of dental operations with multiple extractions and fitting of dental prostheses. The early trismus was attributed to inflammation and after-effects of the extractions. Subsequently the limited mouth opening became increasingly pronounced and neither medical therapy nor physiotherapy was of any help. Within 2 months, the situation had evolved into the total block of mandibular movements, which we objectively recorded when we first saw the patient (Fig. 1a). Three-dimensional computerized axial tomography showed an area of ossification within the right temporal muscle at the anterior margin, on the internal surface of the muscle belly (Fig. 2). Having made the diagnosis of myositis ossificans traumatica, the management decided on surgery.
0385-8146/01/$ - see front matter © 2001 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 3 8 5 - 8 1 4 6 ( 0 1 ) 0 0 0 5 9 - 1
346
E. Me6io et al. / Auris Nasus Larynx 28 (2001) 345–347
tion was maintained for 3 days using rubber separators. Subsequently the separators were positioned for only a few hours a day and at night in order to allow increasingly long periods of greater comfort and a normal diet. Within 8 days, correct mouth opening had been achieved (Fig. 1b). The patient was then prescribed a cycle of physiotherapy. Radiographic follow-up after 2 months and a clinical examination after 6 months confirmed that the result obtained had been maintained.
3. Discussion
Fig. 1. a) Image at admission. The tight trismus caused by the blocked right temporal muscle is clearly evident, b) The same patient 7 days post-operatively with correct mouth opening.
A right hemicoronal approach was taken using transzygomatic access. Once the coronoid process had been sectioned and removed, it was possible to palpate the bony rope-like neoformation within the temporal muscle. This was resected and removed. It was then possible to force the mouth open and this posi-
MOT in the muscles of mastication is rare; indeed only 22 cases were found in a recent review of the literature [3]. The muscles most frequently affected are the masseters, accounting for two-thirds of cases, and the lateral and medial pterygoid muscles [8]. Reports of the temporal muscle being involved, as in our patient, are extremely rare [4–7]. Dental extractions, local infiltrations of anesthetics, badly performed orthodontic treatment, and orthopedic treatment consequent to cervical trauma are among the possible causes mentioned [6,9–12]. Strains or lacerations of muscle fibers or blood extravasation seem to underlie the tissue alterations, which facilitate the development of osseous metaplasia. In itself, the pathology is benign and self-limiting. However, the degree of disability it causes in the patient is often substantial, as in our patient, and thus once the diagnosis has been established, we believe that early removal of the lesion is the best management. Surgical resection is presently the most appropriate therapeutic strategy. The patient should also be advised to avoid other trauma to the muscle region involved, since recurrence is possible.
Fig. 2. Preoperative CT images. CT sagittal section (left) and 3D CT scan (right) of the ossified lesion (arrows) in the antero-interior part of the right temporal muscle.
E. Me6io et al. / Auris Nasus Larynx 28 (2001) 345–347
References [7] [1] Kaplan FS, McCluskey W, Hahn G, Tabas JA, Muenke M. Genetic transmission of fibrodysplasia ossificans progressiva. Report of a family. J Bone Joint Surg Am 1993;75:1214 – 20. [2] Cushner FD, Morwessel RM. Myositis ossificans in children. Orthopade 1995;18:287 –91. [3] Takahashi K, Sato K. Myositis ossificans traumatica of the medial pterygoid muscle. J Oral Maxillofac Surg 1999;57:451 – 6. [4] Shawkat AH. Myositis ossificans:report of a case. Oral Surg 1967;23:615 – 7. [5] Chomette G, Goudot P, Auriol M. Myosite ossifiante circoscrite faciale. Rev Stomatol Chir Maxillfac 1989;90:1 – 6. [6] Salgarelli A, Magnato R, Carminati R, Barbaglio A, Nocini PF. Miosite ossificante dei muscoli pterigoidei e temporale con inter-
[8] [9] [10] [11]
[12]
347
essamento metacrono controlaterale. Minerva Stomatol 1997;46:259 – 65. El Labban NG, Hopper C, Barber P. Ultrastructural finding of vascular degeneration in fibrodysplasia ossificans progressiva (FOP). J Oral Pathol Med 1995;24:125 – 9. Narang R, Dixon RA. Myositis ossificans: medial pterygoid muscle. A case report. Br J Oral Surg 1974;12:229. Mulherin D, Schow CE. Traumatic myositis ossificans after genioplasty. J Oral Surg 1980;38:786 – 8. Cushner FD, Morwessel RM. Myositis ossificans traumatica. Orthop Rev 1992;21:1319. Parkash H, Goyal M. Myositis ossificans of medial pterygoid muscle. A cause for temporo-mandibular joint ankylosis. Oral Surg Oral Med Oral Pathol 1992;73:27 – 8. Tong KA, Christiansen EL, Heisler W, Hinshaw DB, Hasso AN. Asymptomatic myositis ossificans of the medial pterygoid muscles. A case report. J Orofac Pain 1994;8:223 – 6.