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Synovial chondromatosis of the temporomandibular joint: CT and MRI findings
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ARTICLE IN PRESS
Diagnostic and Interventional Imaging (2014) xxx, xxx—xxx
LETTER / ENT Synovial chondromatosis of the temporomandibular joint: CT and MRI findings Keywords: Synovial chondromatosis; Temporomandibular joint; CT; MRI Case report A 42-year-old woman without any relevant medical history presented with a chronic left pre-auricular pain and sensation of crepitation within the temporomandibular joint. At physical examination, a mild swelling of the left retroauricular area was noted, together with a limited opening of the mouth. There was no temperature; the rest of the examination did not reveal any abnormality. The standard biological tests were normal. Panoramic radiograph was then performed and considered normal. No calcifications were seen peripheral to the left TMJ. Subsequently, craniofacial computed tomography (Fig. 1) was performed and revealed a soft tissue mass containing thin calcifications located anterior to the left mandibular condyle. Well-delineated bone erosion of the temporal bone was also demonstrated. At this stage, given these imaging findings, a diagnosis of chondromatosis of the left TMJ was suspected. Magnetic resonance imaging (Fig. 2) was finally performed prior to surgical management. Loose bodies within the joint together associated with effusion could be displayed. Thickening and intense enhancement of the synovial membrane were also shown. Open surgery was decided and numerous, whitish, cartilaginous bodies could be removed from the articular space. Pathologic examination of the surgical specimen confirmed the diagnosis of synovial chondromatosis without any sign of malignancy. Discussion Synovial chondromatosis (SC) is characterised by synovial metaplasia with proliferation of cartilaginous nodules originating from the synovial membrane [1]. It usually affects large joints, mostly the knee, hip and elbow. The TMJ is rarely affected, with about 100 cases reported in literature [2]. Cartilaginous nodules may become pedonculated and detach from the synovial membrane, thus forming ‘‘loose
bodies’’ within the joint [2]. These loose bodies sometimes calcify and become visible on CT examination. The disease is usually limited to the upper compartment of the joint space, but occasionally, as illustrated in our case, erosion of the underlying bone or joint capsule with invasion of the periarticular area can be seen [3]. Women are more likely to be affected than men with a sex ratio of 1.6:1 in the age range between 40 and 50 years [2]. The clinical symptoms in this disease are non-specific and include pre-auricular pain, swelling, limited mouthopening and crepitation of the TMJ. Based on histological findings, three stages are described according to Milgram [4]: • active intrasynovial diseases with no loose bodies; • transitional lesions with both active intrasynovial proliferation and loose bodies; • multiple free osteochondral bodies with no demonstrable intrasynovial disease.
The diagnosis of synovial chondromatosis of the TMJ is usually made using several imaging modalities. Plain Xrays is often the first imaging technique performed in the exploration of TMJ disorders but may be normal if the cartilaginous nodules are not calcified. Widening of the joint space and irregularity of the joint surfaces may be displayed [5]. CT is far more reliable than conventional radiographs in detecting the disease and determining its prognosis; soft tissue swelling, calcified bodies and bony erosions can easily be identified [5]. MRI has dramatically improved the capabilities in the diagnosis of this condition. MRI features [6] mainly include joint effusion, which is best depicted on T2-weighted sequences, loose bodies within the joint space, proliferative synovium, expanded joint capsule, anterior displacement of the mandibular condyle and intracranial involvement. Thanks to its high contrast resolution, extension of the disease into neighbouring structures is best appreciated using this modality. In aggressive cases with extra-articular extension, especially if the skull base is involved, open surgery is the therapeutic modality of choice. In cases with only intracapsular loose bodies, arthroscopy could be a less invasive method to clean out nodules and release symptoms [4]. Careful follow-up evaluation is mandatory and is often made using CT and/or MRI.
2211-5684/$ — see front matter © 2013 Éditions franc ¸aises de radiologie. Published by Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.diii.2013.12.002
Please cite this article in press as: Peyrot H, et al. Synovial chondromatosis of the temporomandibular joint: CT and MRI findings. Diagnostic and Interventional Imaging (2014), http://dx.doi.org/10.1016/j.diii.2013.12.002
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ARTICLE IN PRESS
2
Letter
Figure 1. Axial CT image (a) shows a calcified soft tissue mass (white arrow) developed peripheral to the left TMJ. Sagittal-oblique CT image (b) demonstrates extra-articular involvement with regular erosion of the supracondylar bone (white arrow).
Figure 2. Coronal T2-weighted image (a) displays both the presence of low-signal intensity loose bodies (white arrows) and fluid effusion within the left TMJ. Axial (b) and sagittal-oblique (c) T1-weighted images following intravenous administration of gadolinium (c) show well thickening and intense enhancement of the synovial capsule (arrowheads).
Conclusion Synovial chondromatosis of the temporomandibular joint is a rare but probably overlooked condition. CT and MRI are complementary and represent the two imaging modalities of choice whenever such a diagnosis is suspected. Disclosure of interest
temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109(3):441—8. [5] Yu Q, Yang J, Wang P, Shi H, Luo J. CT features of synovial chondromatosis in the temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;97(4):524—8. [6] Wang P, Tian Z, Yang J, Yu Q. Synovial chondromatosis of the temporomandibular joint: MRI findings with pathological comparison. Dentomaxillofac Radiol 2012;41(2):110—6.
H. Peyrot a , P.F. Montoriol a,∗ , J.L. Beziat b , I. Barthelemy c
The authors declare that they have no conflicts of interest concerning this article. a
References [1] 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(1007):e213—6. [2] Testaverde L, Perrone A, Caporali L, et al. CT and MR findings in synovial chondromatosis of the temporo-mandibular joint: our experience and review of literature. Eur J Radiol 2011;78(3):414—8. [3] Xu WH, Ma XC, Guo CB, Yi B, Bao SD. Synovial chondromatosis of the temporomandibular joint with middle cranial fossa extension. Int J Oral Maxillofac Surg 2007;36(7):652—5. [4] Meng J, Guo C, Yi B, Zhao Y, Luo H, Ma X. Clinical and radiologic findings of synovial chondromatosis affecting the
Department of Radiology and Medical Imaging, CHU Estaing, CHU Clermont-Ferrand, 1, place Lucie-et-Raymond-Aubrac, 63003 Clermont-Ferrand, France b Department of Maxillofacial Surgery, Hopital de la Croix Rousse, CHU Lyon, 103, grande rue de la Croix-Rousse, 69317 Lyon cedex 04, France c Department of Maxillofacial Surgery, CHU Estaing, CHU Clermont-Ferrand, 1, place Lucie-et-Raymond-Aubrac, 63003 Clermont-Ferrand, France ∗ Corresponding
author. E-mail address: [email protected] (P.F. Montoriol)
Please cite this article in press as: Peyrot H, et al. Synovial chondromatosis of the temporomandibular joint: CT and MRI findings. Diagnostic and Interventional Imaging (2014), http://dx.doi.org/10.1016/j.diii.2013.12.002
ARTICLE IN PRESS
Diagnostic and Interventional Imaging (2014) xxx, xxx—xxx
LETTER / ENT Synovial chondromatosis of the temporomandibular joint: CT and MRI findings Keywords: Synovial chondromatosis; Temporomandibular joint; CT; MRI Case report A 42-year-old woman without any relevant medical history presented with a chronic left pre-auricular pain and sensation of crepitation within the temporomandibular joint. At physical examination, a mild swelling of the left retroauricular area was noted, together with a limited opening of the mouth. There was no temperature; the rest of the examination did not reveal any abnormality. The standard biological tests were normal. Panoramic radiograph was then performed and considered normal. No calcifications were seen peripheral to the left TMJ. Subsequently, craniofacial computed tomography (Fig. 1) was performed and revealed a soft tissue mass containing thin calcifications located anterior to the left mandibular condyle. Well-delineated bone erosion of the temporal bone was also demonstrated. At this stage, given these imaging findings, a diagnosis of chondromatosis of the left TMJ was suspected. Magnetic resonance imaging (Fig. 2) was finally performed prior to surgical management. Loose bodies within the joint together associated with effusion could be displayed. Thickening and intense enhancement of the synovial membrane were also shown. Open surgery was decided and numerous, whitish, cartilaginous bodies could be removed from the articular space. Pathologic examination of the surgical specimen confirmed the diagnosis of synovial chondromatosis without any sign of malignancy. Discussion Synovial chondromatosis (SC) is characterised by synovial metaplasia with proliferation of cartilaginous nodules originating from the synovial membrane [1]. It usually affects large joints, mostly the knee, hip and elbow. The TMJ is rarely affected, with about 100 cases reported in literature [2]. Cartilaginous nodules may become pedonculated and detach from the synovial membrane, thus forming ‘‘loose
bodies’’ within the joint [2]. These loose bodies sometimes calcify and become visible on CT examination. The disease is usually limited to the upper compartment of the joint space, but occasionally, as illustrated in our case, erosion of the underlying bone or joint capsule with invasion of the periarticular area can be seen [3]. Women are more likely to be affected than men with a sex ratio of 1.6:1 in the age range between 40 and 50 years [2]. The clinical symptoms in this disease are non-specific and include pre-auricular pain, swelling, limited mouthopening and crepitation of the TMJ. Based on histological findings, three stages are described according to Milgram [4]: • active intrasynovial diseases with no loose bodies; • transitional lesions with both active intrasynovial proliferation and loose bodies; • multiple free osteochondral bodies with no demonstrable intrasynovial disease.
The diagnosis of synovial chondromatosis of the TMJ is usually made using several imaging modalities. Plain Xrays is often the first imaging technique performed in the exploration of TMJ disorders but may be normal if the cartilaginous nodules are not calcified. Widening of the joint space and irregularity of the joint surfaces may be displayed [5]. CT is far more reliable than conventional radiographs in detecting the disease and determining its prognosis; soft tissue swelling, calcified bodies and bony erosions can easily be identified [5]. MRI has dramatically improved the capabilities in the diagnosis of this condition. MRI features [6] mainly include joint effusion, which is best depicted on T2-weighted sequences, loose bodies within the joint space, proliferative synovium, expanded joint capsule, anterior displacement of the mandibular condyle and intracranial involvement. Thanks to its high contrast resolution, extension of the disease into neighbouring structures is best appreciated using this modality. In aggressive cases with extra-articular extension, especially if the skull base is involved, open surgery is the therapeutic modality of choice. In cases with only intracapsular loose bodies, arthroscopy could be a less invasive method to clean out nodules and release symptoms [4]. Careful follow-up evaluation is mandatory and is often made using CT and/or MRI.
2211-5684/$ — see front matter © 2013 Éditions franc ¸aises de radiologie. Published by Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.diii.2013.12.002
Please cite this article in press as: Peyrot H, et al. Synovial chondromatosis of the temporomandibular joint: CT and MRI findings. Diagnostic and Interventional Imaging (2014), http://dx.doi.org/10.1016/j.diii.2013.12.002
+Model DIII-374; No. of Pages 2
ARTICLE IN PRESS
2
Letter
Figure 1. Axial CT image (a) shows a calcified soft tissue mass (white arrow) developed peripheral to the left TMJ. Sagittal-oblique CT image (b) demonstrates extra-articular involvement with regular erosion of the supracondylar bone (white arrow).
Figure 2. Coronal T2-weighted image (a) displays both the presence of low-signal intensity loose bodies (white arrows) and fluid effusion within the left TMJ. Axial (b) and sagittal-oblique (c) T1-weighted images following intravenous administration of gadolinium (c) show well thickening and intense enhancement of the synovial capsule (arrowheads).
Conclusion Synovial chondromatosis of the temporomandibular joint is a rare but probably overlooked condition. CT and MRI are complementary and represent the two imaging modalities of choice whenever such a diagnosis is suspected. Disclosure of interest
temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109(3):441—8. [5] Yu Q, Yang J, Wang P, Shi H, Luo J. CT features of synovial chondromatosis in the temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;97(4):524—8. [6] Wang P, Tian Z, Yang J, Yu Q. Synovial chondromatosis of the temporomandibular joint: MRI findings with pathological comparison. Dentomaxillofac Radiol 2012;41(2):110—6.
H. Peyrot a , P.F. Montoriol a,∗ , J.L. Beziat b , I. Barthelemy c
The authors declare that they have no conflicts of interest concerning this article. a
References [1] 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(1007):e213—6. [2] Testaverde L, Perrone A, Caporali L, et al. CT and MR findings in synovial chondromatosis of the temporo-mandibular joint: our experience and review of literature. Eur J Radiol 2011;78(3):414—8. [3] Xu WH, Ma XC, Guo CB, Yi B, Bao SD. Synovial chondromatosis of the temporomandibular joint with middle cranial fossa extension. Int J Oral Maxillofac Surg 2007;36(7):652—5. [4] Meng J, Guo C, Yi B, Zhao Y, Luo H, Ma X. Clinical and radiologic findings of synovial chondromatosis affecting the
Department of Radiology and Medical Imaging, CHU Estaing, CHU Clermont-Ferrand, 1, place Lucie-et-Raymond-Aubrac, 63003 Clermont-Ferrand, France b Department of Maxillofacial Surgery, Hopital de la Croix Rousse, CHU Lyon, 103, grande rue de la Croix-Rousse, 69317 Lyon cedex 04, France c Department of Maxillofacial Surgery, CHU Estaing, CHU Clermont-Ferrand, 1, place Lucie-et-Raymond-Aubrac, 63003 Clermont-Ferrand, France ∗ Corresponding
author. E-mail address: [email protected] (P.F. Montoriol)
Please cite this article in press as: Peyrot H, et al. Synovial chondromatosis of the temporomandibular joint: CT and MRI findings. Diagnostic and Interventional Imaging (2014), http://dx.doi.org/10.1016/j.diii.2013.12.002