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• W4362522992 abstract "INTRODUCTION The complex anatomy of the orofacial region can make it difficult to localise the cause of a patient’s symptoms to a specific site. If a definitive diagnosis is not apparent on history and physical examination alone, clinicians may need to utilise imaging for further evaluation. Computed tomography (CT) and magnetic resonance imaging (MRI) of the head and neck are the most common modalities performed. Patients with underlying temporomandibular disorders (TMD) form a proportion of cases that may require imaging, as they can present with headache, orofacial pain or other non-specific symptoms[1] that may first require exclusion of more severe or life-threatening aetiologies. An abnormality of the temporomandibular joint (TMJ) may then be incidentally identified on CT or MRI; CT may provide an initial or preliminary diagnosis and MRI (with or without administration of an intravenous gadolinium-based contrast agent) may be considered for further evaluation of specific disease such as infective, inflammatory or neoplastic conditions. We aim to highlight several common and uncommon TMJ conditions that may have imaging findings on a standard CT or MRI of the head and neck [Box 1]. It may also be possible to formulate a list of differential diagnoses by integrating relevant components of the clinical history with the key imaging findings [Figure 1].Box 1: Incidental TMJ conditions on CT and MRI classified by systems.[ 2 ]Figure 1: Flowchart shows the incidental findings involving the temporomandibular joint on computed tomography and magnetic resonance imaging.ANATOMY OF THE TEMPOROMANDIBULAR JOINT The TMJ is a synovial articulation between the mandibular condyle, and mandibular fossa and articular eminence of the temporal bone [Figure 2]. The external auditory meatus and mastoid process are in close relation to the posterior aspect of the TMJ. The articulating surfaces are lined by fibrocartilage and are separated by the fibrocartilaginous articular disc, which divides the joint space into superior and inferior synovial cavities. During jaw opening, the mandibular condyle rotates on the inferior surface of the articular disc, with subsequent translation of the condyle and attached disc over the articular eminence. The disc plays an important functional role during jaw movement by both distributing and absorbing stress. The lateral pterygoid muscle, supported by several other suprahyoid muscles, plays a principal role in jaw opening, with attachments to both the articular disc and anterior surface of the condyle. Arterial supply is provided by branches of the external carotid artery, primarily the superficial temporal artery. The TMJ is innervated by the auriculotemporal and masseteric nerves (branches of the mandibular division of the trigeminal nerve).Figure 2: Image shows the anatomy of the temporomandibular joint.JOINT DISORDERS Disc displacement disorders Disc displacement (DD) accounts for a large proportion of TMD. Patients usually present with typical symptoms such as clicking, popping or snapping noises on jaw movement. They may also experience limitation of jaw movement or locking. Standard CT and MRI studies are usually not sufficient to confirm a diagnosis of DD, although associated abnormalities such as secondary degenerative change and joint effusions may be present.[3] MRI is the reference standard for evaluation of the articular disc, as recommended by the International Research Diagnostic Criteria for Temporomandibular Disorders Consortium Network and Orofacial Pain Special Interest Group, and there are specialised MRI protocols performed in both closed- and open-mouth positions [Figures 3 and 4].[1]Figure 3: Normal temporomandibular joint (TMJ) of a 57-year-old man. (a) Closed-mouth sagittal proton density-weighted, fat-saturated MR image and (b) open-mouth proton density-weighted, non-fat-saturated MR image of the left TMJ show the hypointense biconcave articular disc (arrows) in a normal location with the disc overlying the mandibular condyle in both jaw positions.Figure 4: Abnormal temporomandibular joint (TMJ) of a 63-year-old man presenting with pain and clicking noises on jaw movement. Sagittal proton density-weighted, non-fat-saturated MR images of the left TMJ in (a) closed-mouth position and (b) open-mouth position show an anteriorly displaced disc in both positions (arrows). The disc has also lost its normal hypointense signal and biconcave shape. The imaging appearances are suspicious for disc displacement without reduction.Ankyloses and adhesions/adherence Intra-articular fibrous adhesions, more extensive fibrosis of the joint capsule (fibrous ankylosis) and bony fusion across the TMJ (bony ankylosis) result in restricted mandibular movement. Involvement may be unilateral or bilateral. Deflection to the affected side on jaw opening is seen in unilateral involvement; this asymmetry may be less obvious in cases of bilateral involvement.[2] Possible causes include trauma, systemic arthritides or infections. In adhesions and fibrous ankylosis, there may be decreased condylar translation on jaw opening. Bony ankylosis manifests as bone proliferation at the TMJ with obliteration of all or part of the joint space [Figure 5].Figure 5: Bilateral temporomandibular joint (TMJ) ankylosis in a 4-year old girl with congenital Nager’s syndrome. Coronal CT image shows increased bone proliferation at the bilateral TMJ with complete obliteration of the joint spaces (arrows), in keeping with bony ankylosis.JOINT DISEASES Degenerative joint disease TMJ degenerative disease is a common cause of TMD and can occur when there is chronic, excessive functional loading of the joint. It is more commonly seen in women and those above the age of 40 years.[4] Patients may complain of noise with jaw movement, and there may be crepitus detected on palpation of the TMJ. CT is the mainstay for definitive diagnosis as it offers superior evaluation of the osseous structures and articular cortices of the TMJ. At least one of the following abnormalities should be present on CT for diagnosis of TMJ degenerative disease: subchondral cyst formation, erosions, generalised sclerosis or osteophytosis.[1] Changes first occur at the anterosuperior surface of the mandibular condyle and the opposing articular eminence [Figure 6].Figure 6: Temporomandibular joint (TMJ) degenerative joint disease. (a) Sagittal CT image of the TMJ of a 60-year-old woman shows features of degenerative joint disease, including flattening of the articular eminence (block arrow) and mandibular condyle (notched arrow) with cortical irregularity and osteophyte formation (*). (b) Coronal CT image of the TMJ of a 64-year-old woman shows flattening of the superior surface of the left mandibular condyle (block arrow) and subchondral cyst formation (notched arrow).Systemic arthritides Either unilateral or bilateral TMJ involvement may be seen as part of generalised systemic inflammatory diseases such as rheumatoid arthritis (RA), juvenile idiopathic arthritis (JIA) and calcium pyrophosphate dihydrate deposition disease (CPPD). Patients with RA are usually symptomatic in other joints before the TMJ is involved; the patient may also report TMJ pain, which worsens with acute RA flares.[1] CT is limited to the detection of osseous changes in the TMJ, such as erosions, bone destruction and secondary degeneration, which usually indicate an advanced stage of RA.[5] Erosions and bone destruction have been found to be more common in TMJ RA compared to TMJ degenerative joint disease.[6] The superior soft tissue contrast provided by MRI allows for delineation of inflammatory change in the TMJ, such as joint effusions and marrow oedema [Figure 7]. Contrast-enhanced MRI with a gadolinium-based agent also effectively demonstrates synovial proliferation typically seen in the initial stages of TMJ RA, thus allowing for earlier diagnosis. Associated DD may be seen on MRI.Figure 7: A 43-year-old woman presented with tenderness of the right temporomandibular joint (TMJ) and difficulty chewing with concomitant acute swelling and pain in the small joints of the hands and feet. (a) Coronal T1-W and (b) axial T1-W fat-saturated, post-contrast MR images show oedema and enhancement in the right condylar head and surrounding soft tissue (block arrows), in keeping with active inflammation. Cortical erosion is also noted along the lateral aspect of the mandibular condyle (notched arrows). The patient was diagnosed with rheumatoid arthritis following further laboratory investigations.TMJ involvement in JIA is common and has been associated with all seven subtypes, although those with the oligoarticular, rheumatoid factor-negative polyarticular and juvenile psoriatic subtypes are reported to be at higher risk.[7] Because TMJ involvement is difficult to detect clinically, patients tend to present at advanced stages of disease with severe TMJ degeneration and secondary mandibular growth disturbances. MRI is the modality of choice for early diagnosis of TMJ involvement in children with JIA — in acute phases, joint effusions, synovial enhancement and marrow oedema may be seen; abnormalities of the articular disc, bone erosions and destruction are more chronic findings. It is rare to find CPPD of the TMJ. CPPD is more commonly seen in larger joints like the knee, wrist and shoulder joints. Localised CPPD may be due to previous trauma or underlying arthropathy. Generalised CPPD may be related to underlying metabolic disorders such as hyperparathyroidism.[8] Early disease usually demonstrates evenly distributed, fine synovial calcification within the joint. Late or severe disease may appear as a calcified mass that erodes the condyle and adjacent bony structures; appearances may mimic malignancy [Figure 8].Figure 8: Calcium pyrophosphate dihydrate deposition disease of the temporomandibular joint (TMJ) in a 74-year-old man who presented with unrelated clinical symptoms. Coronal CT image shows a calcified mass in the right TMJ (arrow), which is eroding the mandibular condyle and adjacent mandibular fossa. Differentials would include tumoral calcinosis or a chondroid tumour.Osteonecrosis Osteoradionecrosis is a known complication of radiotherapy for malignancies of the head and neck. Diagnosis requires the fulfilment of certain clinical conditions (e.g. exclusion of recurrence or a second primary malignancy, bone exposure that fails to respond to treatment).[9] Radiological findings are usually absent in the early stages of disease. Evidence of bone destruction within the irradiated field can manifest as areas of radiolucency and cortical destruction on CT [Figure 9]. Marrow signal abnormalities and enhancement may be present on MRI.[2]Figure 9: Osteoradionecrosis in a 54-year-old man with a history of radiotherapy for nasopharyngeal carcinoma. (a) Axial and (b) coronal CT images of the right temporomandibular joint show erosion of the right external ear canal (block arrow), mandibular head (notched arrow) and mandibular fossa. The presence of such findings in the irradiated field makes osteoradionecrosis one of the main considerations.Medication-related osteonecrosis of the jaw (MRONJ) has replaced the previous term, ‘bisphosphonate-related osteonecrosis of the jaw’, in view of the increasing prevalence of cases associated with other pharmacological agents. These can be classified into two pharmacological groups: antiresorptive (including bisphosphonates and denosumab, commonly used in treatment of osteoporosis) and antiangiogenic agents (including bevacizumab, used in treatment of certain cancers). Patients may be considered to have MRONJ if the following features are present: (a) current or previous treatment with antiresorptive therapy alone or in combination with immune modulators or antiangiogenic medications; (b) exposed bone, or bone that can be probed through a fistula in the maxillofacial region, persisting for more than 8 weeks; and (c) no history of previous radiation therapy to the head and neck or metastatic disease to this region.[10] Typical findings on CT include mixed lytic–sclerotic osseous change with or without periosteal reaction. Bone fragmentation may be present in later stages [Figure 10]. MRI can demonstrate marrow signal abnormalities and enhancement secondary to the underlying inflammation.Figure 10: Medication-related osteonecrosis of the jaw in a 61-year-old woman on long-term bisphosphonates for osseous breast metastases. (a) Coronal and (b) sagittal CT images of the left temporomandibular joint show a mixed lytic–sclerotic appearance of the left mandibular condyle with a pathological fracture (block arrows) and periosteal reaction (notched arrows). Biopsy and histology from this region excluded the presence of metastases, which would be the primary differential.Osteomyelitis and septic arthritis Infection can spread to the TMJ from three possible routes: haematogenous, contiguous or by direct inoculation. Direct inoculation is the rarest of the three routes. Haematogenous spread can occur with upper respiratory tract infections. Contiguous spread can occur from infections in the mastoid, parotid or infratemporal spaces [Figure 11].[11] Imaging changes, including marrow abnormalities, bone destruction and joint effusions, may be apparent on both CT and MRI. Osteomyelitis may, on occasion, simulate aggressive intraosseous lesions on imaging.Figure 11: Aseptic arthritis of the right temporomandibular joint (TMJ) with abscess formation in an 84-year-old man with known right-sided malignant otitis externa. (a) Axial non-contrast CT image shows soft tissue stranding at the right peri-auricular region and masticator space (block arrows). (b) Coronal and (c) axial T2-W fat-saturated MR images show a joint effusion in the right TMJ (block arrows in b) and a separate fluid collection adjacent to the joint (notched arrow in c). (d) This fluid collection demonstrates peripheral enhancement on the axial T1W fat-saturated post-contrast image, in keeping with an abscess (notched arrow in d). Overall findings would be suggestive of septic arthritis and abscess formation involving the right TMJ.Osteochondritis dissecans Osteochondritis dissecans (OCD) of the TMJ is extremely rare and is more commonly seen in larger joints such as the knee or ankle joints. Patients with TMJ OCD may present with jaw tenderness, swelling, crepitus and limitation of movement.[2] If the osteochondral fragment is displaced, an intra-articular loose body and the donor site may be visible on CT. MRI of the TMJ is useful in assessing the stability of undisplaced OCD lesions.[12] Underlying rheumatological disorders should be excluded as inflammatory arthropathy is a differential. Synovial chondromatosis is another consideration. Synovial chondromatosis Usually a disorder of large joints, synovial chondromatosis in the TMJ is rare. Jaw malocclusion may be an associated finding. Primary synovial chondromatosis results from the formation of cartilaginous bodies in the synovial membrane that subsequently detach and ossify in the intra-articular space. The secondary form is related to previous trauma or arthropathies and usually results in loose bodies that are more uniform in size. Although benign, intracranial extension has been reported when the TMJ is involved.[13] Arthroscopic removal is necessary in symptomatic cases. Imaging is required for diagnosis, and CT is usually sufficient in demonstrating the main imaging features of multiple calcified intra-articular loose bodies [Figure 12], joint space widening and articular irregularity.[2]Figure 12: Synovial chondromatosis of the temporomandibular joint (TMJ) in a 52-year-old woman with left-sided jaw pain. Axial CT image shows multiple small, calcified loose bodies in the left TMJ (arrow).Tumoral calcinosis Tumoral calcinosis is a disease of phosphate metabolic dysfunction with calcium deposition in intra- or peri-articular soft tissues. The pathogenesis remains uncertain, but a genetic predisposition and an association with chronic haemodialysis are the proposed mechanisms. Serum calcium levels are normal and phosphate levels are elevated. Tumoral calcinosis commonly involves the upper limb and hip regions; TMJ involvement has been reported but is rare. In the TMJ, it may present as single or multiple masses in the intra- or peri-articular space with variable appearances on CT, depending on the stage of disease. In the calcifying stage, there may be increased heterogeneity, cystic areas and fluid–fluid levels due to layering of calcium. With reduced calcification in the quiescent stage, lesions may appear more homogeneous [Figure 13]. Bone erosion and destruction are usually absent.[14]Figure 13: Tumoral calcinosis of the temporomandibular joint (TMJ) in a 59-year-old woman. Coronal CT image of the right TMJ shows a well-defined hyperdense subcutaneous mass (arrow) abutting the right TMJ without bony erosion. The diagnosis was confirmed after biopsy.Pigmented villonodular synovitis Pigmented villonodular synovitis (PVNS) is a rare, benign proliferative disorder of the synovium that can arise in joints, tendon sheaths and bursae. Most commonly monoarticular and occasionally oligoarticular, PVNS is more commonly seen in other joints such as the knee and hip joints. The thickened synovium appears as a mass-like lesion on imaging, with characteristic low signal intensity on MRI and ‘blooming’ artefacts on gradient echo sequences due to extensive haemosiderin deposition. The haemosiderin may appear hyperdense on non-contrast CT, which may also demonstrate associated bone erosion [Figure 14]. The histology of PVNS can mimic sarcomas, making radiological–pathological correlation crucial.[15]Figure 14: Pigmented villonodular synovitis (PVNS) of the temporomandibular joint (TMJ) in an adult patient. Coronal CT images of the (a) soft tissue and (b) bone windows show a large soft tissue lesion involving the left TMJ (block arrow in a) with erosive bone changes (notched arrow in b). (c) On T1-W pre-contrast coronal MR image, the mass demonstrates a rim of low signal intensity. Extension into the middle cranial fossa is also observed (notched arrow in c). (d) Axial T2-W MR image of the mass shows more marked low signal intensity. (e) Coronal T1-W fat-saturated, post-contrast MR image shows heterogeneous enhancement within the mass. [Case courtesy of Kosuke Kato, Available from: https://radiopaedia.org/cases/pigmented-villonodular-synovitis-of-the-temporomandibular-joint?lang=us].Neoplasm Neoplasms with non-aggressive imaging appearances that may involve the TMJ can be further divided into those that are predominantly radiolucent (e.g. simple bone cyst, aneurysmal bone cyst) [Figure 15] and those that are predominantly radiopaque (e.g. osteoma, osteochondroma).Figure 15: Computed tomography (CT) image shows aneurysmal bone cyst. (a) Axial and (b) coronal cone beam CT images from a 15-year-old boy with left-sided jaw pain demonstrate a lytic, expansile lesion in the left condylar head with thinning of the overlying cortex (arrows). Diagnosis was confirmed with biopsy and histology.Differentials for aggressive lesions involving the TMJ include metastases, osteosarcomas and chondrosarcomas, though they are all extremely rare. Osteomyelitis may also be considered in the appropriate clinical context. Metastases to the jaw are challenging to diagnose clinically and are usually only detected at an advanced stage of disease [Figure 16].[16] Osteosarcomas and chondrosarcomas of the TMJ can appear as enhancing lesions with internal osteoid and chondroid matrix, respectively [Figure 17].Figure 16: (a) Post-contrast coronal computed tomography (CT) image in the soft tissue window and (b) sagittal CT image in the bone window from a 74-year-old woman with known metastatic breast cancer demonstrate a destructive lytic lesion involving the left mandibular condyle (block arrows). A separate lytic lesion is also seen in the body of the left hemimandible (notched arrow in b). These are likely to represent osseous metastases.Figure 17: Computed tomography (CT) images and MR images of a 48-year-old man who presented with right cheek swelling, initially thought to be a salivary gland mass. A mass centred in the right temporomandibular joint was incidentally discovered (block arrows). (a) On T1W pre-contrast coronal MR image, the mass is mildly hypointense. Hypointense marrow signal in the adjacent temporal skull base superiorly (notched arrow) corresponds to sclerosis. The degree of surrounding osseous change was not particularly prominent, with only mild bony remodelling of the mandibular fossa and condyle (not shown) — this made a primary bone tumour less likely. (b) T1W fat-saturated post-contrast coronal MR image shows heterogeneous enhancement within the mass. (c) On post-contrast axial CT, an internal hyperdense area is seen (notched arrow), possibly representing matrix formation. Biopsy and histology of the mass revealed a chondrosarcoma of the temporomandibular joint. T1W: T1 weighted, T2W: T2 weightedCONGENITAL AND DEVELOPMENTAL DISORDERS Condylar aplasia Unilateral absence of the mandibular condyle is frequently associated with other facial anomalies and may be part of a congenital syndrome (e.g. Goldenhar syndrome, hemifacial microsomia). Facial asymmetry will be evident in unilateral involvement; micrognathia is the primary abnormality in occasional cases of bilateral involvement.[2] Condylar hypoplasia The causes of condylar hypoplasia may be congenital or acquired. Acquired causes include trauma, infection, previous DD or treatment.[2] Condylar hyperplasia Condylar hyperplasia is usually self-limiting and presents between 10 and 25 years of age. Unilateral involvement is more common. Increased uptake of technetium-99m on bone scintigraphy on the abnormal side indicates active condylar growth [Figure 18].[2]Figure 18: Condylar hyperplasia. Localised bone scintigraphy of the mandibular condyles shows increased technetium-99m uptake in the right mandibular condyle (block arrows) compared to the left (notched arrows), with a count ratio of 1.34, suggestive of right condylar hyperplasia with active condylar growth.POST-TRAUMATIC CHANGES Marked osseous remodelling can occur in displaced condylar fractures that are managed conservatively. This can result in both condylar and mandibular fossa deformities that may be mistaken for neoplasms if a history of previous trauma is not known [Figure 19]. Corroboration with the patient’s past medical history or a review of previous imaging studies may help confirm this diagnosis.Figure 19: Post-traumatic changes in a 40-year-old man. (a) Initial axial CT image shows a displaced right mandibular condyle fracture (block arrow). (b) Subsequent (2 years later) axial CT image shows interval healing of the fracture (notched arrow). Appearances of the remodelled condyle could be mistaken for a benign neoplasm if the study had been interpreted without knowledge of the previous fracture.CONCLUSION Having a systematic approach and knowledge of the spectrum of conditions that can affect the TMJ is useful when an abnormality is incidentally identified on a routine CT or MRI study of the head and neck. By integrating key imaging features with relevant aspects of the patient’s history, it may be possible to make a provisional diagnosis or narrow the differential list, allowing clinicians and radiologists to collaborate on an optimal plan of management. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. SMC CATEGORY 3B CME PROGRAMME Online Quiz: https://www.sma.org.sg/cme-programme Deadline for submission: 6 pm, 10 May 2023" @default.
• W4362522992 created "2023-04-06" @default.
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• W4362522992 date "2023-01-01" @default.
• W4362522992 modified "2023-10-14" @default.
• W4362522992 title "Incidental findings involving the temporomandibular joint on computed tomography and magnetic resonance imaging" @default.
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