A Mass in the Temporomandibular Joint

Abstract

Listen

Translate article

A 55-year-old woman with a three-year history of progressive migraine headaches developed a rightsided posterior open bite and right preauricular facial swelling. Several primary and specialty medical and dental practitioners evaluated her case and made a diagnosis of intractable migraine headaches. Because of her progressive symptoms, she had been referred to the Division of Oral and Maxillofacial Surgery, Mayo Clinic (Rochester, Minn.), for further evaluation. The patient’s medical and surgical histories were unremarkable, including any history of facial trauma. Her facial pain and migraines had been treated with a range of overthe-counter and prescription analgesics, with limited success. At examination, the patient had a mild degree of right-sided preauricular facial swelling that was mildly painful to palpation and was associated with a malocclusion of approximately 3 millimeters on the right side and a posterior open bite with continued and progressive ipsilateral headaches. Panoramic plain radiography showed a spaceoccupying lesion in the right temporomandibular joint (TMJ) (Figure 1). A computed tomographic scan with intravenous contrast material disclosed a hypoattenuated mass occupying the right TMJ space, with cortical erosion and destruction of the glenoid fossa (Figure 2). The cortical architecture of the temporomandibular condyle was well-preserved, although it was displaced significantly and inferiorly, leading to the development of malocclusion. Cranial nerves were grossly intact, with no evidence of neurologic deficit in the trigeminal or facial nerve distributions. There was no evidence of involvement of the middle ear canal, and hearing was preserved. In the absence of a histologic diagnosis, the treating surgeon (D.K.) performed a right TMJ arthroplasty for open joint exposure and exploration. Upon entry into the TMJ space, the surgeon noted a large volume of cartilaginous foreign bodies in the intra-articular joint space. The articular surface of the mandibular condyle appeared to be wellpreserved; however, there was significant erosion and disruption of the glenoid fossa superiorly, with a small focus of intracranial extension. Despite a limited dural exposure, there was no significant cranial extension or cerebrospinal fluid leak. After removing the tumor, the surgeon repositioned the mandibular condyle within the glenoid fossa, resulting in improved occlusion. A mass in the temporomandibular joint