Dentomaxillofacial Radiology (2007) 36, 5558 q 2007 The British Institute of Radiology http:/ /dmfr.birjournals.

org

CASE REPORT

Synovial chondromatosis of the temporomandibular joint: CT and MRI ndings

ez1, J Puig1, JM Trull3 and S Pedraza1 E Balliu*,1, V Medina1, JC Vilanova2, I Pela
1 ` stic per la Imatge, Hospital de Girona, Dr Josep Trueta, Av Franc Department of Radiology and Institut de Diagno a S/N Girona 17007, nica Girona, Girona, Spain; 3Department of Maxillofacial surgery, Hospital de Girona, Spain; 2Department of Magnetic Resonance, Cl Dr Josep Trueta, Av Franc a S/N Girona-17007, Spain

We report a rare case of synovial chondromatosis of the temporomandibular joint (TMJ) in a 31-year-old man. CT examination showed a mixed soft tissue mass with small calcications near the right TMJ joint space. MR images revealed a heterogeneous mass on the different sequences and, after contrast administration, originating in the right TMJ. Cytology showed chondroid cellularity. The lesion was surgically removed and nal histological study demonstrated the diagnosis of a synovial chondromatosis. We highlight the importance of the complementary ndings from CT and MR, especially the important specic feature described for TMJ synovial chondromatosis related to the mixed density within the mass, in order to perform an accurate preoperative diagnosis whenever there is an absence of ossied loose bodies. Dentomaxillofacial Radiology (2007) 36, 5558. doi: 10.1259/dmfr/89319561 Keywords: temporomandibular joint, calcication, condyle, computed tomography (CT), magnetic resonance imaging (MRI) Case report A 31-year-old man presented with a painful swelling in the region of the right temporomandibular joint (TMJ). There was no other signicant past medical history. On physical examination, a tender mass and facial swelling was found in the region. The remaining physical examination and analytical results were normal. CT scan (Philips Mx 8000 multislice, Philips Medical Systems, Highland Heights, OH) showed a marked widening of the joint space, which was occupied by a soft tissue mass adjacent to the right TMJ, involving the right mandibular condyle. This mass extended into the right lateral pterygoid and masseter muscles (masticator space). There was no erosion in the glenoid fossa or mandibular condyle. Some small calcications were seen in the external aspect of the lesion in the pterygoid fossa and masseter muscles (Figure 1). After iodinated contrast administration, the mass demonstrated heterogeneous enhancement suggestive of solid and cystic components (Figure 2). Skull base MRI was performed on a 1.5 T (Signa LX, GE Medical Systems, Milwaukee, WI) using a head and neck coil with the following sequences: axial and coronal
*Correspondence to: E Balliu, MD, Hospital de Girona, Dr Josep Trueta (Radiology Department). Av. Franc a S/N Girona 17007, Spain; E-mail: 34876ebc@comb.es Received 29 September 2005; revised 8 January 2006; accepted 1 February 2006

T1 (before and after gadolinium injection), axial T2 weighted spin-echo and short-time inversion recovery (STIR) sequences. T1 weighted sequences demonstrated an isointense signal of the lesion relative to muscle, while T2 weighted sequences showed the lesion with heterogeneous low isointense signal (Figure 3). STIR sequence showed high heterogeneous signal intensity of the mass (Figure 4). The lesion originated in the joint, as was seen on CT, but spread around and reached the pterygoid and masseter muscles. After intravenous contrast administration, the periphery and some central parts of the lesion enhanced strongly. There was a marked expansion of the joint capsule, which contained soft tissue and uid signal within the lesion (Figures 5 and 6). Under the presumptive diagnosis of a cartilaginous and probably synovial lesion, the mass was submitted to neneedle aspiration. Cytology demonstrated chondroid cellularity, suggestive of synovial chondromatosis. The mass was removed surgically. The cut surface had a whitish-yellow homogeneous appearance and soft consistency. Histological study demonstrated multiple cartilaginous nodules surrounded by synovium. The nal histological diagnosis was synovial chondromatosis. There were no complications in the immediate postoperative period.

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Figure 3 Axial FSE T2 weighted image shows a low isointense signal intensity lesion near the right TMJ and the pterygoid muscle (arrowheads)

Figure 1 Axial CT image with bone window shows two small calcications (arrows) in the periphery of the area of the right lateral pterygoid muscle

Discussion Synovial chondromatosis is a rare, benign, tumour-like disorder of the joint characterized by chondrometaplasia of the synovial membrane. Loose cartilaginous bodies are formed in the joint space, which may calcify.

It is usually monoarticular and occurs in large joints such as the knee or shoulder. Involvement of the TMJ is extremely rare. Although it is considered a benign disorder, it has been described as having a potential capability of destroying the middle cranial fossa and invading intracranial structures.1,2 Moreover, it does not seem to undergo spontaneous resolution. For these reasons early knowledge and diagnoses of this disease are very important, in order to select an appropriate treatment and to achieve a better prognosis. We present a pathologically proven case of this arthropathy in TMJ in order to characterize the CT and MR ndings. Such ndings may

Figure 2 Axial CT after intravenous contrast injection with a soft tissue window shows a lesion in lateral pterygoid muscle of mixed densities, uid (arrowheads) and solid (arrow)
Dentomaxillofacial Radiology

Figure 4 Axial STIR MRI shows the lesion of mixed density, hyperintense synovial uid and isointense solid component due to the metaplasia of the synovial tissue (arrowheads)

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Figure 5 Post-contrast SE T1 weighted axial images demonstrating intense enhancement of the abnormal thickened synovium (arrowheads) around the mandibular condyle, masticator space and pterygoid muscle with solid components (arrow) due to the metaplasia of the synovial tissue

be characteristic of this pathology and may therefore provide an accurate preoperative diagnosis. To our knowledge, there are few radiologic articles describing the radiological features for both CT and MRI for this entity. The main radiological features described in the literature are: widening of joint space, calcied loose bodies (cartilage), soft tissue swelling, limitation of motion, irregularity of the joint surface, and sclerosis or hyperostosis of the glenoid fossa and mandibular condyle. These ndings are not specic; most of them can be seen in osteoarthrosis of the TMJ, which is the

Figure 6 Post-contrast SE T1 weighted coronal images demonstrating intense enhancement of the abnormal thickened synovium (arrowheads) around the mandibular condyle, masticator space and pterygoid muscle with solid components (arrow) due to the metaplasia of the synovial tissue

most common pathology for this joint. CT may characterize all those signs. However, MRI seems more precise in demonstrating the cranial extension and conrming synovial origin. It demonstrates intraarticular cartilaginous loose bodies, the expansion of joint capsule and uid accumulation.3 6 Our case is interesting because it demonstrates the usefulness of the combined performance of CT and MRI examinations for preoperative diagnosis. The former helped us detect the presence of small calcications, whereas the latter showed the synovial origin, extent and precise relationship to the lesion. This case shows only a few of those more frequently described signs of synovial chondromatosis, but does not show the most characteristic ones such as the presence of a large number of calcied loose bodies. On the contrary, a few non-specic small calcications peripherally located were observed in the CT study. The present case, however, reveals a different specic sign that to our knowledge has been observed (via CT) only once. The special feature of this sign is based on a soft tissue swelling mass with mixed density, both solid and uid, where the solid component relates to the metaplasia of the synovial tissue and the uid component relates to the accumulated synovial secretion.7 We observed this sign via both CT and MRI. Knowledge about this more specic feature associated with some of the typical radiological signs described above, can narrow the differential diagnosis from the other more common benign pathologies for this joint, such as osteoarthrosis, osteochondritis dissecans, intracapsular fractures or inammatory arthritis (especially chondrocalcinosis because, even though it rarely involves the TMJ, it may also present microcalcications and make the diagnosis unclear) and for the more aggressive pathologies such as chondrosarcoma.8 Therefore, this nding provides an accurate and reliable preoperative diagnosis in spite of the fact that no loose or calcied bodies could be seen, such as in the present case, and the fact that this is a rare pathology for this specic joint. However, to establish the diagnosis of this disease it is mandatory to verify pathologically a transitional change from brous connective tissue to cartilaginous tissue or chondrometaplasia.4 It is worth mentioning the important extraarticular extension of the lesion to the masticator space, better dened and detailed by the MR examination. An exhaustive description of its extension is of utmost importance, even though this is a benign pathology, in order to achieve a correct surgical planning.9 This is due to the large recurrence index, especially for incomplete resection and to the reported risk of malignant transformation.10 Both CT and MR examinations were also useful in order to discard an origin from the parotid gland, which might have a similar clinical presentation. To summarise, synovial chondromatosis of the TMJ is an uncommon benign tumour-like disorder, which should require both CT and MR preoperatively. Knowledge of the radiologist of the most specic signs is important in order to achieve a reliable preoperative diagnosis, early detection and an exhaustive description of the relationships between
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the lesion and its surrounding structures. All these factors contribute to an early, suitable surgical treatment, thus improving the prognosis and preventing potential recurrences.
References
1. Karlis V, Glickman RS, Zaslow M. Synovial chondromatosis of the temporomandibular joint with intracranial extension. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998; 86: 664 666. 2. Sun S, Helmy E, Bays R. Synovial chondromatosis with intracranial extension: a case report. Oral Surg Oral Med Oral Pathol 1990; 70: 5 9. 3. Wong WC, Cheng PW, Chan FL. MRI appearance of synovial chondromatosis in the temporomandibular joint. Clin Radiol 2001; 56: 773 774. 4. Koyama J, Ito J, Hayashi T, Kobayashi F. Synovial chondromatosis in the temporomandibular joint complicated by displacement and calcication of the articular disk: report of two cases. Am J Neuroradiol 2001; 22: 1203 1206. 5. Herzog S, Mafee M. Synovial chondromatosis of the TMJ: MR and CT ndings. Am J Neuroradiol 1990; 11: 742 745.

Acknowledgments The authors thank Sarah Rodriguez Garrigan and Daniel Balliu ` s for the English translation assistance. Collgro

6. Nokes SR, King PS, Garcia R Jr, Silbiger ML, Jones 3rd JD, Castellano ND. Temporomandibular joint chondromatosis with intracranial extension: MR and CT contributions. Am J Neuroradiol 1987; 148: 1173 1174. 7. Yu Q, Yang J, Wang P, Shi H, Luo J. CT features of synovial chondromatosis of the temporomandibular joint. Oral Surg Oral Med Oral Pathol Endod 2004; 97: 524 528. 8. Wittkop B, Davies AM, Mangham DC. Primary synovial chondromatosis and synovial chondrosarcoma: a pictorial review. Eur Radiol 2002; 12: 2112 2119. 9. Yildiz ST, Demir A, Kaya A. Synovial chondromatosis of the temporomandibular joint extending to temporalis, masticator and parotid spaces. J Comput Assist Tomogr 2001; 25: 126 129. 10. Hermann G, Klein MJ, Abdelwahab IF, Kenan S. Synovial chondrosarcoma arising in synovial chondromatosis of the right hip. Skeletal Radiol 1997; 26: 366 369.

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