Intra-articular osteoid osteoma of tempromandibular joint: A rare entity

Uday Kiran Uppada; Ramen Sinha; BS Ravi Kiran; M Susmitha; Syeda Afroz Ahmed

doi:10.4103/JDRNTRUHS.JDRNTRUHS_39_20

CASE REPORT

Year : 2021 | Volume : 10 | Issue : 1 | Page : 63-66

Intra-articular osteoid osteoma of tempromandibular joint: A rare entity

Uday Kiran Uppada¹, Ramen Sinha¹, BS Ravi Kiran¹, M Susmitha¹, Syeda Afroz Ahmed²
¹ Department of Oral and Maxillofacial Surgery, Sri Sai College of Dental Surgery, Vikarabad, Telangana, India
² Department of Oral and Maxillofacial Pathology, Sri Sai College of Dental Surgery, Vikarabad, Telangana, India

Date of Submission	17-Mar-2020
Date of Decision	01-Jan-2021
Date of Acceptance	10-Feb-2021
Date of Web Publication	19-May-2021

Correspondence Address:
Dr. Uday Kiran Uppada
Department Oral and Maxillofacial Surgery, Sri Sai College of Dental Surgery, Vikarabad, Telangana
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/JDRNTRUHS.JDRNTRUHS_39_20

Abstract

Osteoid osteomas are benign neoplasms of bone that generally manifests in the long bones. Intra-articular osteoid stoma of tempromandibular joint is a rare manifestation. We report a rare case of osteoid osteoma of the mandibular condyle encompassing the intra-articular space with emphasis on how to differentiate it from other benign neoplasms of the bone that affects the jaws.

Keywords: Neoplasm, osteoma, TMJ

How to cite this article:
Uppada UK, Sinha R, Ravi Kiran B S, Susmitha M, Ahmed SA. Intra-articular osteoid osteoma of tempromandibular joint: A rare entity. J NTR Univ Health Sci 2021;10:63-6

How to cite this URL:
Uppada UK, Sinha R, Ravi Kiran B S, Susmitha M, Ahmed SA. Intra-articular osteoid osteoma of tempromandibular joint: A rare entity. J NTR Univ Health Sci [serial online] 2021 [cited 2023 Mar 27];10:63-6. Available from: https://www.jdrntruhs.org/text.asp?2021/10/1/63/316323

Introduction

Osteoid osteoma is a benign, solitary neoplasm of bone. It is the third most common benign bone tumor.^[1] The incidence of this neoplasm accounts to 10% of all benign bone tumors.^[2] It has a male predilection and is most commonly seen in the second decade of life.^[3] Osteoid osteomas occur generally in the long bones predominantly the femur. They have a limited growth potential and are estimated to reach a maximum size of 1.5–2 cm.^[4] Osteoid osteoma can ensue in any part of the skeleton. However, only a few cases have been stated in the craniofacial region, displaying a marked predilection for the mandible.^[5] We report a rare case of osteoid osteoma of the mandibular condyle encompassing the intra-articular space.

Case Presentation

A 27-year-old female reported to our department with pain and clicking sound in her left jaw in addition to difficulty in mouth opening since 1 year. She gave a history of domestic violence 1 year back after which she had pain and clicking in her left jaw on opening and closing of mouth. She used medication for pain relief. Due to difficulty in eating and pain on opening of mouth 3 months later, she reported to a nearby hospital for treatment. Based on the history and the clinical presentation, a provisional diagnosis of left condylar fracture was made and intermaxillary fixation was advised. However, she refused for the treatment.

Patient reported to our unit presently complaining of pain in her left jaw in addition to difficulty in mouth opening. She gives a history that the pain did not subside on medication. Clinical examination revealed no scars over the mid-face on left side and there was no obvious facial asymmetry. Palpation of the preauricular region revealed restricted condylar movements on left side, and a bony hard, non-tender swelling in the left preauricular region. Mouth opening was inadequate in addition to this; the mandible deviated to the opposite side on maximal mouth opening. Orthopantomogram revealed a well circumscribed, uniformly radiopaque, round mass on left TMJ region occupying space of the condyle. A thin irregular joint space can be appreciated within the substance of the mass in antero-posterior direction as shown in [Figure 1]. Radiographic interpretation of CBCT showed a sclerosed nodule measuring approximately 1.5 × 2 cm located anatomically on the superior aspect of the left mandibular condyle as shown in [Figure 2].

Figure 1: Preoperative OPG showing the intra-articular lesion

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Figure 2: CBCT showing the lesion

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A provisional diagnosis of osteoid osteoma of mandible was made and the patient was taken up for surgery under GA. Patients consents was obtained. A preauricular incision was given and the neoplasm was approached following layer wise dissection. Surgical osteotomy was carried out and the neoplasm was separated from the left mandibular condyle as shown in [Figure 3] and [Figure 4]. Surgical contouring of the residual left mandibular condyle was done and the wound was closed in layers. The pain immediately resolved after surgery and there was an improvement in mouth opening gradually. Histopathology revealed areas of mature lamellar bone with resting and reversal lines and few osteocytes within the bone. It showed anastomotic trabeculae of osteoid and woven bone lined by osteoblasts in loose fibro vascular strong and multinucleated giant cells. Foci of hematopoietic elements are surrounded by cortical bone margin with minimum fibro-fatty marrow suggestive of osteoid osteoma of the mandible as shown in [Figure 5]. On 1 year follow-up, the patient revealed adequate pain free mouth opening without any deviation. There was no recurrence as shown in [Figure 6].

Figure 3: Intraoperative view showing the lesion superior to the condyle in the intra-articular region

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Figure 4: Intraoperative view showing the surgically removed lesion

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Figure 5: (a) 10x magnification of the histopathologic view of the lesion. (b) 40x magnification of the histopathologic view of the lesion

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Figure 6: Postoperative OPG showing proper TMJ architecture following removal of the intra-articular lesion

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Discussion

The etiopathogenesis of osteoid osteoma is still indistinct. Few authors believe that the neoplasm forms when there is uninhibited growth in the bone. However, the possibility of reactive mechanism, triggered by trauma or infection has been postulated as the most common cause for osteoid osteoma.^[4],[6] In this present case, the patient gives a history of traumatic incidents with a hard object 1 year prior to the onset of her symptoms. Hence, it can be postulated that the trauma she sustained could be a contributory factor in the pathogenesis.

Clinically, the neoplasm is characterized by severe pain that gets worse at night and can be relieved by the use of NSAIDs.^[7] Literature shows that high levels of inflammatory mediators are found in the nidus of this neoplasm revealing the characteristic nociception and rationale for the use of NSAIDs.^[8] Several studies have shown that these neoplasms are found to be less responsive to NSAIDs when they occurs in the joints compared to the extra-articular lesions.^{[1],[2],[7],[9]} This could be the reason as to why in the present case, there was no pain relief following use of medication.

Literature shows that intra-articular neoplasm manifests as a diffuse joint pain that is typically associated with swelling and tenderness of the involved area. It mimics an intra-articular derangement, resulting in a possible delayed of diagnosis.^[1],[4] Literature also states that when the neoplasm involves the mandibular condyle it presents with trismus, limitation of mouth opening, progressive malocclusion with midline shift toward the unaffected side, contralateral mandibular deviation, and facial asymmetry.^[10],[11]

On plain film radiographs, they present as well-defined, densely sclerotic radio-opacities. However, it is difficult to differentiate osteomas from osteochondromas or condyle hyperplasia particularly when they involve the intra-articular region on a plain radiograph.^[12] Osteomas are difficult to differentiate from foci of condensing osteitis, focal chronic sclerosing osteomyelitis, or idiopathic osteosclerosis.^[13] Three-dimensional CT is the gold standard in assessing the dimensions of the lesion and planning the surgery.^[12] Activity in the lesion can be evaluated using scintigraphy.^[14]

Osteoid osteoma has a close resemblance to osteoblastoma. However, due to its limited growth potential, size and the anatomical areas involved, osteoid osteoma can be differentiated from osteoblastoma.^[3],[7],[14] Once an osteoid osteoma is diagnosed, patients need to be evaluated for Gardners syndrome.^[15] Surgical intervention remains the most commonly recommended treatment option for osteoid osteoma in order to restore the function and aesthetics.^[3],[16] In the present case, a surgical excision, with a conservative removal of the lesion followed by TMJ arthroplasty was performed. Even though recurrence associated with this neoplasm is extremely rare, it is necessary to review the patient both clinically and radiographically periodically after the surgery.^[12]

Conclusion

Intra-articular osteoid osteoma of tempromandibular joint is a rare manifestation. Due to its nonspecific symptoms the diagnosis is deceptive. CT images were helpful in revealing the distinctive radiographic features and localization of the lesion. Surgical intervention for removal of the neoplasm resulted in the complete relief of symptoms and uneventful healing of the area.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Ethical clearance

Institutional ethical clearance taken.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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