Braz. j. . vol.81 número3

BrazJOtorhinolaryngol.2015;81(3):339---341

www.bjorl.org

Brazilian

Journal

of

OTORHINOLARYNGOLOGY

CASE

REPORT

Spontaneous

temporomandibular

joint

herniation

into

the

external

auditory

canal

夽

Herniac

¸ão

espontânea

da

articulac

¸ão

temporomandibular

no

conduto

auditivo

externo

Wei

Li,

Chunfu

Dai

DepartmentofOtologyandSkullBaseSurgery,EyeandENTHospital,FudanUniversity,Shanghai,China

Received6November2014;accepted6February2015 Availableonline31March2015

Introduction

Spontaneoustemporomandibularjoint(TMJ)herniationinto theexternal auditorycanal (EAC)resultingfromthe fora-menofHuschkeis averyrarecondition, observedinonly 0.4% of the population.1 _{The herniation may mimic the}

presentations in the osseous wall of the EAC eroded by cholesteatoma,trauma,andotherneoplasticor inflamma-torylesions.2

Case

report

A 57-year-old woman complained of one-year history of auralfullnessandotalgiainherleftear,especiallyduring mastication.Shereportednotinnitus,otorrhea,orhearing loss. The patient had no history of ear infection,trauma orsurgery.Attheotoendoscopicexamination,thetympanic membranewasnormalbuttherewasprotrusionofthesoft tissue,originatingfromtheanteriorwalloftheleftEAC.The

夽

Pleasecitethisarticleas:LiW,DaiC.Spontaneous temporo-mandibularjointherniationintotheexternalauditorycanal.Braz JOtorhinolaryngol.2015;81:339---41.

∗_{Correspondingauthor.}

E-mail:[email protected](C.Dai).

protrusionappearedasadome-shapedmasswhenthemouth wasclosed(Fig.1a).Whenthemouth wasopen,themass wasretractedanteriorly,leavinganinvaginationwithinthe meatus(Fig.1b). Ahigh-resolution computed tomography (HRCT)scan oftemporal bone withclosed mouth demon-strateda3mm defectintheanteriorwalloftheleftEAC (Fig. 1c),witha soft-tissuemass extending fromtheTMJ intotheEAC(Fig.1d). Sinceitisabenignlesion,and fur-thermore,the patient did notsuffer muchinconvenience fromthe auralfullness and otalgia, we offereda conser-vativetreatment tothe patient,andbiopsy wasavoided. Whenthepatientreturnedforfollow-uponeyearlater,the otalgiahaddisappeared,whiletheauralfullnesswasalmost thesameasbefore.

Discussion

Inaworldwideliteraturesearch,only25caseswith sponta-neousTMJherniationhadbeenpreviouslydescribed.Their agesranged from15to87years,withan average of56.6 years,and20 cases(80%)were50yearsoldor older.One hypothesisstatesthattheinitialdehiscenceintheforamen ofHuschkewouldbetoosmalltoresultinherniationofTMJ oranyother softtissuecontentsintotheEAC.Over time, yearsof mastication could have softened the intervening tissueor enlargedtheforamenwithage.This maybethe explanationoftheagedistributionofthereportedcases.3

http://dx.doi.org/10.1016/j.bjorl.2015.02.001

340 LiW,DaiC

Figure1 Otoendoscopicfindingsshowingtheprotrusionasadome-shapedmasswhenthemouthwasclosed(a),andretracted whenthemouthwasopen(b).Theaxial(c)andsagittal(d)high-resolutioncomputedtomographyshowedabonedefectofthe anteriorwalloftheexternalauditorycanal(arrow)withherniationofsofttissuematerial(asterisk).

The symptoms in patients withTMJ herniation were non-specific,butthemostcommonwereotalgia(36%),clicking tinnitus(36%,)andotorrhea(32%),followedbyhearingloss (20%)andauralfullness(10%);8%wereasymptomatic.

Diagnosis can be established based on otoscopic find-ingsand imagingstudies.The herniation ischaracteristic, because it is more prominent when the mouth is closed andretractswhen the mouth is open. Evaluationof mass intheEACduringmasticatorymovementsmaybehelpful.4

ThemanagementofTMJshouldbebasedonthesymptoms experiencedbythepatientsaswellasonthepatient’s will-ingnessandsuitabilityforsurgery.5_{Usually,ifpatientswith}

TMJherniationspresentwithtrivialsymptomsorare asymp-tomatic,surgeryisnotconsidered.However,surgicalclosure ispossibleinpatientswithsignificantsymptoms.6_Ofthe25

publishedcases,15underwentsurgery:seven(46.67%)cases withclickingtinnitus,six(40%)caseswithotalgia,andfive (33.33%)caseswithotorrhea.Forourcase,thepatient pre-sentedwithtrivialsymptomsthatwhichdidnotbotherher toomuch,andtumorintheEACwasexcluded.Conservative managementwasproposed.

Conclusion

WhenassessingpatientswithmassintheEAC,itisimportant toconsiderthepossibilityofherniation.Formostpatients

with trivial symptoms, a conservative strategy can be chosen.

Funding

This study was supported by the project on Advanced and Frontier Techniques for Shanghai Municipal Hospital (SHDC12010119).

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

References

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2.KimTH,LeeSK,KimSJ,ByunJY.Acaseofspontaneous temporo-mandibularjointherniationintotheexternalauditorycanalwith clickingsound.KoreanJAudiol.2013;17:90---3.

Spontaneoustemporomandibularjointherniation 341

4.Lacout A, Marsot-Dupuch K, Smoker WR, Lasjaunias P. Fora-mentympanicum,orforamenofHuschke:pathologiccasesand anatomicCTstudy.AJNRAmJNeuroradiol.2005;26:1317---23. 5.ProwseSJ,KellyG,AgadaF.Temporomandibularjointherniation

andtheforamenofHuschke:anunusualexternalauditorycanal mass.JLaryngolOtol.2011;125:1279---81.