Chronic, progressive limitation of mouth opening

Traumatic Myositis Ossificans of Temporalis Muscle: Systematic Review, Meta-Analysis and Case Reports

Introduction

Traumatic myositis ossificans is rare pathology affecting muscles/soft tissue. Its involvement in temporalis muscle is rarely reported in literature. The aetiopathogenesis is unknown, the diagnosis is based on clinco-radiological findings. Surgical management and follow-up are paramount.

Materials and Methods

A database search was done using Science Direct and PubMed search engines along with other published and unpublished literature. The final publications were tabulated using a custom made Performa. The available publications were subjected to appropriate statistical analysis. The data were recorded on excel spreadsheet (Microsoft Inc), and review was made using Review Manager (Rev Man) software for meta-analysis.

Results

A total of 21 articles were considered for systemic review and meta-analysis. Forest plotting for demographics included the gender predilection/age of involvement. The data segregation was done with "temporalis involved" group and "other than temporalis involved" group. The study was free of homogeneity ( τ 2 = 0.26 I 2 = 5%) for gender and age. The overall analysis revealed that Temporalis muscle although rare to be affected shows greater propensity for involvement. This is supported by a lesser degree of heterogeneity ( τ 2 = 0.000) with a I 2 value of (The test showed a higher degree of significance for overall effect of muscle involvement (Z = 2.33, p = 0.02) (< 25%). The test showed a higher degree of significance for overall effect of muscle involvement (Z = 2.33, p = 0.02) (< α = 0.05).Case reports.Two male cases with similar age predilection, reported after sustaining trauma. Both the cases presented with limited mouth opening and ultrasound was done for the first time to arrive at clinic-radiological diagnosis. The management was conservative with temporalis myotomy and coronidectomy.

Conclusion

Traumatic myositis ossificans presents as a rare disorder that poses a dilemma to the treating surgeon. The present article makes an attempt to critically analyse the pathology that is scantly reported in the literature.

Myositis Ossificans Traumatica, an Unusual Cause of Mandibular Hypomobility

ABSTRACT

Myositis ossificans traumatica is a rare condition in which causes restriction of mandibular movement. In this entity, temporomandibular joint is depleted of any problems; although all the patients have the history of trauma to the mandible and the face. Myositis ossificans traumatica can involve other parts of the body like femoral region with higher incidence in compare to the maxillofacial area. Blunt trauma to the head and neck causes muscle contusion injury, hematoma formation in the injured muscles or nearby soft tissues. Calcification of hematoma and heterotopic bone formation in the muscle, soft tissue, or near bony structures causes progressive decrease in mouth opening. Surgical removal of calcified body has been the only and one method for treatment of this disorder but rate of recurrence is high in the literature. The authors want to introduce 2 new cases of myositis ossificans traumatica, and then discuss about etiology and different treatment modalities.

Myositis Ossificans Traumatica of the Temporal Muscle: a Case Report and Literature Review Emphasizing Radiographic Features on Computed Tomography and Magnetic Resonance Imaging

Objectives

Heterotopic bone formation within a muscle is designated as ‘myositis ossificans’, and it is associated with multiple aetiologies, such as trauma, genetic predisposition, post-infection, or undetermined causes. When the disease develops as a result of a trauma, the myositis ossificans is classified as ‘myositis ossificans traumatica’. In this case report, a case of myositis ossificans traumatica is described, emphasizing its imaging features. Additionally, a literature review of the imaging features of myositis ossificans is discussed.

Material and Methods

A 60-year old male patient presented with restricted mouth opening and pain during mastication. Multislice computed tomography and magnetic resonance imaging examinations were conducted. Case reports in the literature of myositis ossificans were searched databases from August 1984 until April 2019 using the keyword ‘masticatory muscles’ combined with ‘myositis’; ‘inflammatory myositis’; infectious myositis’; ‘inflammatory muscle diseases’; ‘focal myositis’ and ‘proliferative myositis’. Data was summarised and evaluated according to a critical appraisal checklist for case reports.

Results

Multislice computed tomography demonstrated an ectopic hyperdense area arising from the coronoid bone and within the temporal muscle. Magnetic resonance imaging demonstrated the same area with a hypointense signal. In the literature review, 53 myositis ossificans cases were identified, and 12 cases affecting the temporal muscle were found.

Conclusions

The main imaging feature of myositis ossificans is the presence of a radiopaque, hyperdense or hypointense mass in the affected muscle, which is seen on multislice computed tomography and magnetic resonance imaging, respectively. The final diagnosis is through histopathological examination, although imaging can suggest the most likely diagnosis.

Myositis ossificans traumatica of the masticatory muscles: etiology, diagnosis and treatment

BACKGROUND

Myositis ossificans describes a heterotopic bone formation within a muscle. Thereby myositis ossificans is classified in two different groups: myositis ossificans progressiva (MOP) which describes a genetic autosomal dominant rare disease and myositis ossificans traumatica (MOT). The exact pathogenesis of MOT is unclear. The aim of this article was to analyse and interpret the existing literature reporting MOT of masticatory muscles and compare the results with our own clinical experience with MOT. Risk-factors, etiology, clinical features, diagnostic imaging, as well as different treatment options were evaluated and recommendations for the prevention, diagnosis, and therapy of MOT of the masticatory muscles were given.

METHODS

Following the PRISMA-Guidelines, a systematic search within the PubMed/Medline database with a view to record literature of MOT of the masticatory muscles was performed. Furthermore, the database of our own clinic was screened for cases of MOT.

RESULTS

In total, 63 cases of MOT of the masticatory muscles which were reported in English-based literature were included in this study. Overall, 25 female and 37 male patients could be analysed whereas one patient's gender was unknown. Complication of wisdom-tooth infection (n = 3) as well as the results of dental procedures like dental extraction (n = 7), mandibular nerve block (n = 4), periodontitis therapy (n = 1) were reported as MOT cases. From the 15 reported cases that appeared after dental treatment like extraction or local anesthesia the medial pterygoid (n = 10) was the most affected muscle. Hereof, females were more affected (n = 9) than males (n = 6). The most reported clinical symptom of MOT was trismus (n = 54), followed by swelling (n = 17) and pain (n = 13). One clinical case provided by the authors was detected.

CONCLUSIONS

Dental procedures, such as local anesthesia or extractions, may cause MOT of the masticatory musculature. Demographical analyses demonstrate that females have a higher risk of developing MOT with respect to dental treatment. The most important treatment option is surgical excision. Subsequent physical therapy can have beneficial effects. Nevertheless, a benefit of interpositional materials and drugs as therapy of MOT of the masticatory muscles has not yet been proven. Myositis ossificans progressiva has to be excluded.

Operative management of idiophatic myositis ossificans of lateral pterygoid muscle

INTRODUCTION

Myositis ossificans (MO) is characterized as heterotopic bone formation within muscle. MO rarely occurs in the head and neck region. Excision of the heterotopic bone is the standard treatment. This report summarizes a case of a 12-year old female with MO involving the lateral pterygoid muscle. The heterotopic bone was excised using an intraoral incision. Despite intensive physical therapy, the operation failed as evidenced by new bone formation in the area within three weeks of the operation.

PRESENTATION OF CASE

A twelve years old female patient presenting with mouth opening of 10 mm, no facial asymmetry, and no jaw joint pain or other symptoms. Computer tomography (CT) exam was requested and revealed calcification of the left lateral pterygoid muscle. No other masticatory or head muscles showed any signs of calcification. The calcified muscle was completely removed beyond the ossified segment and a 35 mm mouth opening was achieved immediately after the procedure. One month after total bone structure removal (first surgery) the patient could not open her mouth anymore due to a significant calcified mass.

DISCUSSION

The surgical technique used in this case avoided invasive gap arthroplasty to access lateral pterygoid muscle and anaesthetic scarring formation, by using an intraorally incision accessing the muscle directly. The authors of these study did not see any relation with the condylar dislocation that the patient had five years prior to the pathology, and they could not find any real cause for the myositis ossificans of lateral pterygoid muscle.

CONCLUSION

The outcome of the surgical procedure was not successful, perhaps due to the expression of the disease, indicating the need to further physiologic and genetic studies to elucidate the aetiology of MO as well as to provide directions to an adequate treatment choice for such cases.

A rare isolated unilateral myositis ossificans traumatica of the lateral pterygoid muscle: a case report

Introduction

Myositis ossificans traumatica is a pathological condition characterized by the extraskeletal formation of bony tissue, induced by violent or repeated trauma.

Case presentation

A 30-year-old Italian man, after surgical treatment for multiple facial fractures, presented with a progressive limitation of mouth opening. A computed tomography scan showed a significant calcification of the fibers of the left lateral pterygoid muscle. The working diagnosis was myositis ossificans traumatica of the left lateral pterygoid muscle. Surgical excision was suggested but not performed. Our patient underwent physiotherapy treatment resulting not in a complete restoration of mandibular movements but in an acceptable recovery of mouth opening.

Conclusions

Myositis ossificans is a rare complication that can be caused by muscle trauma. Therefore, special attention should be paid to surgical trauma. In the present case, surgical excision was considered, in accordance with the literature, and suggested to our patient, but he declined due to the absence of any pain or any significant limitation to his daily life activities. He therefore underwent physiotherapy treatment, in line with our unit’s guidelines, resulting not in a complete restoration of mandibular movements but in an acceptable recovery of mouth opening.

Myositis ossificans of the left medial pterygoid muscle: case report and review of the literature of myositis ossificans of masticatory muscles

Myositis ossificans is a disease that is characterized by nonneoplastic, heterotopic bone formation within a muscle. Myositis ossificans traumatica, also called myositis ossificans circumscripta, is a disease in which muscles are ossified presumably following acute trauma, burns, surgical manipulation, or repeated injury. It is often remitted after surgical excision though some patients have repeated recurrences. Myositis ossificans traumatica of masticatory muscles is not frequently reported in the literature, with the most common clinical finding being a progressive limitation of motion in the mandible. The aim of this article is to present and discuss a case of myositis ossificans traumatica of the left medial pterygoid muscle and to review the literature of myositis ossificans of the masticatory muscles.

Myositis ossificans in medial, lateral pterygoid, and contralateral temporalis muscles: a rare case report

Myositis ossificans is ossification and bone formation within muscle. It is a rare and unusual pathologic entity that has defied most efforts to establish definite etiology, pathogenesis, and satisfactory treatment. Myositis ossificans is mainly of 2 types: myositis ossificans progressiva (MOP) and myositis ossificans traumatica (MOT). Myositis ossificans idiopathic is also reported in the literature. When it affects the muscles of mastication, it causes severe trismus. Computed tomography scans and magnetic resonance imaging can effectively delineate the calcified mass. In this article, we present a case of MOT of the medial, lateral pterygoid, and contralateral temporalis muscles.

Myositis ossificans traumatica of the temporalis muscle: a case report and diagnostic considerations

BACKGROUND

The present paper reported the case of a trauma-related myositis ossificans, with focus on considerations for a differential diagnosis process.

CASE REPORT

A 50-year-old male with a severe painful limitation (12 mm) of jaw opening referred a trauma to the right temporomandibular joint (TMJ) area occurring about 40 days before. Posttraumatic TMJ ankylosis was ruled out on the basis of negative magnetic resonance and cone-beam computerized tomography findings, and the patient underwent treatment with arthrocentesis, botulinum toxin injections, and physiotherapy on the basis of two diagnostic hypotheses, viz., an anchored disk phenomenon or a myofibrotic contracture of the right masseter muscle due to prolonged myospasm. After 4 months, jaw opening was slightly increased to 23 mm, but limitation and pain persisted. A new CT was performed to investigate for the emerging clinical picture compatible with traumatic myositis ossificans of the right temporalis muscle. Once the diagnosis was confirmed, the patient underwent surgery for coronoidectomy. At the 6-month follow-up, mouth opening was increased to up to 35 mm and pain was absent.

DISCUSSION

It is fundamental that patients suspected of having uncommon clinical pictures leading to mouth opening restriction are promptly referred to specialized centers, where the differential diagnosis process should be based on a comprehensive assessment taking into account for the potential etiologic factors described in the literature.

Myositis ossificans of the medial pterygoid muscle

Myositis ossificans (MO) is a disease whose main feature is the formation of heterotopic bone involving muscle or any other soft tissue. Pathogenesis is not all clear, but trauma is universally recognized as a trigger event. Myositis ossificans can be divided into 2 classifications: MO progressiva and MO traumatica. The authors present a case of a 64-year-old man who was diagnosed with MOT of the left medial pterygoid muscle. The patient had a long clinical history of signs and symptoms of temporomandibular articulation related to previous conditions, and no major traumatic events were reported, apparently related to MOT.

Myositis ossificans traumatica of the medial pterygoid

Myositis ossificans traumatica (MOT) is a non-neoplastic, heterotopic bone formation within muscle or fascia, presumably due to acute trauma, a burn, surgical manipulation, or repeated injury. A 36-year-old woman presented with progressive limitation of mouth opening over the past 5 months. Computed tomography revealed an irregular ossified mass attached to the medial aspect of the left ramus, extending to the medial and lateral pterygoid plates. MOT of the medial pterygoid is rare, with only four previously reported cases in the English language literature. Surgical excision of the ossification is the main treatment modality. The authors were able to establish a cleavage plane of 3 cm between the bony mass and the medial surface of the ramus. Abdominal fat was placed as an interpositional material to prevent fibrosis and heterotopic bone formation.

Myositis Ossificans of the Abdominal Rectus Muscle: Report of a Case

We herein report a rare case of myositis ossificans originating from the abdominal rectus muscle, found in a 38-year-old woman who presented with a left upper abdominal mass. The mass was initially suspected to be a malignant neoplasm because no history of either operation or trauma existed for this patient. Moreover, the location of the mass was unusual and the enhancement patterns of the dynamic magnetic resonance images were similar to that of a malignant tumor. Based on the radiologic findings, a surgical exploration was performed. A well-circumscribed mass, which measured 3.2 x 2 cm, was found in the rectus muscle. Microscopic findings showed a typical zonal pattern with a fibroblastic central zone and a zone of ossification at the periphery. Although abdominal myositis ossificans is extremely rare, it is one of the causes of abdominal mass lesions and can be mistaken for a malignant tumor. Therefore, a thorough knowledge of the evolution of myositis ossificans is necessary and in cases with malignant suggestion on magnetic resonance imaging, like that seen in our case, we suggest that a surgical excision may be necessary for both the diagnosis and treatment.

Post-traumatic Severe Trismus Caused by Impairment of the Masticatory Muscle

Restriction of the mouth opening from a pathologic condition outside the temporomandibular joint is called a pseudo- or extra-articular ankylosis. The authors report two cases of severe post-traumatic pseudoankylosis. One case showed fibrous degeneration of the bilateral masseter muscles without a facial bone fracture, which caused severe trismus, a mouth opening of less than 2 mm, and gradually appeared after blunt injuries to the face. The other was a rare case accompanied with the bone formation in the masseter muscle and was diagnosed as myositis ossificans traumatica, which also presented as severe trismus, with a maximal mouth opening of 5 mm after facial violence. Both were surgically treated with dissection of the affected muscles. In addition, a hemicoronoidotomy was performed in the case of myositis ossificans traumatica. Although a conservative therapy with physical rehabilitation is the basic policy for the management of pseudoankylosis of the temporomandibular joint, a surgical treatment should be considered when the origin of the problems is an osteogenic character or severe extra-articular ankylosis resistant to conservative therapy before completion of true temporomandibular joint ankylosis.