Calcium pyrophosphate deposition disease of the temporal bone

Pseudogout growing from the temporomandibular joint into the middle cranial fossa

Calcium pyrophosphate dihydrate deposition disease (CPDD or pseudogout) is a degenerative joint disease. It is defined by the presence of calcium pyrophosphate dihydrate crystals. It usually manifests in the knee and wrist. Manifestation in the temporomandibular joint (TMJ) is only reported in case reports. We present a patient with CPDD mimicking a malignant tumor of the TMJ. A 53-year-old woman presented with progressive pain and a slow-growing swelling of the left TMJ. Imaging showed an extensive mass in the infratemporal fossa extending into the middle cranial fossa and compressing the temporal lobe. Assuming a potential malignancy, we excised the growth, which extended into the dura. We covered the resulting tissue defect within the primary surgery using a microsurgically anastomosed scapular flap and performed further reconstructive surgeries. Calcium pyrophosphate dihydrate crystals were found in the histopathologic examination of the excised tissue, resulting in the diagnosis of CPDD. That is a benign diagnosis, but we treated it like a malignancy. This leads us to the question, was there overtreatment? Tumoral CPDD in the TMJ can be a difficult diagnosis to obtain. The treatment remains controversial, but complete excision of the mass was performed in most reported cases.

Calcium pyrophosphate deposition disease: A case report with bilateral involvement of the temporomandibular joints and concurrence of psoriatic arthritis

Calcium pyrophosphate dehydrate deposition (CPDD) disease very rarely affects the temporomandibular joint (TMJ). It may resemble synovial chondromatosis, chondrosarcoma, chondroblastoma, or a parotid tumor. Clinical examination, CT, and MRI are important in making the correct diagnosis. Surgical removal of CPDD is necessary with or without excision of the TMJ.

Tophaceous Gout of the Middle Ear: Case Reports and Review of the Literature

Tophaceous gout of the middle ear is a rare occurrence that presents as a granular white-colored mass. It is frequently misdiagnosed as cholesteatoma or tympanosclerosis in patients who otherwise may not manifest any clinical or biochemical signs of gout. While uncommon, it can lead to clinically significant disease such as conductive hearing loss. The present report describes 2 cases of middle ear gouty tophi initially mistaken for another entity. Both patients underwent surgery, and the diagnosis of gout was revealed after final histopathological analysis. A review of the literature is also presented.

Temporal mandibular joint chondrocalcinosis (tophaceous pseudogout) diagnosed by ultrasound-guided fine-needle aspiration

Tophaceous pseudogout is a calcium pyrophosphate dihydrate crystal (CPPD) deposition disease that frequently affects elderly patient in the temporomandibular joint (TMJ). A diagnosis of CPPD deposition disease in the TMJ is challenging due to its mimicking of other benign and malignant entities. Surgical exploration followed by histologic examination is by far the most frequently used diagnostic modality. We present a case of an 87-year-old female who presented with a right TMJ mass. A final diagnosis of tophaceous pseudogout was made on cellular material obtained by ultrasound-guided fine-needle aspiration (US-guided FNA). Based on our case and current available literature, ultrasound-guided FNA is a reliable tool for diagnosing tophaceous pseudogout of the TMJ.

Case report: Calcium pyrophosphate dihydrate deposition of the temporomandibular joint diagnosed by fine-needle aspiration cytology

Calcium pyrophosphate dihydrate deposition (CPDD) is the accepted name for a disease that mainly occurs in elderly patients. This disease affects many joints in particular the knee joint. CPDD is extremely rare in the temporomandibular joint (TMJ) with only few cases reported in the English literature. Herein, we present a case of an 89 years old woman with a radiological diagnosis of chondrosarcoma of TMJ. Fine-needle aspiration cytology however showed crystals, multinucleated giant cells and macrophages which allowed a correct diagnosis of CPDD.

Osseous abnormalities related to the temporomandibular joint

With the arrival of arthrography, computed tomography, and magnetic resonance imaging, diagnostic imaging of the temporomandibular joint has improved tremendously over the last 20 years. In patients with temporomandibular joint pain and dysfunction, the main focus was on meniscal pathology. The purpose of this article is to discuss several osseous abnormalities and demonstrate their association with temporomandibular joint pain and dysfunction.

MR imaging of the temporomandibular joint

Temporomandibular joint (TMJ) internal derangement is fairly prevalent in patients presenting with facial pain. MR imaging has become the primary modality for the assessment of the temporomandibular joint. A review of the normal anatomy and the key imaging findings of the different pathologic entities affecting this joint are presented. A reading algorithm to facilitate a systematic interpretation of the TMJ imaging study also is provided.

Common abnormalities in temporomandibular joint imaging

Magnetic resonance imaging has evolved as a prime diagnostic method for soft-tissue abnormalities of the temporomandibular joint. The most common temporomandibular joint abnormalities are internal derangement and osteoarthritis, but there are many other reasons for pain and dysfunction that are often overlooked. The purpose of this paper is to illustrate several of these more unusual and less well-recognized causes for temporomandibular joint pain and dysfunction. For example, internal derangement is often seen in asymptomatic individuals. Another purpose is to illustrate the difference in magnetic resonance imaging of asymptomatic and symptomatic internal derangement.

Temporomandibular joint: MR imaging

Diagnostic imaging of TMJ has improved remarkably in the last 20 years. Various abnormalities related patient symptoms. Further studies using the latest imaging techniques will allow a better understanding of the sources of joint pain and the discrepancy between imaging findings and patient symptoms. For clinical practice, appropriate clinical examinations are needed to determine exactly which imaging findings are significant.

MR imaging of the temporomandibular joint

Technologic advances in MR imaging have had a decisive effect on the capacity of investigators to image the TMJ. This article provides a description of the normal anatomy and function of this joint. emphasizing the key imaging findings of internal derangement. A reading algorithm is given to achieve a systematic approach to the interpretation of a temporomandibular MR imaging study. Finally, a summary of key imaging findings of other miscellaneous pathologic processes involving this joint is provided.

Tumors and tumorous masses presenting as temporomandibular joint syndrome

OBJECTIVE

Neoplasms of the temporomandibular joint (TMJ) usually mimic common causes of TMJ syndrome, leading to delay in diagnosis. To increase awareness of TMJ neoplasms and establish guidelines for early intervention, we performed a retrospective analysis of a series of patients with neoplasms of the TMJ.

STUDY DESIGN AND SETTING

A retrospective review of the records of patients with neoplasms of the TMJ from 1990 to 1997 was done.

RESULTS

Six patients were identified. The neoplasms included benign and malignant neoplasms. The time from initial presentation to final diagnosis was in most cases prolonged, ranging from 3 months to 8 years. Patients typically showed advanced lesions radiographically. All patients required surgical extirpation. Postoperative radiation therapy was used for malignant lesions. Patient outcomes were delineated.

CONCLUSIONS AND SIGNIFICANCE

Neoplasms, both benign and malignant, of the TMJ are rare but represent a challenging diagnostic problem. In patients with 1 month or more of recalcitrant TMJ swelling or pain, radiographic imaging may be considered to rule out these rare neoplasms. This may lead to earlier intervention and improved outcome.

What is new about crystals other than monosodium urate?

Recently, attention has focused on the effects of weather conditions and seasonal changes on the incidence of acute microcrystalline events. Acute gout attacks are more frequent during the spring, but seasonal variations in the incidence of acute pseudogout attacks are less clearly defined. Genetic analysis of two unrelated families with calcium pyrophosphate dihydrate (CPPD) crystal deposition disease showed linkage to the short arm of chromosome 5p. Several recent reports show CPPD crystal disease occurring in association with Gitelman syndrome, the hypocalciuric-hypomagnesemic variant of Bartter syndrome. Two signaling pathways, protein kinase C and adenyl cyclase, modulate generation of extracellular pyrophosphate by porcine cartilage chrondrocytes. These transduction mechanisms may provide potential targets for the treatment of CPPD crystal deposition disease. A controlled clinical trial showed ultrasound therapy to be beneficial in the treatment of symptomatic chronic calcific tendinitis of the shoulder. There is evidence that apatite crystals may contribute to cartilage damage in osteoarthritis and that therapeutic interventions to prevent the formation and biologic effects of the crystals may potentially retard the progression of the osteoarthritic process.

Familial and clinical aspects of calcium pyrophosphate deposition disease

The mechanisms involved in calcium pyrophosphate dehydrated deposition disease (CPPDD) are unknown and those families with the disease, described in different countries, provide a fertile file for genomic research. Genomic DNA studies in these kindred with secondary or primary form of CPPDD provide a shortcut for trying to investigate the biomolecular basis of the disease. Mutations in the COL2A1 gene have been identified in one family with spondyloepiphyseal dysplasia and secondary deposits of pyrophosphate and apatite crystalline deposits. In another kindred with CPPDD due to precocious osteoarthritis, the phenotype was linked to markers of chromosome 8p. In four other kindreds (British, Argentinean, French, and the United States), the phenotypes were linked to a precise region of chromosome 5p. Two possible genes located in this region that are expressed in the articular cartilage, but of unknown articular physiologic role are being investigated as possible CPPDD genes. From the clinical point of view, CPPDD spectrum of clinical and radiographic manifestations is enlarging, especially those related to spine involvement or pseudo tumoral forms. At the end, the present review of a current therapeutic approach for CPPDD is discussed.