Temporomandibular joint (TMJ) lesions with intracranial extension: illustrative cases from a systematic review of the literature and our institution.

Abstract

Background: Intracranially extending temporomandibular joint (TMJ) lesions may be radiologically misinterpreted as primary intracranial or skull base pathologies, leading to diagnostic delays or inappropriate management.

Purpose: This systematic review aimed to characterize the clinical and imaging features of such TMJ lesions and evaluate the impact of radiologic misclassification. We also aimed to develop a diagnostic framework for when to consider an intracranially extending TMJ lesion, based on clinical and radiologic features.

Data sources: A comprehensive search of MEDLINE, SCOPUS, and Embase, conducted in accordance with PRISMA guidelines, yielded 2,255 records.

Study selection: After screening with a pre-determined inclusion and exclusion criteria, 128 studies involving 152 patients were included in the final analysis.

Data analysis: Statistical analyses were performed using STATA software. We also identified 3 patient cases through our institutional neuroradiology practice who were clinically and radiologically assessed for intracranially extending TMJ lesions.

Data synthesis: Patients had symptoms for an average of 34 months prior to diagnosis (47% female, mean age 50 years). The most common pathologies were pigmented villonodular synovitis/tenosynovial giant cell tumor (43%) and synovial chondromatosis (24%). Neurological symptoms were reported in 48% of cases, most frequently hearing loss (70%). Nearly one-third (33%) of cases with an imaging differential did not list a TMJ pathology (18/55). In cases with accurate imaging diagnosis, 90% had both CT and MRI performed. Most lesions were non-enhancing (CT 83%, MRI 75%) and demonstrated no adjacent brain edema (96%). In two cases, a TMJ ganglion cyst and pseudogout were misdiagnosed as intracranial tumors, resulting in unnecessary intervention, including repeat craniotomy and radiotherapy.

Limitations: Inherent biases of case report literature, including variability in the reporting of the imaging and clinical features, management and follow-up.

Conclusions: TMJ lesions with intracranial extension often present with non-specific symptoms and can mimic extra-axial tumors, leading to misdiagnosis on imaging. Recognition of hallmark imaging features, including lack of parenchymal invasion and distinct imaging patterns, may help improve radiologic accuracy and prevent overtreatment. We propose a diagnostic framework outlining when to suspect intracranially extending TMJ lesions based on clinical and imaging features, and how to avoid common diagnostic pitfalls.