Mastoiditis, Osteomyelitis, and Septic Arthritis of Temporomandibular Joint

Abstract

A 58-year-old homeless male was brought to emergency department with altered mental status, lethargy, right ear pain, and right ear discharge for the past few days. His past medical history was significant for acquired immunodeficiency syndrome (AIDS) noncompliant with antiretroviral therapy, chronic hepatitis C, chronic kidney disease, and polysubstance abuse especially snorting cocaine. On physical examination, the patient appeared cachectic, in no acute distress. There was tenderness to palpation over the right periauricular area with a visible abscess measured 2 cm  3 cm just anterior to the tragus, grossly visible right nasal perforation measuring 1 cm  1 cm (Figure 1). Ear, nose, and throat evaluation showed right otorrhea, intact right tympanic membrane, opaque, anterior canal wall erythematous with significant prolapse of the right temporomandibular joint (TMJ) into canal, there was pain with palpation of right TMJ, left external auditory canal was occluded by cerumen. The rest of the physical examination was not contributory. An initial noncontrast computed tomography scan of the head showed possible right mastoiditis and TMJ osteomyelitis (OM) (Figure 2). Magnetic resonance imaging of the head without contrast confirmed these findings along with OM involving the mandibular condyle and septic arthritis of the TMJ (Figure 3). Blood and right ear drainage fluid cultures grew methicillin-sensitive Staphylococcus aureus. The patient was placed on intravenous nafcillin 2 gram every 4 hours. Transesophageal echocardiogram did not reveal any vegetation on the cardiac valves. The patient underwent incision and drainage of the right infected TMJ, arthrotomy, and a biopsy of the mandibular right condyle. During the procedure, pus was noted in the right TMJ space, the right condyle was partially eroded, debris was removed and the joint space was thoroughly irrigated. Bone biopsy pathology showed limited fragments of bone with marrow fibrosis and spindle cells without acute inflammation. Bone biopsy culture isolated rare growth of Candida glabrata after 2 weeks thought to be a contaminant.

Perspective on Temporomandibular Joint Disorder: Foramen Tympanicum Defect

“…Infections in the mastoid area can cause TM problems. 24 The presence of an FT defect may also affect TMJ function through a similar pathway. Nowadays, as the causes and symptoms of mastoiditis have become more known to clinicians, the factors in diagnosing TMJ problems can be more easily determined.…”

“…Infections in the mastoid area can cause TM problems 24 . The presence of an FT defect may also affect TMJ function through a similar pathway.…”

Exploring the Complexities of Temporomandibular Joint Function and Dysfunction: A Contemporary Review

“…Despite its rarity, severe long-term disability frequently occurs in patients with TMJ septic arthritis (54). Staphylococcus aureus is the most frequently observed bacterium, and it can infect a joint through hematogenous dissemination or direct inoculation (55).…”

“…The clinical appearance and severity of the indications serve as the primary criteria for differentiating septic arthritis from other inflammatory disorders. Septic arthritis is characterized by sudden onset of acute pain, excessive tenderness upon palpation, and other general symptoms, including fever, malaise, or nausea/vomiting (55).…”