Tuberculous osteomyelitis of mandibular condyle: a diagnostic dilemma.

Abstract

The incidence of tuberculosis (TB) is increasing worldwide and so are its consequences. Its oral manifestations are infrequent, occurring in approximately 3% of all cases. Although the primary lesion occurs as a pulmonary infection, the extrapulmonary infections have also shown an increase over the past few years. These infections generally involve the head and neck through haematogenous or lymphatic routes. The clinical presentation may be as an ulcer, granuloma, orofacial TB, TB of the salivary glands or tuberculous lymphadenitis. Rarely, secondary oral manifestations associated with pulmonary infection are seen, which can appear as lesions on the gingiva, palate, lips, tongue, buccal mucosa, frenulum and in the jaw bones. Owing to the rarity of orofacial TB, it seldom arouses clinical suspicion, especially when a positive history of a systemic infection or therapy is denied. Tuberculous involvement of the mandibular condyle is even rarer, and only two such cases are reported so far, both in English-language literature. Further, the diagnosis of such a case is extremely difficult as there are no specific signs pathogonomic of infection. The only manifestation may be a localized painful swelling of the jaw. The presented case is of osteomyelitis of the mandibular condyle in a 20-year-old male patient in whom TB was later suspected. In this case report the role of diagnostic techniques is emphasized as the osteomyelitis of the condyle has the risk of being easily missed owing to its atypical signs and symptoms and atypical radiographic appearance.

Full text

Page 1

CASE REPORT
Tuberculous osteomyelitis of mandibular condyle: a diagnostic
dilemma
S Sheikh1, S Pallagatti1, D Gupta*,1and A Mittal2
1Department of Oral Medicine and Radiology, M.M. College of Dental Sciences and Research, Mullana, Ambala, Haryana, India;
2Department of Radiodiagnosis and Imaging, M.M. Institute of Medical Sciences and Research, Mullana, Ambala, Haryana, India
The incidence of tuberculosis (TB) is increasing worldwide and so are its consequences. Its
oral manifestations are infrequent, occurring in approximately 3% of all cases. Although the
primary lesion occurs as a pulmonary infection, the extrapulmonary infections have also
shown an increase over the past few years. These infections generally involve the head and
neck through haematogenous or lymphatic routes. The clinical presentation may be as an
ulcer, granuloma, orofacial TB, TB of the salivary glands or tuberculous lymphadenitis.
Rarely, secondary oral manifestations associated with pulmonary infection are seen, which
can appear as lesions on the gingiva, palate, lips, tongue, buccal mucosa, frenulum and in the
jaw bones. Owing to the rarity of orofacial TB, it seldom arouses clinical suspicion, especially
when a positive history of a systemic infection or therapy is denied. Tuberculous involvement
of the mandibular condyle is even rarer, and only two such cases are reported so far, both in
English-language literature. Further, the diagnosis of such a case is extremely difficult as
there are no specific signs pathogonomic of infection. The only manifestation may be a
localized painful swelling of the jaw. The presented case is of osteomyelitis of the mandibular
condyle in a 20-year-old male patient in whom TB was later suspected. In this case report the
role of diagnostic techniques is emphasized as the osteomyelitis of the condyle has the risk of
being easily missed owing to its atypical signs and symptoms and atypical radiographic
appearance.
Dentomaxillofacial Radiology (2012) 41, 169–174. doi: 10.1259/dmfr/56238546
Keywords: tuberculosis; osteomyelitis; condyle
Case report
A 20-year-old male patient presented with a gradually
progressive swelling at the side of his face in front of the
right ear for about 15 days (Figure 1). 2 months
beforehand, there was a sudden onset of dull pain at
the right temporomandibular joint (TMJ) region which
aggravatedduringmouthopening;itwasassociated with
reduced mouth opening. The patient’s medical history
was non-contributory. There was no history of any
trauma to the TMJ region. He was moderately built and
nourished, and afebrile at the time of examination. He
otherwise reported weakness and malaise over the past
month along with some weight loss. General physical
and systemic examinations were unremarkable. All the
vital signs were in normal range. He was a gutka chewer
(a preparation of tobacco mixed with areca nut) and had
chewed it 5–6 times a day for 3 years.
Extraorally, a unilateral solitary swelling was seen at
the right TMJ region measuring 1.561.5 cm in size. It
was oval with normal overlying skin. On palpation, the
swelling was firm, tender and non-fluctuant. There was
a localized rise in temperature. Tenderness was elicited
in the temporalis muscle of the same side with no
obvious lymphadenopathy of the head and neck region.
Intraorally, the buccal mucosa of the left side was
opaque and blanched. There were no other significant
findings. The occlusion was not affected. On palpation,
thick fibrous bands were felt in the left buccal mucosa.
This gave a clinical impression of oral submucous
fibrosis which could be a contributory factor for the
patient’s reduced mouth opening apart from the swelling.
Suspecting a middle ear infection, the patient was
referred to an otolaryngologist for otoscopy. The
findings were not significant.
*Correspondence to: Dr Deepak Gupta, Department of Oral Medicine and
Radiology, M.M. College of Dental Sciences and Research, Mullana, Ambala,
Haryana, India. Email: drdeepak_26@rediffmail.com
Received 15 April 2010; revised 24 July 2010; accepted 26 August 2010
Dentomaxillofacial Radiology (2012) 41, 169–174
’ 2012 The British Institute of Radiology
http://dmfr.birjournals.org

Page 2

Radiographic findings
On the digital panoramic radiograph (shot by Ortho-
phos XG 5 DS Ceph; Sirona, Bensheim, Germany)
there was an ill-defined area of radiolucency seen in the
right condyle (Figure 2).
The resorption of the condyle was suggestive of
osteomyelitis.
Ultrasonography (USG) of the right parotid region
was then advised. USG was done on Logiq 500 Pro
(GE Medical Systems, Milwaukee, WI) with a high
frequency linear array transducer (9.6 MHz frequency).
Ultrasonographic findings
The parotid gland appeared normal. The condyle and
neck of the mandible of the right side showed
irregularity with erosions suggestive of abscess forma-
tion (Figure 3). One lymph node anterior to the tragus
on right side was enlarged and hypoechoic. Thus,
osteomyelitis of the condyle and ramus of the mandible
of the right side with abscess formation was suspected.
A CT of the head was taken after injecting 60 ml
of non-ionic intravenous contrast by single slice spiral
CT scanner (Somatom Emotion, Siemens, Munich,
Germany) at 80 mAs, 130 Kv and 5 mm slice width. A
reconstruction of the images was done as required.
CT findings
In the bone window there was evidence of erosion
with comminuted destruction of the right mandibular
condyle. In the soft-tissue window with contrast there
was abscess formation with peripheral enhancement
surrounding the right condyle extending into the right
masseter and pterygoid muscles (Figure 4). There were
a few minimally enlarged right cervical lymph nodes
along the jugular chain. The findings correlated to the
osteomyelitis of the right mandibular condyle with a
surrounding abscess and cervical lymphadenopathy.
Diagnosis
Chronic suppurative osteomyelitis of the condyle was
suspected but there was no significant intraoral finding
Figure 1 Patient with swelling in the right pre-auricular area
Figure 2 Panoramic radiograph showing a radiolucent lesion involving the right condylar process of the mandible
Tuberculous osteomyelitis of condyle
170
S Sheikh et al
Dentomaxillofacial Radiology

Page 3

related to it. A haematological examination revealed a
mildly increased erythrocytic sedimentation rate (ESR:
26 mmh–1) and raised polymorphonuclear leucocytes
suggestive of infection. As there was no significant
intraoral finding and no history of trauma or operative
procedure performed, a systemic source of infection
was suspected. Ultrasound-guided fine needle aspira-
tion was done from the dependent part in between
the centre and the lower border of the swelling with
the help of a syringe. Blood-tinged pus was obtained
on aspiration. This was sent for cytopathological
examination. Meanwhile, the patient was prescribed
capsule amoxycillin (with Lactobacillus) 500 mg three
times a day (T.I.D), tablet metronidazole 400 mg T.I.D
andtablet diclofenacsodium50 mg as needed for5 days.
The swelling worsened and there was no relief in the
signs and symptoms after 5 days. The pus smear showed
a few epitheloid cells, histiocytes and chronic inflamma-
tory cells (Figure 5), which were suggestive of chronic
granulomatous infection.
Based on the cytopathology report along with raised
ESR and non-responsiveness towards conventional
antibiotic treatment, chronic granulomatous diseases
like tuberculosis (TB) or deep fungal infections were
suspected, but the culture result for fungal infection
was negative. Also, there was no response to systemic
antifungal therapy (tablet fluconazole 200 mgday–1).
Tuberculous osteomyelitis of the condyle was suspected.
Although there were no specific identifying features
to demonstrate TB, the patient belonged to an area
where the incidence of TB is higher, hence it was
suggested that TB should not be excluded as a diagnosis
and could be the cause of the patient’s symptoms.
However, tuberculous infection was suspected owing to
the presence of epitheloid cells and histiocytes in the
pus smear. Further, the inefficacy of the conventional
antibiotic therapy on the patient cannot be overlooked.
Based on these findings, investigations to confirm TB
including chest radiograph, Mantoux test, culture and
staining of acid fast bacilli (AFB) were advised. All the
tests were negative. The value of Mantoux test was
9 mmh–1.
Meanwhile, 10 days after his first visit, the patient
complained of pain in the back. The patient was referred
for detailed general physical examination. Tenderness in
the L5–S1 area and in right sacroiliac joint area was
elicited. MRI of the lumbosacral spine and sacroiliac
joint was done in axial, coronal and sagittal planes with
Signa Profile (GE Medical Systems) 0.2Tesla MRI
Figure 4
abscess surrounding the eroded right condylar process
Coronal CT with contrast in soft-tissue window showing
Figure 5
cytes and red blood cells are also seen
Pus smear showing epitheloid cells. Histiocytes, lympho-
Figure 3
condyle of mandible with erosions
Ultrasonography showing abscess surrounding the right
Tuberculous osteomyelitis of condyle
S Sheikh et al
171
Dentomaxillofacial Radiology

Page 4

machine. T2weighted, T1weighted sagittal sequence and
coronalshort tauinversion recovery sequence was taken.
MRI findings
There was evidence of bilateral paravertebral and pre-
vertebral abscess at L5–S1 level (Figure 6) and inflam-
mation and erosion in the right sacroiliac joint, which is
highly suggestive of caries of the right sacroiliac joint.
Based on these findings, the final diagnosis of tuber-
culous osteomyelitis of the right mandibular condyle with
caries in the sacroiliac joint was made. The patient was
referred for anti-tubercular treatment (ATT) without any
delay.
Management
ATT was started. Duration of the treatment was
9 months. Prescription involved first-line anti-tubercular
drugs. The patient showed an excellent response to
treatment so no consideration was given to surgical
intervention. Complete regression of the swelling
was achieved within 1 month of ATT (Figure 7). Digit-
al panoramic radiograph (Figure 8) and CT scan
(Figure 9) were repeated after 4 months of treatment.
The radiographs had no evidence of any abscess or
lymphadenopathy. Since the foci of infection had not
been traced, the other physicians he had been consulting
in the past were approached. On rechecking his medical
records, it was found that he was diagnosed as a case of
pulmonary TB by a local government hospital 7 years
earlier and had been under ATT.
Discussion
TB is one of the oldest diseases known to affect
humans.The causative
tuberculosis, infects 20–43% of the world’s population.
It is very important to diagnose this disease at an early
stage. If left untreated, it may prove fatal within 5 years
in more than half of the cases.1There was a massive
decrease in the incidence of this disease in 1980s due
to advances in chemotherapy, inoculation with BCG
(Bacillus Calmette-Gue ´rin) vaccine and improvement
in public health and nutritional status. This decline was
organism,
Mycobacterium
reversed in 1985 owing to population explosion, immigra-
tion from developing nations, increase in HIV (human
immunodeficiency virus) positive cases and development
of multiple drug resistance worldwide.1,2
According to the World Health Organization (WHO)
in the late 1990s, between 3.5–4 million new cases of
TB were diagnosed annually.1These cases represented
only a fraction of the total affected people owing to
a low level of case detection and incomplete notifi-
cation in many of the national programmes. The new
reported cases rose to 8 million in 1997. In the same
year, 2 million patients died of TB, 98% of whom were
from developing countries.1Without greater control
efforts, the annual global incidence of TB may increase
by 40% between now and 2020.1
Although the primary lesion occurs as a pulmonary
infection, the extrapulmonary infections have also
shown an increase over the past few years. Surpris-
ingly, it is the musculoskeletal system which is more
commonly affected than the respiratory system. Most
of the cases in the literature regarding TB of jaws are
primary. Rarely, secondary oral manifestations asso-
ciated with pulmonary infection are seen, which can
appear as lesions on the gingiva, palate, lips, tongue,
buccal mucosa, frenulum and in the jaw bones.4
This case deserves special attention as tuberculous
osteomyelitis is very rare and constitutes less than 2%
of the skeletal TB. Jaw involvement in TB is even rarer
and usually affects older individuals.3Most likely, this
case of tuberculous involvement of the condyle with
complete lytic pattern along with caries of spine has not
been reported so far in dental literature. Besides, it can
also be easily misdiagnosed owing to its atypical signs
and symptoms and atypical radiographic appearance.
The diagnosis of such cases is based on clinical
findings and radiographs, which have to be confirmed
by sputum or tissue smears showing the bacilli.2,3The
Figure 6
and pre-vertebral collections at L5–S1
Axial T2weighted image showing bilateral paravertebral
Figure 7 Swelling completely regressed after 1 month of treatment
Tuberculous osteomyelitis of condyle
172
S Sheikh et al
Dentomaxillofacial Radiology

Page 5

site-specific tissue or fluid aspirate must be submitted for
smear culture and histological analysis as has been done
in this case. Histologically, it presents as caseating or
non-caseating granuloma with giant cells, which was not
so in our case. Radiographically, it usually presents as
blurring of bone details producing a diffuse radiolucency
and erosion of bone, as in this reported case, or it may be
a mixed radiolucent-radiopaque lesion.3About half of
such patients do not have pulmonary disease at the time
they report, as the primary infection heals leaving some
surviving tubercle bacilli.4With a lowering of resistance,
these are reactivated producing local as well as heama-
togenous spread.4,5TB should be considered in the
differential diagnosis of chronic joint disease4even if
routine investigations for TB are negative.5
A study by Lanka et al6on the role of fine needle
aspiration cytology of lymph nodes in the diagnosis of
cutaneous TB states that the fine needle aspiration
cytology smears in their patients with cutaneous TB with
lymphadenitis were negative for AFB by the Ziehl–
Neelsen stain, while varying degrees of positivity are
reported by others. It was concluded that an absence of
AFB in smears showing an otherwise characteristic
cytological picture should not weigh against the diag-
nosisofTB.7,8Theystatethatalltheirpatientsinthesaid
study responded to standard anti-TB treatment.
Furthermore, according to Pandit et al,9when con-
sidering the overall prevalence of TB in the Indian
population, the presence of epithelioid cell granuloma is
indicative of TB unless proven otherwise, which is simi-
lar to our findings. It is also reported that the percen-
tage of cases showing AFB positivity declines when
more epithelioid cell granulomas are observed.10
In our country, a standard recommendation of 10 mm
is given in the Revised National Tuberculosis Program
(RNTPC) guidelines and is both appropriate and re-
levant for our country. The situation changes in popula-
tion surveys where a cut off of .15 mm is taken to make
the test more specific. Such surveys use Mantoux test as
the only criteria to find out the prevalence of tubercular
disease without the help of risk factors for any other
investigation. But many authors, such as Jorgen11and
Diba et al12, have stated that the cut-off varies from
Figure 8Panoramic radiograph after 4 months of treatment showing bone formation as compared with previous pre-treatment radiograph
Figure 9
4 months of treatment without any abscess surrounding the resorbed
condyle and without lymphadenopathy
Coronal CT with contrast in soft-tissue window after
Tuberculous osteomyelitis of condyle
S Sheikh et al
173
Dentomaxillofacial Radiology

Page 6

region to region depending on the prevalence of atypical
mycobacteria and BCG vaccination.
Some authors have also stated that if there is a higher
probability of TB infection, such as in the case of recent
contact with an infectious case or residence in a high
prevalence country as in our case, then an induration of
8 mm or greater is more likely to be due to TB.
Based upon these findings, we conclude that even if the
titre of the Mantoux test is borderline, as in this case, the
diagnosis and treatment for latent tubercular infection is
considered if the person (a) was in contact with another
person with infectious TB, (b) was born or has lived in a
high TB prevalence country or (c) is continually exposed
to populations where TB prevalence is high.
There is no specific standard for diagnosing TB in
young patients and under some circumstances diagnosis
can be based on circumstantial evidence, which in the
presentcaseincludedasmear-positiveTBpatient,clinical
and radiographic features consistent with TB and a very
good response to treatment. Further caries of spine in
MRI also added weight towards tuberculous infection.
WHO guidelines for appropriate TB chemotherapy
include the necessity for a long-term treatment interval
with a multidrug regimen, which can extend up to 9
months.3Some authors suggest that medical treat-
ment alone is effective. Others believe that aggressive
debridement with primary closure is required as an
adjunct to chemotherapy to prevent recurrence or the
formation of a draining sinus.13,14According to some
authors, surgery is not indicated in smaller lesions.
Close follow-up is advised in such patients to determine
the need for surgical treatment.14
The role of a history of TB is very important in such
cases; however, in this presented case the patient and his
parents denied positive history of the disease. The
patient did not consider the disease as significant as he
was quite young when he suffered from TB. The parents
denied it as they considered it as a social stigma for their
son to be seen as a TB patient. So these patients usually
try to hide any history regarding TB as in this reported
case. Hence, proper counselling of the patient as well as
parents is stressed to reveal their medical history, which
sometimes proves very beneficial to achieve a correct
diagnosis. With varying presentations, the particular
disease has a tendency to get overlooked. This report
highlights a rare case of TB of the condyle. It is an
attempt to familiarize the general dental practitioner on
the various presentations of TB and hopefully lead to a
reduction in the unnecessary investigations leading to
erroneous treatment.
It can be concluded that the morbidity and emer-
gence of TB can be effectively reduced with early
diagnosis and initiation of effective regimen. With the
increased prevalence of TB, especially in developing
countries, the chances of patients reporting first to a
dental professional are very high. Leighty et al15
reported that once the bacteria gain access to the
synovial space, they can cause irreversible changes
within a few days. Thus, the dental professional plays a
crucial role in identifying such high risk patients and
can initiate prompt isolation and management.
Acknowledgments
We acknowledge Dr Sachin Kumar Rai (reader), Department
of Oral and Maxillofacial Surgery, Genesis Institute of Dental
Sciences and Research, Ferozepur, Punjab, for his invaluable
suggestions and help to prepare this manuscript.
References
1. Raviglione MC, O’Brien RJ. Tuberculosis. In: Braunwald E,
Fauci AS, Kasper DL, Hauser SL, Longo DL, Jameson JL, (eds).
Harrison’s principles of internal medicine. Volume 1, 15th edn.
International edition. New York, NY: McGraw-Hill, 2001; 12:
1024–1035.
2. Lynch MA. Diseases of the respiratory system. In: Lynch MA,
Brightman VJ, Greenberg MS, (eds). Oral medicine diagnosis and
treatment. 9th edn. Philadelphia, PA: Lippincott-Raven, 1994:
441–445.
3. Chaudhary S, Kalra N, Gomber S. Tuberculous osteomye-
litis of the mandible: a case report in a 4-year old child. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod 2004; 97:
603–606.
4. Soman D, Davies SJ. A suspected case of tuberculosis of the
temporomandibular joint. Br Dent J 2003; 194: 23–24.
5. Dinkar AD, Prabhudessai V. Primary tuberculous osteomyelitis
of the mandible: a case report. Dentomaxillofac Radiol 2008; 37:
415–420.
6. Lanka P, Lanka LR, Krishnaswamy B. Role of fine needle
aspiration cytology of lymph nodes in the diagnosis of cutaneous
tuberculosis. Indian J Tuberc 2004; 51: 131–135.
7. Rajwanshi A, Bhambhani S, Das DK. Fine needle aspira-
tion cytology diagnosis of tuberculosis. Diagn Cytopathol 1987;
3: 13–16.
8. Shahabuddin MD, Raghuveer CV. Role of fine needle aspiration
cytology in detecting extra-pulmonary tuberculosis. J Odontol
Conserv 2003; 20: 77–78.
9. Pandit AA, Khilani PH, Prayag AS. Tuberculous lymphadenitis,
extended cytomorphological features. Diagn Cytopathol 1995; 12:
23–27.
10. Das Gupta A, Gosh RN, Poddar AK, Mukherjee C, Mitra PK,
Gupta G, et al. Fine needle aspiration cytology of cervical
lymphadenopathy with special reference to tuberculosis. J Indian
Pathol Microbiol 1996; 39: 74–75.
11. Jorgen N. The efficacy of tuberculin test—an analysis based on
results from 33 countries. Bull WHO 1960; 2: 5–37.
12. Diba S, Ghose S, Krishanmurthy MS, Shashidhara AN.
Tuberculosis infection rate in rural population of Bikaner district.
Indian J Tuberculosis 1996; 43: 91–97.
13. Hsu HS, Wang LS, Wu YC, Fahn HJ, Huang MH. Management
of chest wall tuberculosis. Scand J Thorac Cardiovasc Surg 1995;
29: 119–123.
14. Sharma S, Juneja M, Garg A. Primary tubercular osteomyelitis of
the sternum. Indian J Pediatr 2005; 72: 709–710.
15. Leighty SM, Spach DH, Myall RW, Burns JL. Septic arthritis of
the temporomandibular joint: review of the literature and report
of two cases in children. Int J Oral Maxillofac Surg 1993; 22:
292–297.
Tuberculous osteomyelitis of condyle
174
S Sheikh et al
Dentomaxillofacial Radiology