A 34-year-old woman visited our clinic with complaints of trismus, numbness in the left half of the tongue, and pain in tooth 34. At the patient’s initial visit to our clinic, the maximum assisted jaw opening movement was 20 mm, pointing to severe trismus. The patient complained of spontaneous pain in tooth 34 but did not evince percussion pain. Her pain remained unchanged even under local anesthesia. Radiography showed no pathological findings. A tenderness test of masticatory muscles failed to induce pain. The presence of severe trismus argued against temporomandibular disorders, resulting in suspicion of other inflammatory disease. In view of numbness of the tongue, other diseases such as inflammation or neoplastic disease in the head and neck region were considered. The patient was referred to the departments of neurosurgery and otolaryngology for examination. The results of MRI and CT diagnosis led to the identification of acute myositis of the left medial pterygoid muscle requiring the prescription of nonsteroidal anti-inflammatory drugs, and relaxation of mandibular muscles. With time, maximum unassisted jaw opening improved and pain in tooth 34 ceased, but tongue numbness persisted. The condition was attributed to compression of lingual nerve (LN) and mandibular nerve (MN) resulting from medial pterygoid muscle inflammation.
References
[1]
Okeson, J. (2014) Bell’s Oral and Facial Pain. 7th Edition, Quintessence, Chicago.
[2]
De Laat, A. (2020) Differential Diagnosis of Toothache to Prevent Erroneous and Unnecessary Dental Treatment. Journal of Oral Rehabilitation, 47, 775-781. https://doi.org/10.1111/joor.12946
[3]
Noma, N., Hayashi, M., Kitahara, I., Young, A., Yamamoto, M., et al. (2017) Painful Trigeminal Neuropathy Attributed to a Space-Occupying Lesion Presenting as a Toothache: A Report of 4 Cases. Journal of Endodontics, 43, 1201-1206. https://doi.org/10.1016/j.joen.2017.02.002
[4]
Sessle, B.J. (2000) Acute and Chronic Craniofacial Pain: Brainstem Mechanisms of Nociceptive Transmission and Neuroplasticity, and Their Clinical Correlates. Critical Reviews in Oral Biology & Medicine, 11, 57-91. https://doi.org/10.1177/10454411000110010401
[5]
Wright E.F. (2000) Referred Craniofacial Pain Patterns in Patients with Temporomandibular Disorder. Journal of the American Dental Association, 131, 1307-1315.
[6]
Simons, D.G. and Travell, J.G. (1983) Myofascial Pain and Dysfunction: The Trigger Point Manual. 1st Edition, Williams & Wilkins, Baltimore.
[7]
Kamio, T., Yakushiji, T., Takaki, T., Shibahara, T., Imoto, K., et al. (2019) Incidental findings during Head and Neck MRI Screening in 1717 Patients with Temporomandibular Disorders. Oral Radiology, 35, 135-142. https://doi.org/10.1007/s11282-018-0327-y
[8]
Ciacchella, A.P. and Higgins, W.L. (1990) MR Imaging of Pterygoid Muscle Inflammation. Magnetic Resonance Imaging, 8, 665-667. https://doi.org/10.1016/0730-725X(90)90148-U
[9]
Satheeshkumar, P.S., Mohan, M.P. and Jacob, J. (2014) Restricted Mouth Opening and Trismus in Oral Oncology. Oral Surgery, Oral Medicine, Oral Pathology, and Oral Radiology, 117, 709-715. https://doi.org/10.1016/j.oooo.2014.02.031
[10]
Alvarez-Arenal, A., Gonzalez-Gonzalez, I., Moradas Estrada, M., de Llanos-Lanchares, H. and Costilla-Garcia, S. (2016) Temporomandibular Disorder or Not? A Case Report. Cranio, 34, 264-269. https://doi.org/10.1179/2151090315Y.0000000018
[11]
Heo, M.S., An, B.M., Lee, S.S. and Choi, S.C. (2003) Use of Advanced Imaging Modalities for the Differential Diagnosis of Pathoses Mimicking Temporomandibular Disorders. Oral Surgery, Oral Medicine, Oral Pathology, and Oral Radiology, 96, 630-638. https://doi.org/10.1016/S1079-2104(03)00373-1
[12]
Thangavelu, A., Vaidhyanathan, A. and Narendar, R. (2011) Myositis Ossificans Traumatica of the Medial Pterygoid. International Journal of Oral and Maxillofacial Surgery, 40, 545-549. https://doi.org/10.1016/j.ijom.2010.10.024
[13]
Hanisch, M., Hanisch, L., Fröhlich, L.F., Werkmeister, R. and Bohner, L. (2018) Myositis Ossificans Traumatica of the Masticatory Muscles: Etiology, Diagnosis and Treatment. Head & Face Medicine, 14, Article No. 23. https://doi.org/10.1186/s13005-018-0180-6
[14]
Boffano, P., Zavattero, E., Bosco, G. and Berrone, S. (2014) Myositis Ossificans of the Left Medial Pterygoid Muscle: Case Report and Review of the Literature of Myositis Ossificans of Masticatory Muscles. Craniomaxillofacial Trauma and Reconstruction, 7, 43-50. https://doi.org/10.1055/s-0033-1356760
[15]
Reddy, S.P., Prakash, A.P., Keerthi, M. and Rao, B.J. (2014) Myositis Ossificans Traumatica of Temporalis and Medial Pterygoid Muscle. Journal of Oral and Maxillofacial Pathology, 18, 271-275. https://doi.org/10.4103/0973-029X.140781
[16]
Choudhary, A.K., Sahoo, N.K. and Chattopadhyay, P.K. (2012) Myositis Ossificans Traumatica of the Medial Pterygoid Muscle: A Case Report. Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology, 24, 241-244. https://doi.org/10.1016/j.ajoms.2011.12.004
[17]
Rattan, V., Rai, S. and Vaiphei, K. (2008) Use of Buccal Pad of Fat to Prevent Heterotopic Bone Formation after Excision of Myositis Ossificans of Medial Pterygoid Muscle. Journal of Oral and Maxillofacial Surgery, 66, 1518-1522. https://doi.org/10.1016/j.joms.2007.05.020
[18]
Piagkou, M., Demesticha, T., Skandalakis, P. and Johnson, E.O. (2011) Functional Anatomy of the Mandibular Nerve: Consequences of Nerve Injury and Entrapment. Clinical Anatomy, 24, 143-150. https://doi.org/10.1002/ca.21089
[19]
Piagkou, M.N., Demesticha, T., Piagkos, G., Androutsos, G. and Skandalakis, P. (2011) Mandibular Nerve Entrapment in the Infratemporal Fossa. Surgical and Radiologic Anatomy, 33, 291-299. https://doi.org/10.1007/s00276-010-0706-5
[20]
Sakamoto, Y. and Akita, K. (2004) Spatial Relationships Between Masticatory Muscles and Their Innervating Nerves in Man with Special Reference to the Medial Pterygoid Muscle and Its Accessory Muscle Bundle. Surgical and Radiologic Anatomy, 26, 122-127. https://doi.org/10.1007/s00276-003-0177-z
[21]
Shimokawa, T., Akita, K., Sato, T., Ru, F., Yi, SQ., et al. (2004) Penetration of Muscles by Branches of the Mandibular Nerve: A Possible Cause of Neuropathy. Clinical Anatomy, 17, 2-5. https://doi.org/10.1002/ca.10169
[22]
Akita, K., Sakaguchi-Kuma, T., Fukino, K. and Ono, T. (2019) Masticatory Muscles and Branches of Mandibular Nerve: Positional Relationships between Various Muscle Bundles and Their Innervating Branches. The Anatomical Record (Hoboken), 302, 609-619. https://doi.org/10.1002/ar.23943
