MYOSITIS OSSIFICANS TRAUMATICA OF THE MASSETER MUSCLE

http://dx.doi.org/10.5272/jimab.2013194.411
Journal of IMAB - Annual Proceeding (Scientific Papers) 2013, vol. 19, issue 4
ISSN: 1312-773X (Online)
MYOSITIS OSSIFICANS TRAUMATICA OF THE
MASSETER MUSCLE- review of the literature and
case report
Elitsa G. Deliverska,
Department of Oral and Maxillofacial surgery, Faculty of dental medicine, Medical
University, Sofia, Bulgaria
ABSTRACT:
Introduction: Myositis ossificans traumatica (MOT) is
known mostly in the orthopedic literature as non-neoplastic,
heterotopic bone formation within muscle or fascia,
presumably due to acute trauma or repeated injury. Myositis
ossificans traumatica of the masseter muscle is uncommon
disease producing limitation of opening of the jaws.
Purpose: To present a case of MOT of the masseter
muscle in patient with history of facial trauma.
Material and methods: The medical history of a 53
years patient with complaint of decreasing ability to open his
mouth over the past 10 years after a blow to face. CT revealed
enlarged calcification in the left masseter muscle.
Conclusion: Treatment of MOT of the masseter muscle
is surgical- total extirpation of the ossified muscle but also
surgical techniques including osteotomy that involve the
muscle attachment region should be considered and after that
appropriate physical therapy.
Key words: MOT; masseter muscle;
INTRODUCTION:
Myositis ossificans traumatica (eponyms: myositis
ossificans circumscripta, ossifying hematoma, calcified
hematoma, parosteal bone formation) was initially described
by Thorma [9] in 1958 as a condition generally caused by
calcification and progressive ossification of an intramuscular
hematoma after trauma. [7, 8] Very few cases have been
reported in the head and neck region. Arima et al. [2]
reviewed the literature and discovered 26 cases involving the
head and neck. The muscles most commonly affected, in
decreasing order of involvement, are the masseter (75%),
temporalis, genioglossus, buccinator, and medial pterygoid.
[2, 5] Only few cases have been reported with bilateral
involvement .[7] Myositis ossticans traumatica (MOT) should
be differentiated from its related counterpart myositis
ossificans progressiva (MOP). MOP is a rare hereditary
connective tissue disorder of unknown origin occurring
primarily in children. [4, 6, 10] The condition is autosomal
dominant, with variable expressivity. MOP is characterized
by progressive ossification of any and all skeletal muscles of
the body unrelated to trauma. Ossification of skeletal muscle,
fascia, tendons, and ligaments occurs with seemingly no
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definitive pattern. [1, 11]
Many theories have been proposed. Carey’l [3]
summarized these as 1) displacement of bony fragments into
the soft tissue and hematoma with subsequent proliferation,
2) detachment of periosteal fragments into the surrounding
tissue with proliferation of osteoprogenitor cells, 3) “leakage”
of subperiosteal osteoprogenitor cell into surrounding soft
tissue through periosteal perforations suffered via trauma, and
4) differentiation of extraosseous cells exposed to bone
morphogenic protein (BMP). Most clinicians adhere to the
last theory. According to this theory, bone fragmentation
during trauma may result in autolysis and release of BMP into
the soft tissue mass; BMP induction of cellular differentiation
with progressive ossification then occurs. [2, 5]
Potential diagnoses to be considered are:
1. Fibrous ankylosis, left temporomandibular joint; 2.
Scarring or calcification of the left masseter muscle (myositis
ossificans); 3. Left anterior disc displacement without
reduction or “anchored disc phenomenon”; 4. Right coronoid
impingement; 5. Tumor
CASE REPORT
We present a 55 years-old man complained of a
decreasing ability to open his mouth over the past 10 years
(fig. 1). After soft tissue blunt trauma (intramuscular
hematoma of left masseter) he reveal progressive limitation
of motion of the mandible (fig. 2). The patient was treated
initially with nonsteroidal anti-inflammatory medications
(NSAIDs), cold and hot compresses, and range of motion
exercises. Nonsurgical therapy was unsuccessful and the
patient was referred to our department for evaluation in
February 2013. Clinical examination showed limited mouth
opening- incisal opening to 3 mm and no lateral movements.
Painless swelling palpated in this region. Palpation and
auscultation of temporomandibular joints (TMJs) were
unremarkable. Differential diagnosis should be considered: 1)
benign or malignant tumors; 2) degenerative condylar
irregularities, or 3) a pathologic fracture.
The two most likely diagnoses were fibrous ankylosis
and myositis ossificans. Scarring or myositis ossiticans (MO)
of the masseter muscle seem like rare possibilities at first, but
achieving an accurate diagnosis should not be difficult with
the addition of the medical history, physical, and imaging
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findings. CT finding showed of impressive extensive
calcifications of the masseter muscle attached to the adjacent
bone by a broad, calcified stalk. CT revealed no obvious TMJ
pathology. The images could not rule out intraarticular
adhesion or a fibrous ankylosis. (Fig. 3, Fig. 4)
The patient was scheduled for operation with extraoral
approach and release(osteotomia) the bony attachment of the
involved left masseter muscle to the mandible, arthrotomy
and release of fibrous ankylosis / coronoidectomia if
indicated.
DISCUSSION
Myositis ossificans traumatica (eponyms: myositis
ossificans circumscripta, ossifying hematoma, calcified
hematoma, parosteal bone formation) was initially described
by Thoma [9] in 1958 as a condition generally caused by
calcification and progressive ossification of an intramuscular
hematoma after trauma. Very few cases have been reported
in the head and neck region. Arima et al. [2] reviewed the
literature and discovered 26 cases involving the head and
neck. Primarily single muscle involvement was reported. The
muscles most commonly affected, in decreasing order of
involvement, are the masseter, temporalis, genioglossus,
buccinator, and medial pterygoid. The case presented here is
MOT that involve the masseter muscle unilaterally. There is
a prominent male:female ratio of 24:4. Myositis ossticans
traumatica (MOT) should be differentiated from its related
counterpart myositis ossificans progressiva (MOP). MOP is
a rare hereditary connective tissue disorder of unknown origin
occurring primarily in children. [9] Histologic findings of
MOT typically include newly formed lamellar bone within
fibrous strands of muscle tissue where previous trauma is
suspected. There is a mixture of fibrous tissue, bone, and
occasionally cartilage. Careful histologic examination should
be performed to rule out extraosseous osteosarcoma. Elevated
alkaline phosphatise levels seem to occur during evolution of
MOT as a result of progress of the disease. Signs and
symptoms within the head and neck region can oftentimes be
minimal until severe trismus is evident.[1, 2] A history of
trauma to the affected area is commonly elicited. Typically,
there is limited posttraumatic evidence of ossification until
trismus occurs. In the case presented, trauma caused by buffet
may have produced the hemorrhage/ autolysis to stimulate the
sequence of events. Plain films are rarely helpful in
diagnosing early ossification, and the introduction of CT
scanning and MR imaging has aided in more timely
recognition of the condition. It is not clear why some muscles
are prone to ossification and others are not. No clinical or
laboratory studies have been linked to the diagnosis. [7] The
case presented raises a question about the degree of trauma
necessary to initiate ossification, as well as the theory behind
its inception. In addition, it substantiates the belief that
optimum postoperative results are achieved through complete
excision of the affected muscles and appropriate physical
therapy.
CONCLUSION:
It is not clear why some muscles are prone to
ossification and others are not. No clinical or laboratory
studies have been linked to the diagnosis. There are no
treatment protocols, as the literature is unclear as to the need
for surgical intervention, surgical timing, recurrence rates, and
effectiveness of nonsurgical therapies. Good postoperative
results are achieved through complete excision of the affected
muscles and appropriate physical therapy after surgery.
Fig. 1. Patient with myosistis ossificans traumatic.
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Fig. 2. Limitation of motion of the mandible.
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Fig. 3. CT revealed enlarged
calcification in the left masseter muscle.
Fig. 4. Calcification of the left masseter
muscle (myositis ossificans);
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Address for correspondence:
dr Elitsa Deliverska,
Department of Oral and Maxillofacial surgery, Faculty of Dental Medicine,
1, Georgi Sofiyski blvd., 1431 Sofia, Bulgaria; tel.+359 888 949 740;
email: elitsadeliverska@yahoo.com,
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