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58-Year-Old Woman with Left-Sided Conductive Hearing Loss
This case features a 58-year-old woman presenting with left-sided conductive hearing loss, ultimately diagnosed with pigmented villonodular synovitis (PVNS) of the temporomandibular joint.
Imaging overview:
Coronal bone CT with contrast demonstrates a multifocal destructive osseous lesion centered in the left temporomandibular joint with aggressive osseous erosion. Coronal T2 MRI shows low signal intensity within the lesion reflecting hemosiderin deposition. Coronal T1 fat-saturated post-contrast MRI demonstrates variable enhancement of the mass, with persistently low signal from iron-laden hemosiderin on both T1 and T2 sequences.
Clinical insight:
Pigmented villonodular synovitis is a locally aggressive proliferative disorder of the synovium characterized by hemosiderin deposition within synovial tissue. When arising from the temporomandibular joint, it can extend into the middle cranial fossa and external auditory canal, producing conductive hearing loss. The hallmark imaging feature is markedly low T1 and T2 signal intensity due to iron-laden hemosiderin, which may also produce gradient-echo blooming artifact. CT is best for demonstrating the extent of osseous erosion, while MRI characterizes soft tissue involvement and hemosiderin content. Enhancement is variable on post-contrast sequences. Awareness of PVNS as a cause of TMJ-related conductive hearing loss is important given its aggressive local behavior and tendency for recurrence.
Case courtesy of Hezro Da Silva, BS, and Richard Wiggins, MD, University of Utah.