What are the management options for Titze syndrome?

Management of Tietze Syndrome

Tietze syndrome should be managed initially with conservative therapy including NSAIDs and local corticosteroid injections, with surgical resection reserved only for severe, medically refractory cases.

Initial Conservative Management

Start with nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line therapy for pain control. 1 This benign, self-limiting arthropathy typically responds to conservative measures without requiring invasive intervention. 1

Local Injection Therapy

For patients not responding adequately to NSAIDs alone, proceed to local corticosteroid injection combined with local anesthetic. 2 This approach provides rapid and effective pain relief:

• Inject a mixture of triamcinolone hexacetonide and prilocaine hydrochloride directly into the affected costochondral, sternoclavicular, or costosternal joint. 2
• Expect 75% of patients to experience more than 70% reduction in pain level after injection. 2
• Pain relief is typically evident within the first week, with sustained improvement at 2-3 weeks post-injection. 2
• This treatment provides statistically significant pain reduction regardless of patient age, sex, or employment status. 2

Alternative Injection Therapy: Prolotherapy

Consider prolotherapy (dextrose-based proliferant injection) as an alternative to corticosteroid injection, particularly in patients with contraindications to NSAIDs or corticosteroids. 3

• Prolotherapy demonstrates faster recovery compared to systemic NSAID therapy alone. 3
• Pain scores drop significantly by the first injection and continue to improve through the third injection. 3
• This may be ideal for patients with limited liver or kidney reserve, significant comorbidities, or those experiencing adverse effects from systemic medications. 3

Diagnostic Considerations and Pitfalls

Before initiating treatment, confirm the diagnosis through physical examination showing localized tenderness, pain, and edema at the affected joint (typically second or third rib costochondral junction). 1

Critical Pitfall: Rule Out Chest Wall Tumors

In patients whose swelling increases in size during follow-up (typically over 8-9 months), perform early diagnostic biopsy to exclude primary chest wall tumors that can mimic Tietze syndrome. 4

• Approximately 10% of patients initially diagnosed with Tietze syndrome may actually have chest wall tumors (both benign and malignant). 4
• If swelling doubles in size during follow-up, reevaluate with chest CT and bone scintigraphy, followed by biopsy. 4
• CT has 92.3% sensitivity but only 64.2% specificity for detecting tumors, so imaging alone is insufficient—biopsy is necessary when clinical suspicion arises. 4

Laboratory and Imaging Workup

• Obtain inflammatory markers (elevated in Tietze syndrome). 1
• Consider ultrasound or MRI for diagnostic confirmation. 1
• Exclude differential diagnoses including acute coronary syndrome, costochondritis (which lacks swelling), and inflammatory lung/pleural conditions. 1

Surgical Management

Reserve surgical resection exclusively for severe, debilitating cases that remain refractory to all conservative therapies including NSAIDs, local injections, and prolotherapy. 5

• Perform complete resection of the involved cartilage and adjacent rib for definitive symptomatic control. 5
• Surgery is not typical treatment but can achieve symptomatic control when conservative measures fail. 5, 1
• This should only be considered after exhausting all medical options in patients with persistent, disabling symptoms. 5

Treatment Algorithm Summary

1. First-line: Systemic NSAIDs for pain control 1
2. Second-line: Local corticosteroid (triamcinolone) + local anesthetic (prilocaine) injection into affected joint 2
3. Alternative second-line: Prolotherapy for patients with NSAID/steroid contraindications 3
4. Monitor closely: If swelling increases in size over months, obtain CT/bone scan and perform biopsy to exclude tumor 4
5. Last resort: Surgical resection of cartilage and adjacent rib for medically refractory cases 5

Expected Natural History

Most cases are self-limiting and resolve with conservative management alone. 1 The condition is benign without purulent character, typically affecting one joint unilaterally. 1