Soft tissue calcifications of the head and neck Flashcards
What is a heterotopic calcification vs heterotopic ossification?
heterotopic calcification = when deposition of calcium salts occurs in the skeleton in an unorganised fashion
heterotopic ossification = “” organised (e.g. ossification of stylohyoid ligament, osteoma cutis, myositis ossificans)
What are the 3 types of heterotopic calcification? (DIM acronym)
dystrophic
idiopathic
metastatic
Define and give examples for dystrophic, idiopathic and metastatic calcification. (6)
Dystrophic = calcification that forms in degenerating, diseased and dead tissue despite normal serum calcium and phosphate levels (DDD,D) → calcified lymph nodes, tonsilloliths, atherosclerotic plaque
Idiopathic = deposition of calcium in normal tissue depsite normal serum and phosphate levels → sialoliths, phleboliths, triteceous cartilage calcifications, rhinolith, antrolith
Metastatic = when minerals precipitate into normal tissue as a result of higher than normal serum levels of calcium → hyperparathyroidism, chronic renal failure
What is a General dystrophic calcification of oral region? (1) Gives its radiographic features (site, size appearance) (3)
precipitation of calcium salts into primary sites of chronic inflammation or dead and dying tissue
site: long standing chronically inflamed cysts
size: rarely exceed 0.5cm diameter
appearance: varies from fine grains of ROs to large irregular radioopacities
What is shown in the image
large residual cyst with ill-defined calcifications → general dystrophic calcification of oral regions
What is shown in the image
large residual cyst with ill-defined calcifications → general dystrophic calcification of oral regions
What causes calcified lymph nodes? give some examples of conditions
occurs in lymph nodes that have been chronically inflamed because of various granulomatous disorders
e.g. TB, sarcoidosis, cat-scratch disease, lymphoma treated with radiotherapy, fungal infections, metastases from distant calcifying neoplasms
What are the clinical features of calcified lymph nodes? (4) (which nodes, signs/symptoms, how its found, palpation)
- submd and cervical (superficial and deep) most commonly involved
- no signficant signs or symptoms
- usually incidental finding
- upon palpation - may be single/multiple, mobile, hard/round whose outline is well contoured and defined
What are the radiographic features of calcified lymph nodes? (location, periphery, internal structure, size)
location: below inferior border of mandible near angle OR between posterior border of ramus and cervical spine
periphery: well-defined, irregular and lobulated (cauliflower-like)
internal structure: may have a varying degree of radioopacity, giving impression of collection of spherical or irregular masses, looks like mass of coral
size: big or small
What are the differential diagnoses of calcified lymph nodes?
sialolith
phlebolith
What is the management for a calcified lymph node?
usually requires no tx, but the underlying cause should be determined in case tx is required
How are tonsilloliths (dystrophic calcification) formed? (2)
when there are repeated bouts of inflammation enlarge the tonsilar crypts, incomplete resolution of dead bacteria and pus serve as the nidus for dystrophic calcification
What are the clinical features of tonsilloliths? (5)
- hard, round, white or yellow objects projecting from the tonsillar crypts
- small calculi are usually asymptomatic
- large carger calcifications: pain, swelling, fetor oris, dysphagia and foreign body feeling on swallowing
- in rare cases with giant tonsilloliths, may stretch the lymphoid tissue, resulting in ulcerations and extrusion
- 20-68 years, more common in older
What are the radiographic features of tonsilloliths? (location, periphery shape and size, internal structure)
location: single or multiple radioopacities that overlap the mid-portion of the mandibular ramus in the region where the image where the dorsal surface of the tongue crosses the ramus in palatoglossal air spaces
periphery, shape, size: clusters of multiple or single small ill-defined radioopacities
size: 0.5-1.5cm in diameter
internal structure: the radioopacity is of the same density as that of cortical bone and a little more radiopaque than cancellous bone
What is the differential diagnosis for tonsilloliths?
enostosis
What is the management for tonsilloliths?
smaller: no tx required
larger: ones associated with symptoms are surgically removed (refer to ENT)
What are the 2 types of arterial calcifications which can be identified both radiographically and histologically?
Monckerberg’s Medial Calcinosis (Arteriosclerosis)
Calcified Atherosclerotic Plaque
What is Monckerberg’s Medial Calcinosis?
characterised by the fragmentation degeneration and eventual loss of elastic fibres followed by deposition of calcium within the medial coat of the vessel
What are the clinical features of Monckerberg’s Medial Calcinosis
- initially most patients asymptomatic
- eventually may develop cutaneous gangrene, peripheral vascular disease and myositis due to vascular insufficiency
- EXTREMELY rare
What are the radiographic features of Monckerberg’s Medial Calcinosis? (site, periphery, internal structure)
site: those involving facial (pic) or carotid artery may be seen on panoramic radiographs
periphery: calcific deposits in walls of artery outline an image of the artery, from the side it may appear as a parallel pair of thin, RO lines that have a straight or tortuous path (pipe stem or tram track appearance), in cross section the involved vessels display a circular ring like pattern
internal structure: no specific internal structure
How do you manage Monckerberg’s Medial Calcinosis?
evaluation of patient for occlusive arterial disease or peripheral vascular disease - refer to GP or cardiologist
What is a calcified atherosclerotic plaque? Why is it dangerous?
found in carotid vasculature and is a major contributing source of cerebrovascular embolic and occlusive disease
forms at bifurcation of common carotid artery, which has high blood pressure, if the atherosclerotic plaque is dislodged it may go into the vessels of brain and cause stroke
What are the radiographic features of calcified atherosclerotic plaque? (site, periphery, shape and size, internal structure)
site: at bifurcation of common carotid artery adjacent to greater cornu of hyoid bone and cervical vertebrae C3, C4 or intervertebral space between them
periphery, shape, size: multiple and irregularly shaped, sharply-defined from surrounding soft tissues and vertical linear distribution
internal structure: heterogenous radioopacity
What is a differential diagnosis of calcified atherosclerotic plaque?
calcified triticeous cartilage -uniform size, shape and location
What is the management for calcified atherosclerotic plaque?
URGENT referral to GP for cerebrovascular and cardiovascular assessment
What causes idiopathic calcification? give some examples of idiopathic calcifications
deposition of calcium in normal tissue despite normal serum calcium and phosphate levels
e.g. sialolith, phleboliths, triteceous cartilage calficiations, rhinolith, antrolith
What are sialoliths? Where are they commonly found?
stones found within salivary glands ducts
can form in any major or minor salivary gland (glandular sialolith) or ducts (ductal sialolith)
common in submd glands
Where are sialoliths most commonly found? (1) Explain why (4) *exam q
submandibular salivary glands
- gland and ductal system lie in a dependent position
- Wharton’s duct is long and has irregular, tortuous course
- An uphill flow in proximal portion
- salivary secretion is more viscous and has higher mineral content
Which age and gender do sialoliths have more incidence in?
age: common in middle age, slight predilection for men
What proportion of submd sialoliths are found in different areas?
half in distal portion of Wharton’s duct
20% in proximal portion
30% in gland
When can sialoliths be palpated?
if in more peripheral portion of duct if of sufficient size
What are signs and symptoms of sialoliths? What difference is noticed between intra and extraglandular stones?
may be asymptomatic OR may have hx of pain and swelling in FOM and involved gland
intraglandular stones cause less severe symptoms than extraglandular
discomfort may intensify at meal times when salivary flow is stimulated
if blockage is only partial, then pain and swellig gradully subside
pus may excude from duct orifice, the surrounding soft tissue may be inflamed and tender and overlying mucosa may ulcerate
What are the radiographic features of sialoliths? (shape, internal structure, how many are RL in submd and parotid)
in submd gland: cylindrical or long cigar shaped to oval or round shaped
stones are homeogenously radioopaque and show evidence of multiple layers
less than 20% of submd and 40% of parotid gland sialoliths are radiolucent because of low mineral content
What must you do when taking a radiograph in order to be able to see a sialolith?
- reduce exposure to almost half (half of iopa 1.6s)