Soft tissue calcifications of the head and neck Flashcards

1
Q

What is a heterotopic calcification vs heterotopic ossification?

A

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)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What are the 3 types of heterotopic calcification? (DIM acronym)

A

dystrophic

idiopathic

metastatic

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Define and give examples for dystrophic, idiopathic and metastatic calcification. (6)

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What is a General dystrophic calcification of oral region? (1) Gives its radiographic features (site, size appearance) (3)

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What is shown in the image

A

large residual cyst with ill-defined calcifications → general dystrophic calcification of oral regions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What is shown in the image

A

large residual cyst with ill-defined calcifications → general dystrophic calcification of oral regions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What causes calcified lymph nodes? give some examples of conditions

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What are the clinical features of calcified lymph nodes? (4) (which nodes, signs/symptoms, how its found, palpation)

A
  • 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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What are the radiographic features of calcified lymph nodes? (location, periphery, internal structure, size)

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What are the differential diagnoses of calcified lymph nodes?

A

sialolith

phlebolith

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What is the management for a calcified lymph node?

A

usually requires no tx, but the underlying cause should be determined in case tx is required

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

How are tonsilloliths (dystrophic calcification) formed? (2)

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What are the clinical features of tonsilloliths? (5)

A
  • 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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What are the radiographic features of tonsilloliths? (location, periphery shape and size, internal structure)

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What is the differential diagnosis for tonsilloliths?

A

enostosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What is the management for tonsilloliths?

A

smaller: no tx required
larger: ones associated with symptoms are surgically removed (refer to ENT)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What are the 2 types of arterial calcifications which can be identified both radiographically and histologically?

A

Monckerberg’s Medial Calcinosis (Arteriosclerosis)

Calcified Atherosclerotic Plaque

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What is Monckerberg’s Medial Calcinosis?

A

characterised by the fragmentation degeneration and eventual loss of elastic fibres followed by deposition of calcium within the medial coat of the vessel

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What are the clinical features of Monckerberg’s Medial Calcinosis

A
  • initially most patients asymptomatic
  • eventually may develop cutaneous gangrene, peripheral vascular disease and myositis due to vascular insufficiency
  • EXTREMELY rare
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What are the radiographic features of Monckerberg’s Medial Calcinosis? (site, periphery, internal structure)

A

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 well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

How do you manage Monckerberg’s Medial Calcinosis?

A

evaluation of patient for occlusive arterial disease or peripheral vascular disease - refer to GP or cardiologist

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What is a calcified atherosclerotic plaque? Why is it dangerous?

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

What are the radiographic features of calcified atherosclerotic plaque? (site, periphery, shape and size, internal structure)

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

What is a differential diagnosis of calcified atherosclerotic plaque?

A

calcified triticeous cartilage -uniform size, shape and location

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

What is the management for calcified atherosclerotic plaque?

A

URGENT referral to GP for cerebrovascular and cardiovascular assessment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

What causes idiopathic calcification? give some examples of idiopathic calcifications

A

deposition of calcium in normal tissue despite normal serum calcium and phosphate levels

e.g. sialolith, phleboliths, triteceous cartilage calficiations, rhinolith, antrolith

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

What are sialoliths? Where are they commonly found?

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Where are sialoliths most commonly found? (1) Explain why (4) *exam q

A

submandibular salivary glands

  1. gland and ductal system lie in a dependent position
  2. Wharton’s duct is long and has irregular, tortuous course
  3. An uphill flow in proximal portion
  4. salivary secretion is more viscous and has higher mineral content
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Which age and gender do sialoliths have more incidence in?

A

age: common in middle age, slight predilection for men

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

What proportion of submd sialoliths are found in different areas?

A

half in distal portion of Wharton’s duct

20% in proximal portion

30% in gland

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

When can sialoliths be palpated?

A

if in more peripheral portion of duct if of sufficient size

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

What are signs and symptoms of sialoliths? What difference is noticed between intra and extraglandular stones?

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

What are the radiographic features of sialoliths? (shape, internal structure, how many are RL in submd and parotid)

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

What must you do when taking a radiograph in order to be able to see a sialolith?

A
  • reduce exposure to almost half (half of iopa 1.6s)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

Which types of radiographs are better to visualise differently positioned sialoliths and why? (3)

A

PA: there may be superimposition of stone over md premolar and molar apices

standard Md occlusal view: best view for visualising stones in distal portion of Wharton’s duct

panoramic view: to view stones in more posterior location

36
Q

What do these radiographs show?

A

sialolith in submandibular gland duct

37
Q

What does this radiograph show?

A

sialolith in right submandibular gland

38
Q

What does this radiograph show?

A

calcification in right parotid gland and its duct

39
Q

What is shown in this radiograph?

A

multiple microliths in parotid gland on both sides

40
Q

Which two types of radiographs may be used to view parotid gland duct sialolith and how?

A
  1. PA film placed in buccal sulcus with reduced exposure and time and central ray directed through cheek
  2. A-P skull view with “blow out” cheek or an open-mout lat ceph
41
Q

What can be done to help detect non-calcified salivary gland stones?

A

sialography

helpful in locating obstructions that are undetectable w plain radiography

42
Q

What is the management for sialoliths of different sizes? (3)

A

small stones: milked out through duct orifice by TA + bimanual palpation

larger stones: minimally invasive sialolithotomy using intracorporeal lithotripters

exceedingly large stones: surgical removal of the stone or gland

43
Q

What are pheboliths?

A

calcified thrombi found in the veins, venulae or sinusoidal vessels of hemangiomas (especially the cavernous type)

44
Q

What are the clinical features of a phlebolith?

A

in the H + N region, phleboliths always indicate the presence of a hemangioma

the involved soft tissue may be swollen, throbbing or discoloured by the presence of veins or a soft tissue hemangioma

45
Q

What is shown in the radiograph?

A

multiple phleboliths on the right side

46
Q

What are the radiographic features of phleboliths? (site, periphery and shape, internal structure)

A

site: commonly found in hemangiomas

periphery and shape: round or oval, up to 6mm in diameter with a smooth periphery

internal structure: may be homogenously radioopaque but more commonly appearance of laminations, giving a bull’s eye/target appearance

radiolucent centre may be seen, which may represent the patent portion of the vessel

47
Q

What is the differential diagnosis of a phlebolith?

A

sialolith

48
Q

What does correctly identifying phleboliths depend on? And why is this important to dentists?

A

identification of possible vascular lesion such as haemangioma

critical if surgical procedures being contemplated

49
Q

What is a triticeous cartilage calcification?

A

calcification of cartilages within lateral thyrohyoid ligaments

have tendency to calcify or ossify with advancing age

triticeous means grain of wheat

50
Q

What are the radiographic features of triticeous cartilage calfications? (how is it found, site, periphery and shape, internal structure)

A

incidental finding within panoramic radiograph

site: within pharyngeal air space inferior to the greater cornu of hyoid bone and adjacent to superior border of C4
size: 7-9mm in length and 2-4mm in width
periphery: well defined and smooth

internal structure: homogenous radiopacity with occasional outer cortex

51
Q

What is shown in the image below?

A

bilateral tricticeous cartilage calcification and calcification of superior horn of thyroid cartilage

52
Q

What is the differential diagnosis for triticeous cartilage calcification?

A

adjacent vs inferior to greater cornu of hyoid bone

multiple and irregular vs well defined and smooth

heterogenous radiopacity, homogenousradiopacity with occasional outer cortex

53
Q

What is the management for triticeous cartilage calcifications?

A

none

54
Q

What is shown in this image?

A
55
Q

What is a rhinolith/antrolith and what are they caused by?

A

hard, calcified bodies or stones that occur in nose (rhinolith) or antrum (antroliths) arising from the deposition of mineral salts around a nidus

rhinolith: nidus usually exogenous foreign body (coins, beads etc)
antrolith: endogenous (root tip, bone fragment, masses of stagnated mucus etc)

55
Q

What is a rhinolith/antrolith and what are they caused by?

A

hard, calcified bodies or stones that occur in nose (rhinolith) or antrum (antroliths) arising from the deposition of mineral salts around a nidus

rhinolith: nidus usually exogenous foreign body (coins, beads etc)
antrolith: endogenous (root tip*, bone fragment, masses of stagnated mucus etc)

*could be P root of upper molars

56
Q

What are the signs/symptoms of rhinolith/antrolith?

A

may be asymptomatic initially

with increasing size of expanding mass, it may impinge on mucosa → causing pain, congestion and ulceration

patient may develop unilateral purulent rhinorrhea, sinusitis, headache, epistaxis (nosebleed), nasal obstruction (may have difficulty breathing), anosmia (partial-full loss of smell), fetor (foul smell), fever and facial pain

57
Q

What are the radiographic features of rhinoliths/antroliths? (site, periphery and shape, internal structure)

A

site: rhinoliths - nose, antrolith - antrum

periphery and shape: variety of shapes and sizes, well-defined smooth or irregular borders

internal structure: homogenous OR heterogenous radioopacigties

58
Q

What are the 2 differential diagnoses for rhinolith/antrolith?

A

osteoma

root fragments (should be differentiated from antroliths by presence of root anatomy and root canal)

59
Q

What is the management for rhinolith/antrolith?

A

refer to GP then ENT for removal of stone

60
Q

Where does ossification of styloid ligament usually occur and is it usually bilateral or unilateral? At which length is it considered abnormal?

A

usually extends downwards from base of skull

commonly bilateral

if >30mm considered abnormal

61
Q

What are the associated conditions of ossified styloid ligament? Give brief signs & symptoms/or lack thereof of each

A

Styloid Chain Ossification (asymptomatic)

Eagle’s Syndrome (symptomatic and hx of tonsilectomy or surgery to neck)

Styloid Syndrome aka carotid artery syndrome (symptomatic and no hx of neck trauma + ear symptoms)

62
Q

Give the clinical features of styloid chain ossification. (age group, symptoms, how is it detected intraorally?)

A

>40yrs

usually symptomless (95%)

may be detected by palpation over tonsil as a hard pointed structure

63
Q

What are the signs/symptoms and relevant medical history of Eagle’s Syndrome?

A

vague nagging to intense pain in pharynx on swallowing, turning head or opening mouth, especially yawning

above symptoms + recent hx of neck trauma (e.g. tonsilectomy)

64
Q

What is the probable cause of pain in Eagle’s syndrome?

A

elongated styloid process and local scar tissue probably cause symptoms by impinging on glossopharyngeal nerve (CN9)

65
Q

What are the symptoms of stylohyoid (carotid artery) syndrome

A

similar to Eagles syndrome but WITHOUT hx of neck trauma

additionally may have attacks of otalgia (ear pain), tinnitus, temporal headache and vertigo or transient syncope

66
Q

What may be the cause of pain in Stylohyoid (carotid artery) Syndrome?

A

mechanical irritation of sympathetic nerve tissue in arterial wall, producing regional carotidynia (unilateral tenderness of carotid artery)

67
Q

What are the radiographic features of Stylohyoid Syndrome? (site, shape, internal structure)

A

site: linear, long, tapering, thin radioopaque process that is thicker at its base, extending forward from region of mastoid process and crosses the posteroinferior aspect of ramus towards hyoid bone
shape: may have bilateral radiolucent joint like junctions (pseudarticulations)

internal structure: homogenously radioopaque

68
Q

What is the differential diagnosis and management for stylohyoid ligament ossification?

A

temporomandibular joint dysfunction (no radiographic evidence of ligament ossification)

refer to ENT for amputation of stylohyoid process

69
Q

Label this diagram

A
70
Q

What do these images show?

A

range of NORMAL positions of the mx sinus relative to premolar and molar teeth

71
Q

What does this radiograph show?

A

left mx sinus mimicking a benign space-occupying lesion

72
Q

Name 4 intrinsic diseases of the maxillary sinus

A

mucositis

maxillary sinusitis

retention pseudocyst

mucocele

73
Q

Name extrinsic diseases of the maxillary sinus

A

periostitis

cysts

74
Q

What are the symptoms, treatment and radiographic appearance of mucositis?

A

asymptomatic, discovered as incidental finding (can follow up after 6 months)

non-corticated band paralleling the bony wall of the sinus

2-4mm is normal, greater than 4mm considered pathology

75
Q

What is maxillary sinuitis and what is it caused by?

A

generalised inflammation of sinus mucosa

caused by allergen, bacteria or virus

in 10% of cases inflammation from dental origin

76
Q

What are the 3 types of sinusitis?

A

acute - less than 2 weeks

chronic - more than 3 months

pansinusitis - all sinuses involved

77
Q

What are the clinical features of acute sinusitis vs chronic sinusitis?

A

Acute:

  • clear nasal discharge or pharyngeal drainage
  • nasal stuffiness
  • pain and tenderness to pressure or swelling over the involved sinus
  • may have referred pain to pm or m on affected side
  • teeth may be TTP
  • may have pain on jumping or stomping
  • ask patient to bend down for 2-3 minutes and ask if they have pain in that particular mx sinus area and palpate

Chronic:

  • no external signs occur except during periods of acute exacerbations when increased pain and discomfort are apparent
78
Q

What are different radiographic appearances of maxillary sinusitis?

A
  • localised mucosal thickening along sinus floor
  • generalised thickening of mucosal lining around entire wall of sinus
  • complete radiopacity of the sinus
  • uniform cloudiness of the maxillary sinus
  • fluid level seen (usually in the lowest portion of the sinus)
79
Q

Give the etiology, predominant gender and symptoms and treatment of retention pseudocysts

A

blockage of secretory ducts of seromucous

males

asymptomatic - incidental finding BUT symptomatic when it completely fills the mx sinus

no tx - self limiting

(if small and asymptomatic/ incidental finding tx may not be necessary, recommended to moniter with periodic imaging, if large tx may be required, advise CBCT, may be removed by minor endoscopic surgery that includes either enucleation - difficult or curreettage - more common)

80
Q

Why is a retention pseudocyst considered a pseudocyst?

A

no epithelial lining

81
Q

What are the radiographic features of retention pseudocysts? (bi/unilateral, size, periphery and shape)

A

bilateral (sometimes unilateral aswell)

size: ranges from finger tip size to large enough to completely fill sinus

periphery and shape: non-corticated, dome-shaped radiopacity in the antrum

82
Q

What is shown in the images below?

A

retention pseudocyst

(bottom image fills about ¼ of mx sinus)

83
Q

What is a mucocele:

type of lesion, which sinus, etiopathogenesis, radiographic appearance, treatment

A

expanding and destructive lesion when sinus ostium is blocked and causes excrutiating pain

in ethmoidal, frontal sinuses and maxillary sinus

highly symptomatic

R/F: radioopacity, causing thinning and expansion of sinus walls

tx: urgent referral to GP/ENT

*sinus ostium (opening of mx sinus - at middle meatus)

84
Q

What is periostitis?

A

when mx 1st or 2nd molar has periapical inflammation and it ‘lifts’ the periosteum and floor of mx sinus as a result of inflammation, once recedes it will drop down to normal level

85
Q

How do you different a cyst from normal floor of the maxillary antrum? (borders-2, aspiration)

A

borders: cyst will be smooth, straight and clear outline whereas normal sinus has irregular, scalloped outline

+ cortical border wider in cyst than sinus

aspiration: in cyst yields yellow straw coloured fluid but nothing from sinus

+

subsequent injection of radioopaque contrast medium will remain in cyst rather than drain out through ostium

86
Q

What is the radiographic appearance of a periapical cyst?

A

uniform radiolucency bordered by thin, well-defined radioopaque margin that displaces the maxillary sinus upward + non-vital teeth