W3 - Soft Tissue Calcifications - Amar

Question 1

What is heterotopic calcification?

Answer 1

When deposition of calcium salts occurs in an unorganised fashion

Question 2

What is heterotopic ossification?

Answer 2

When deposition of calcium salts occurs in an organised fashion

Question 3

3 Types of heterotopic Calcification

Answer 3

Dystrophic calcification

Idiopathic calcification

Metastatic calcification

Question 4

What is dystrophic calcification?

Answer 4

Calcification that forms in degenerating, diseased and dead tissue, despite normal serum and phosphate levels

ex. calcified lymph nodes, atherosclerotic plaque

Question 5

What is idiopathic calciification?

Answer 5

Results from deposition of calcium in normal tissue, despite normal serum and phosphate levels

Ex. Sialoliths

Question 6

What is metastatic calcification + examples

Answer 6

When minerals precipitate into normal tissue as a result of higher than normal serum levels of calcium

Ex. Hyperparathyroidism, chronic renal failure

Question 7

Radiographic features of dystrophic calcifications (site, size, appearance)

Answer 7

Common sites - long standing chronically inflamed cysts

Size - rarely more than 0.5 cm in diameter

Appearance - varies from fine radiopacity grains to larger irregular radiopacities

Question 8

Why/where are calcified lymph nodes found?

Answer 8

Found in lymph nodes that have been chronically inflamed because of various granulomatous disorders

Such as pts with TB, cat-scratch disease, lymphoma treated by radiation therapy

Question 9

Answer 9

Calcified lymph nodes

Question 10

Clinical features of calcified lymph nodes (4)

Answer 10

• No significant signs or symptoms
• Most commonly in the submandibular region but can be anywhere on OPG
• Detected as incidental finding during OPG
• Upon palpation - may be single/multiple, mobile, hard, round, well-defined

Question 11

Answer 11

calcified lymph node

Question 12

Answer 12

calcified lymph node

Question 13

What does the periphery of calcified lymph nodes look like?

Answer 13

Well-defined, irregular and lobulated

“cauliflower-like”

Question 14

Management of calcified lymph nodes

Answer 14

Usually does not require tx.. BUT

Underlying cause should be determined

Question 15

What are tonsilloliths and how are they formed?

Answer 15

Tonsillolith - incomplete resolution of dead bacteria and pus serve as the nidus for dystrophic calcification

Formed when repeated bouts of inflammation enlarge tonsillar crypts

Question 16

Answer 16

Tonsillolith

Question 17

Clinical features of tonsillolith

Answer 17

• Wide age group (20-68), more common in older age group
• Usually hard, white and yellow
• Asymptomatic if small

If large,

• Pain
• Swelling
• Halitosis
• Feeling of foreign body when swallowing

Question 18

Answer 18

Tonsillolith

Question 19

Answer 19

Tonsillolith

Question 20

Periphery, shape and size of tonsillolith

Answer 20

• Clusters of multiple, small, ill-deined radiopacities
• Size varies from 5 - 15 mm

Question 21

Answer 21

Multiple tonsilloliths on both sides

Question 22

Managment of tonsillolith

Answer 22

Small - no tx

Large - refer to ENT for removal

Question 23

2 patterns of arterial calcifications that can be identified radiographically

Answer 23

• Monckerberg’s medial calcinosis (arteriosclerosis)
• Calcified atherosclerotic plaque

Question 24

Answer 24

Monckerberg’s medial calcinosis

• Calcific deposits in walls of artery, outline the artery
• Appears as a parallel pair of thin radiopaque lines
• “pipe stem” or “tram-track” appearance
• Extremely rare

Question 25

Management of Monkerberg's medial calcinosis and atherosclerotic plaque

Answer 25

Refer to GP or cardio-vascular surgeon for evaluation of arterial and vascular disease

Question 26

Largest concern with calcified atherosclerotic plaque

Answer 26

If dislodges, can travel to brain and cause **_stroke_**

Question 27

Where are the calcified atherosclerotic plaque most frequently found?

Answer 27

Found in the **carotid vasculature** (common carotid, external/internal carotid)

Question 28

Close to which anatomical landmarks are you most likely to find calcified atherosclerotic plaque?

Answer 28

Between **C3 and C4** is the **birfurcation of the common carotid (**most likely to see plaque) Adjacent to the greater cornu of **hyoid bone**

Question 29

Answer 29

Calcified atherosclerotic plaque

Question 30

Describe the Periphery, shape and size of atherosclerotic plaque

Answer 30

Multiple and irregular in shape Sharply defined Vertical linear distribution Heterogenous internal radiopacity

Question 31

Why are Sialoliths common in submandibular glands?

Answer 31

1. Gland and suct system lie in a **dependent position** 2. Wharton duct is **long** and has an **irregular tortuous** course 3. Duct runs **upwards** in an **uphill flow** 4. Salivary secretion is **more viscous** and has **higher mineral content**

Question 32

Clinical features of sialolith (4)

Answer 32

1. History of pain and swelling of floor of mouth and involved gland 2. May be asymptomatic at the time (saliva has drained, and no longer has pressure) 3. Discomfort may increase around meal-times due to increase in salivation 4. Duct orifice may be inflamed, tender, pus or ulcerated

Question 33

What has more severe symptoms - intra or extra glandular types of sialolith

Answer 33

Extraglandular type

Question 34

Answer 34

Sialolith

Question 35

Answer 35

sialolith

Question 36

Answer 36

sialolith

Question 37

How do sialoliths appear radiographically?

Answer 37

Cylindrical Cigar-shaped homogenous radiopacity

Question 38

Why must you reduce the exposure to visualise sialoliths?

Answer 38

Most sialoliths are radiolucent due to low mineral content

Question 39

Answer 39

Sialolith

Question 40

Answer 40

Sialolith

Question 41

Answer 41

Sialolith in right submandibular gland Differential dx: calcified lymph node (however its not cauliflower shaped or heterogenous radiopaque) *will require signs, symptoms and history to actually distinguish from differential dx*

Question 42

Answer 42

Sialolith in right parotid gland and duct \*extremely rare Diff dx: tonsillolith, enostosis

Question 43

Describe the radiography technique of observing sialoliths in the parotid gland duct

Answer 43

Film placed in the buccal vestibule, with reduced exposure and time Central ray directed through the cheek