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Dr Amar > Week 3- Soft Tissue Calcifications > Flashcards

Week 3- Soft Tissue Calcifications Flashcards

1
Q

What is the difference between heterotrophic calcification and heterotrophic ossification?

A

Calcification: when deposition of calcium in the skeleton occurs in an unorganized fashion

_O_ssifcation: when deposition of calcium in the skeleton occurs in an _o_rganized fashion.

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2
Q

What are the 3 types of heterotrophic calcification?

A

Dystrophic

Idiopathic

Metastatic

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3
Q

What is dystrophic calcification?

A

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

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4
Q

What are examples of dystrophic calcification?

A
  • Calcified lymph nodes
  • Tonsilloliths
  • Atherosclerotic plaque
  • Monckerberg’s medial calcinosis
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5
Q

What is idiopathic calcification?

A

Deposits of calcium in normal tissue despite normal calcium and phosphate serum levels.

No etiology.

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6
Q

What are examples of idiopathic calcification?

A
  • Sialoliths
  • Phleboliths
  • Triticeous cartilage calcifications
  • Rhinolith/Antrolith
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7
Q

What is metastatic calcification?

A

Results when minerals precipitate into normal tissue as a result of higher than normal phosphate and calcium serum levels.

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8
Q

What are examples of metastatic calcification?

A

Hyperparathyroidism

Chronic renal failure

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9
Q

What are examples of heterotrophic ossification?

A
  • Ossification of stylohyoid ligament
  • Osteoma cutis
  • Myositis ossificans
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10
Q

What is general dystrophic calcification of oral regions?

A

Precipitation of calcium salts into primary sites of chronic inflammation or dead and dying tissue.

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11
Q

What are radiographic features of general dystrophic calcification of oral regions?

A
  • Common in long standing chronically inflamed cysts
  • Rarely exceeds 0.5cm
  • Varies from fine grains of radiopacities to larger irregular radiopacities
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12
Q

What is this?

A

Large residual cyst with ill-defined calcifications

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13
Q

What are calcified lymph nodes? What patients is this seen in?

A

Calcification occurs in lymph nodes that have been chronically inflamed bc of various granulomatous disorders

  • Tuberculosis, sarcoidosis, cat-scratch disease, fungal infection
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14
Q

What are clinical features of calcified lymph nodes?

A
  • Common in submandibular and cervical nodes
  • No significant signs or symptoms
  • Incidental finding on OPG
  • Nodes may be single/multiple/mobile/hard/round
  • Outline well contoured and well defined.
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15
Q

Where are calcified lymph nodes often seen?

A

Submandibular region below inferior border of md near angle OR between posterior border of ramus and cervical spine.

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16
Q

How does the periphery of calcified lymph nodes appear?

A

Well defined, irregular and lobulated (cauliflower like)

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17
Q

How does the internal structure of calcified lymph nodes appear?

A

May look like mass of coral (varying degree of radiopacity, giving an impression of a collection of spherical or irregular masses)

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18
Q

What are the differential diagnoses of calcified lymph nodes?

A

Sialolith

Phlebolith

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19
Q

What is the management of calcified lymph nodes?

A

Usually require no tx but the underlying cause should be determined in case tx is required.

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20
Q

How do tonsilloliths form?

A

Repeated bouts of inflammation enlarge tonsillar crypts. Incomplete resolution of dead bacteria and pus serve as the nidus for dystrophic calcification.

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21
Q

What are clinical features of tonsilloliths?

A
  • More common in older age groups
  • Hard, round, white/yellow objects projecting from tonsillar crypts
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22
Q

What are symptoms of smaller vs larger tonsil calcifications?

A
  • Smaller: usually asymptomatic
  • Larger: pain, swelling, halitosis, dysphagia, foreign body feeling on swallowing.
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23
Q

What can happen to lymphoid tissue if tonsilloliths are giant?

A

Can stretch the lymphoid tissue, resulting in ulcerations and extrusion.

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24
Q

What is the location of tonsilloliths in radiograph?

A

Located in region of palatoglossal air space overlapping ramus of md

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25
Q

What is the periphery, shape and size of tonsilloliths?

A
  • Clusters of multiple, small ill-defined radiopacities.
  • 0.5-1.5cm
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26
Q

What is the internal structure of tonsilloliths?

A

Radiopacity is of the same density as cortical bone and a little more radiopaque than cancellous bone.

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27
Q

What are differential diagnoses for tonsilloliths?

A

Enostosis

Sialolith in parotid gland

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28
Q

What is the management of smaller vs larger tonsilloliths?

A

Smaller: no tx required

Larger: surgically removed- referral to ENT surgeon

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29
Q

What are the 2 different patterns of arterial calcification?

A
  • Monckerberg’s Medial Calcinosis (arteriosclerosis)
  • Calcified atherosclerotic plaque
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30
Q

What is Monckerberg’s Medial Calcinosis?

A

Arteriosclerosis/vessel hardening, where calcium deposits are found in the middle layer of the walls of arteries

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31
Q

What are clinical features of Monckerberg’s Medial Calcinosis?

A
  • Most pts are initially asymptomatic
  • May eventually develop cutaneous gangrene, peripheral vascular disease and myositis.
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32
Q

What is the location of Monckerberg’s Medial Calcinosis in an OPG?

A

Facial or carotid artery

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33
Q

What is the periphery of Monckerberg’s Medial Calcinosis?

A

Calcific deposits in the walls of the artery outline an image of the artery.

  • From the side it may appear as a parallel pair of thin, radiopaque lines.
  • In cross section, vessels display a circular ring like pattern.
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34
Q

What is the internal structure of Monckerberg’s Medial Calcinosis?

A

No specific internal structure

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35
Q

What is the management of Monckerberg’s Medial Calcinosis?

A

Evaluation of pt for occlusive arterial disease and peripheral vascular disease- referral to GP.

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36
Q

What is a calcified atherosclerotic plaque?

A

Plaque found in carotid vasculature and is major contributing source of cerebrovascular embolic and occlusive disease.

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37
Q

What is the location of calcified atherosclerotic plaque?

A

First develops at arterial bifurcation. On OPG, this is adjacent to greater cornu of hyoid bone and C3, C4 or intervertebral space between them.

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38
Q

What is the risk of calcified atherosclerotic plaque?

A

If calcification dislodges bc of pressure, it could go into vessels of brain and pt could suffer stroke.

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39
Q

What is the periphery shape and size of calcified atherosclerotic plaque?

A
  • Multiple and irregular in shape
  • Sharply defined from surrounding soft tissues
  • Vertical linear distribution
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40
Q

What is the internal structure of calcified atherosclerotic plaque?

A

Heterogenous radiopacity

41
Q

What is differential diagnosis of calcified atherosclerotic plaque?

A

Calcified triticeous cartilage- uniform size, shape and location

42
Q

What is the management of calcified atherosclerotic plaque?

A

Pt should be referred to physician for cerebrovascular and cardiovascular work up

43
Q

What are sialoliths?

A

Stones found within salivary glands or their ducts.

44
Q

Why are sialoliths more common in submandibular salivary glands?

A
  • Wharton’s duct has long and irregular torturous course
  • Uphill flow
  • Saliva more viscous and has higher mineral content
45
Q

Where do submandibular stones lie?

A
  • 50%: distal portion of duct
  • 20% proximal portion of duct
  • 30% in gland
46
Q

What are differences between intraglandular or extra glandular stones?

A
  • Intraglandular: located in parenchyma of gland and have less severe symptoms
  • Extraglandular: located in duct and are more common. More severe symptoms.
47
Q

Describe symptoms associated with sialoliths?

A
  • Pt may be asymptomatic or have pain and swelling in FOM and gland
  • Discomfort may intensify at meal times when salivary flow is stimulation
  • Pain when pt has citrus
  • Pus may exude from duct orifice
  • Surrounding soft tissue may be inflamed, tender and ulcerated
48
Q

What are radiographic features of sialoliths?

A
  • Submandibular sialoliths are usually cylindrical/long cigar shaped to oval/round
  • Homogenously radiopaque
  • May be radiolucent if low mineral content
49
Q

Why are sialoliths sometimes radiolucent and how can you identify these in a radiograph?

A

May have low mineral content. Would need to reduce exposure to half in order to visualise on radiograph.

50
Q

What teeth do submandibular sialoliths superimpose over?

A

Md premolar and molar apices

51
Q

What radiographic view is best for visualising stones in distal portion of Wharton’s duct?

A

Standard md occlusal view

52
Q

What is this?

A

Sialolith in submandibular gland duct

53
Q

What is this?

A

Sialolith in submandibular gland

54
Q

What is this?

A

Sialolith in right parotid gland and duct

55
Q

What is this?

A

Multiple microliths in parotid gland on both sides

56
Q

How can you take radiograph to demonstrate stones in parotid gland duct?

A

Periapical film placed in buccal vestibule with reduced exposure and time with central ray directed through cheek .

AP skull view with blow out cheek or open mouth lateral skull projection.

57
Q

How are small, larger vs exceedingly large sialoliths managed?

A

Small: milked out thourgh duct orifice by bimanual palpation

Larger: MI sialolithotomy using intracorporeal lithotripters

Exceedingly large stones- surgical removal of stone or gland.

58
Q

What is this?

A

Calcified lymph node (cauliflower shaped radiopacity)

59
Q

What is this?

A

Multiple tonsilloliths in the lower ⅓ of the md ramus on both sides.

60
Q

What is this?

A

Monckerberg’s Medial Calcinosis (arteriosclerosis)

61
Q

What is a DD for sialolith in parotid gland?

A
  • Tonsilollith
  • Enostosis
62
Q

What are Phleboliths?

A

Calcified thrombi found in veins, venulae or sinusoidal vessels of haemangiomas

63
Q

What are clinical features of phleboliths?

A
  • Always indicate presence of haemangioma
  • Soft tissue may be swollen, throbbing or discoloured
64
Q

What is this?

A

Multiple phleboliths on RHS

65
Q

What is the the location, periphery and shape of phleboliths on radiograph?

A
  • Commonly found in haemangiomas
  • Round or oval
  • Up to 6mm in diameter
  • Smooth periphery
66
Q

What is the internal structure like on phleboliths?

A

May be homogenously opaque but more commonly has appearance of laminations, giving bulls eye appearance. Radiolucent centre may be seen

67
Q

What are differential diagnoses of pleboliths?

A

Sialolith

68
Q

What is the importance of a phlebolith to dentists?

A

Importance of correctly identifying phleboliths lies in ID of possible vascular lesion such as haemangioma. This is critical if surgical procedures are contemplated

69
Q

What is triticeous cartilage calcification?

A
  • Cartilages found within the lateral thyroid ligaments.
  • Have tendency to calcify or ossify with advancing age.
70
Q

What are the radiographic features of triticeous cartilage calcifications?

(location, periphery & shape, internal structure)

A
  • Location: within pharyngeal air space inferior to greater cornu of hyoid bone and adjacent to superior border of C4.
  • Periphery & shape: measures 7-9mm in length and 2-4mm in width. Periphery well defined and smooth
  • Internal structure: usually present as homogenous radiopacity, with occasional outer cortex.
71
Q

What is this?

A

Triticeous cartilage (blue arrow)

Directly inferior is thyroid cartilage

72
Q

Where is triticeous cartilage located on radiograph?

A

Between greater horn of hyoid and superior horn of thyroid cartilage

73
Q

What are differential diagnoses for triticeous cartilage calcifications?

A

Calcified atheromatous plaque

74
Q

Describe differences between calcified atheromatous plaque and calcified triticeous cartilage location, shape, size and internal structure?

A
75
Q

What is the management of triticeous cartilage calcifiactions?

A

No tx required

76
Q

What structures are the black and white arrows pointing to?

A

Black: epiglottis

White: thyroid cartilage calcification

77
Q

What are rhinoliths?

A

Hard calcified bodies/stones that occur in nose. Usually from an exogenous foreign body

78
Q

What are antroliths?

A

Hard calcified bodies/stones that occur in the antrum. Nidus is usually endogenous (root tip, bone fragment, masses of stagnated mucous)

79
Q

What do antroliths and rhinoliths arise from?

A

Arise from deposition of mineral salts around a nidus.

80
Q

What should you ask pt if you suspect rhinolith?

A

Have you ever stuck something up you nose?

81
Q

What are clinical features of rhinolith/antrolith?

A
  • Pt may be asymptomatic initially
  • With increase in size, it may impinge on mucosa producing pain, congestion and ulceration.
  • Can develop unilateral purulent rhinorrhoea, sinusitis, headache, epistaxis, nasal obstruction, anosmia, fetor, fever and facial pain.
82
Q

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

A
  • Periphery and shape: shape & size varies. Well-defined smooth or irregular borders.
  • Internal structure: may be homogenous or heterogenous radiopacities.
83
Q

What is this?

A

Antrolith on floor of sinus

84
Q

What is this?

A

Rhinolith in floor of nose

85
Q

What are differential diagnoses of rhinolith and antrolith?

A
  • Osteoma
  • Root fragments: should be differentiated from antroliths by presence of root anatomy and root canal.
86
Q

What is the management of rhinolith/antrolith?

A

Referral to ENT surgeon via GP for removal of stone.

87
Q

What is the location of the styloid ligament?

A

Linear, long, tapering, thin, radiopaque process that is thicker at its base, extending forward from the region of the mastoid process and crosses the posteroinferior aspect of the ramus towards the hyoid bone.

88
Q

What measurement of styloid process is considered abnormal?

A

More than 30mm

89
Q

What are the 3 associated conditions with ossification of styloid ligament?

A
  • Styloid chain ossification
  • Eagle’s syndrome
  • Styloid syndrome
90
Q

What are features of styloid chain ossification?

A
  • Pts >40 years age
  • Usually symptomless
  • Can be detected by palpation over tonsil
91
Q

What are clinical features of eagle’s syndrome?

A
  • Pain in pharynx when swallowing, turning head, opening mouth and yawning
  • Recent history of neck trauma/tonsillectomy
92
Q

What are the symptoms of Eagle’s syndrome caused by?

A

Impingement on glossopharyngeal nerve

93
Q

What are clinical features of stylohyoid (carotid artery syndrome)?

A
  • Similar findings to eagles syndrome without history of neck trauma
  • Otalgia, tinnitus, temporal headaches, vertigo, transient syncope.
94
Q

What is pain from stylohyiod syndrome caused by?

A

Mechanical irritation of sympathetic nerve tissue in arterial wall, producing unilateral tenderness of carotid artery.

95
Q

What is this?

A

Ossification of stylohyoid ligament (this case has radiolucent, joint like junctions)

96
Q

What is the internal structure of ossification of stylohyoid ligament?

A

Homogenously radiopaque

97
Q

What are DD of ossification of stylohyoid ligament?

A

TMD (no radiographic evidence)

98
Q

How should ossification of stylohyoid ligament be managed?

A

Referral to ENT surgeon to amputate stylohyoid process.

Dr Amar (2 decks)

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