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.
2
Q
What are the 3 types of heterotrophic calcification?
A
Dystrophic
Idiopathic
Metastatic
3
Q
What is dystrophic calcification?
A
Calcification that forms in degenerating, diseased and dead tissue despite normal calcium and phosphate serum levels
4
Q
What are examples of dystrophic calcification?
A
- Calcified lymph nodes
- Tonsilloliths
- Atherosclerotic plaque
- Monckerberg’s medial calcinosis
5
Q
What is idiopathic calcification?
A
Deposits of calcium in normal tissue despite normal calcium and phosphate serum levels.
No etiology.
6
Q
What are examples of idiopathic calcification?
A
- Sialoliths
- Phleboliths
- Triticeous cartilage calcifications
- Rhinolith/Antrolith
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.
8
Q
What are examples of metastatic calcification?
A
Hyperparathyroidism
Chronic renal failure
9
Q
What are examples of heterotrophic ossification?
A
- Ossification of stylohyoid ligament
- Osteoma cutis
- Myositis ossificans
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.
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
12
Q
What is this?
A
Large residual cyst with ill-defined calcifications
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
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.
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.
16
Q
How does the periphery of calcified lymph nodes appear?
A
Well defined, irregular and lobulated (cauliflower like)
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)
18
Q
What are the differential diagnoses of calcified lymph nodes?
A
Sialolith
Phlebolith
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.
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.
21
Q
What are clinical features of tonsilloliths?
A
- More common in older age groups
- Hard, round, white/yellow objects projecting from tonsillar crypts
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.
23
Q
What can happen to lymphoid tissue if tonsilloliths are giant?
A
Can stretch the lymphoid tissue, resulting in ulcerations and extrusion.
24
Q
What is the location of tonsilloliths in radiograph?
A
Located in region of palatoglossal air space overlapping ramus of md
25
What is the periphery, shape and size of tonsilloliths?
* Clusters of multiple, small ill-defined radiopacities.
* 0.5-1.5cm
26
What is the internal structure of tonsilloliths?
Radiopacity is of the same density as cortical bone and a little more radiopaque than cancellous bone.
27
What are differential diagnoses for tonsilloliths?
Enostosis
Sialolith in parotid gland
28
What is the management of smaller vs larger tonsilloliths?
Smaller: no tx required
Larger: surgically removed- referral to ENT surgeon
29
What are the 2 different patterns of arterial calcification?
* Monckerberg's Medial Calcinosis (arteriosclerosis)
* Calcified atherosclerotic plaque
30
What is Monckerberg’s Medial Calcinosis?
Arteriosclerosis/vessel hardening, where calcium deposits are found in the middle layer of the walls of arteries
31
What are clinical features of Monckerberg’s Medial Calcinosis?
* Most pts are initially asymptomatic
* May eventually develop cutaneous gangrene, peripheral vascular disease and myositis.
32
What is the location of Monckerberg’s Medial Calcinosis in an OPG?
Facial or carotid artery
33
What is the periphery of Monckerberg’s Medial Calcinosis?
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.
34
What is the internal structure of Monckerberg’s Medial Calcinosis?
No specific internal structure
35
What is the management of Monckerberg’s Medial Calcinosis?
Evaluation of pt for occlusive arterial disease and peripheral vascular disease- referral to GP.
36
What is a calcified atherosclerotic plaque?
Plaque found in carotid vasculature and is major contributing source of cerebrovascular embolic and occlusive disease.
37
What is the location of calcified atherosclerotic plaque?
First develops at arterial bifurcation. On OPG, this is adjacent to greater cornu of hyoid bone and C3, C4 or intervertebral space between them.
38
What is the risk of calcified atherosclerotic plaque?
If calcification dislodges bc of pressure, it could go into vessels of brain and pt could suffer stroke.
39
What is the periphery shape and size of calcified atherosclerotic plaque?
* Multiple and irregular in shape
* Sharply defined from surrounding soft tissues
* Vertical linear distribution
40
What is the internal structure of calcified atherosclerotic plaque?
Heterogenous radiopacity
41
What is differential diagnosis of calcified atherosclerotic plaque?
Calcified triticeous cartilage- uniform size, shape and location
42
What is the management of calcified atherosclerotic plaque?
Pt should be referred to physician for cerebrovascular and cardiovascular work up
43
What are sialoliths?
Stones found within salivary glands or their ducts.
44
Why are sialoliths more common in submandibular salivary glands?
* Wharton's duct has long and irregular torturous course
* Uphill flow
* Saliva more viscous and has higher mineral content
45
Where do submandibular stones lie?
* 50%: distal portion of duct
* 20% proximal portion of duct
* 30% in gland
46
What are differences between intraglandular or extra glandular stones?
* Intraglandular: located in parenchyma of gland and have less severe symptoms
* Extraglandular: located in duct and are more common. More severe symptoms.
47
Describe symptoms associated with sialoliths?
* 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
What are radiographic features of sialoliths?
* Submandibular sialoliths are usually cylindrical/long cigar shaped to oval/round
* Homogenously radiopaque
* May be radiolucent if low mineral content
49
Why are sialoliths sometimes radiolucent and how can you identify these in a radiograph?
May have low mineral content. Would need to reduce exposure to half in order to visualise on radiograph.
50
What teeth do submandibular sialoliths superimpose over?
Md premolar and molar apices
51
What radiographic view is best for visualising stones in distal portion of Wharton’s duct?
Standard md occlusal view
52
What is this?
Sialolith in submandibular gland duct
53
What is this?
Sialolith in submandibular gland
54
What is this?
Sialolith in right parotid gland and duct
55
What is this?
Multiple microliths in parotid gland on both sides
56
How can you take radiograph to demonstrate stones in parotid gland duct?
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
How are small, larger vs exceedingly large sialoliths managed?
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
What is this?
Calcified lymph node (cauliflower shaped radiopacity)
59
What is this?
Multiple tonsilloliths in the lower ⅓ of the md ramus on both sides.
60
What is this?
Monckerberg's Medial Calcinosis (arteriosclerosis)
61
What is a DD for sialolith in parotid gland?
* Tonsilollith
* Enostosis
62
What are Phleboliths?
Calcified thrombi found in veins, venulae or sinusoidal vessels of haemangiomas
63
What are clinical features of phleboliths?
* Always indicate presence of haemangioma
* Soft tissue may be swollen, throbbing or discoloured
64
What is this?
Multiple phleboliths on RHS
65
What is the the location, periphery and shape of phleboliths on radiograph?
* Commonly found in haemangiomas
* Round or oval
* Up to 6mm in diameter
* Smooth periphery
66
What is the internal structure like on phleboliths?
May be homogenously opaque but more commonly has appearance of laminations, giving bulls eye appearance. Radiolucent centre may be seen
67
What are differential diagnoses of pleboliths?
Sialolith
68
What is the importance of a phlebolith to dentists?
Importance of correctly identifying phleboliths lies in ID of possible vascular lesion such as haemangioma. This is critical if surgical procedures are contemplated
69
What is triticeous cartilage calcification?
* Cartilages found within the lateral thyroid ligaments.
* Have tendency to calcify or ossify with advancing age.
70
What are the radiographic features of triticeous cartilage calcifications?
(location, periphery & shape, internal structure)
* 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
What is this?
Triticeous cartilage (blue arrow)
Directly inferior is thyroid cartilage
72
Where is triticeous cartilage located on radiograph?
Between greater horn of hyoid and superior horn of thyroid cartilage
73
What are differential diagnoses for triticeous cartilage calcifications?
Calcified atheromatous plaque
74
Describe differences between calcified atheromatous plaque and calcified triticeous cartilage location, shape, size and internal structure?
75
What is the management of triticeous cartilage calcifiactions?
No tx required
76
What structures are the black and white arrows pointing to?
Black: epiglottis
White: thyroid cartilage calcification
77
What are rhinoliths?
Hard calcified bodies/stones that occur in nose. Usually from an exogenous foreign body
78
What are antroliths?
Hard calcified bodies/stones that occur in the antrum. Nidus is usually endogenous (root tip, bone fragment, masses of stagnated mucous)
79
What do antroliths and rhinoliths arise from?
Arise from deposition of mineral salts around a nidus.
80
What should you ask pt if you suspect rhinolith?
Have you ever stuck something up you nose?
81
What are clinical features of rhinolith/antrolith?
* 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
What are radiographic features of rhinoliths and antroliths (periphery and shape, internal structure)?
* Periphery and shape: shape & size varies. Well-defined smooth or irregular borders.
* Internal structure: may be homogenous or heterogenous radiopacities.
83
What is this?
Antrolith on floor of sinus
84
What is this?
Rhinolith in floor of nose
85
What are differential diagnoses of rhinolith and antrolith?
* Osteoma
* Root fragments: should be differentiated from antroliths by presence of root anatomy and root canal.
86
What is the management of rhinolith/antrolith?
Referral to ENT surgeon via GP for removal of stone.
87
What is the location of the styloid ligament?
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
What measurement of styloid process is considered abnormal?
More than 30mm
89
What are the 3 associated conditions with ossification of styloid ligament?
* Styloid chain ossification
* Eagle's syndrome
* Styloid syndrome
90
What are features of styloid chain ossification?
* Pts \>40 years age
* Usually symptomless
* Can be detected by palpation over tonsil
91
What are clinical features of eagle's syndrome?
* Pain in pharynx when swallowing, turning head, opening mouth and yawning
* Recent history of neck trauma/tonsillectomy
92
What are the symptoms of Eagle's syndrome caused by?
Impingement on glossopharyngeal nerve
93
What are clinical features of stylohyoid (carotid artery syndrome)?
* Similar findings to eagles syndrome without history of neck trauma
* Otalgia, tinnitus, temporal headaches, vertigo, transient syncope.
94
What is pain from stylohyiod syndrome caused by?
Mechanical irritation of sympathetic nerve tissue in arterial wall, producing unilateral tenderness of carotid artery.
95
What is this?
Ossification of stylohyoid ligament (this case has radiolucent, joint like junctions)
96
What is the internal structure of ossification of stylohyoid ligament?
Homogenously radiopaque
97
What are DD of ossification of stylohyoid ligament?
TMD (no radiographic evidence)
98
How should ossification of stylohyoid ligament be managed?
Referral to ENT surgeon to amputate stylohyoid process.
