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Soft tissue calcification in the neck

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Soft tissue calcification in the neck observed in cone beam CT scans

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Soft tissue calcification in the neck

  1. 1. Soft Tissue Calcification in the Neck Judy H. Oh, D.D.S. UCLA School of Dentistry, 1992 Preceptorship in Oral & Maxillofacial Radiology, Rutgers School of Dental Medicine, 2016 3D Oral & Maxillofacial Imaging Center, North Bethesda, MD 3DOMI.net
  2. 2. Types of Calcification in the Neck 1. Carotid Artery Calcification CAC 0.1 ~ 37% 2. Calcified Stylohyoid Chain CSC 1.4 ~ 30% 3. Calcified Triticeous Cartilage CTC 5 ~ 29% 4. Calcified Tonsils CT 16% 5. Calcified Superior Cornu of Thyroid Cartilage CSCT 6. Sialolith 7. Calcification of Lymph Nodes 8. Phlebolith(calcified vascular thrombus) 9. Intradermal Calcifications 10. Cutaneous Ossifications
  3. 3. FREQUENCY OF SOFT TISSUE CALCIFICATIONS FROM 380 CBCT SCANS Locations No % Stylohyoid Chain 144 47.6 Triticeous Cartilage 103 27.1 Tonsils 86 22.6 Superior Cornu of Thyroid Cartilage 76 20.0 Carotid Artery 72 19.0 Salivary glands 10 2.6 Lymph Nodes 2 0.5 Ali Z Syed, PREVALENCE OF CAROTID ATHEROMA AND ITS CONFOUNDERS ON CONE BEAM COMPUTED TOMOGRAPHY, Master thesis for OMFR program at UNC, Chapel Hill, 2014
  4. 4. Location of soft tissue calcification: panoramic radiograph Laurie C. Carter, DDS, Ph.D, pocketdentistry.com, Chapter 28, Soft Tissue Calcifications and Ossifications
  5. 5. Types of Heterotopic Calcification: Dystrophic Calcification Forms in chronic inflammation, cyst, diseased tissue Due to trauma, infection, inflammation Normal serum Calcium & Phosphate levels Localized to the site of injury, Asymptomatic Irregular or indistinct shape Found in Residual cyst, Inflammatory fibrous hyperplasia Idiopathic Calcification Calcium deposit in normal tissue Normal serum Calcium & Phosphate levels Found in Chondrocalcinosis, Phleboliths Metastatic Calcification Mineral precipitation into normal tissue due to higher serum level of Calcium & Phosphate
  6. 6. Heterotopic Ossification(vs. calcification) When mineral is deposited in soft tissue as organized, well-formed bone May be all compact bone or may include trabeculae & fatty marrow Caused by trauma, tumors, diseases - myositis ossificans - ankylosing spondylitis
  7. 7. Network of Arteries: coronal view
  8. 8. Network of Arteries: sagittal view
  9. 9. Atheroma in Internal Carotid Artery at or just above the bifurcation of common carotid artery Bifurcation at lateral & inferior to Hyoid bone
  10. 10. Reference: Metrowestdentalgroup.com CAC: axial view single or multiple semi-circular or ovoid latero-posterior to GCHB (greater cornu of hyoid bone) postero-lateral to pharyngeal airway
  11. 11. Dr. Douglas K Benn DDS PhD DDR (RCR, England) Oral & Maxillofacial Radiologist CAC: 71 year old male with CV disease and hypertension: a 4 mm opacity with 2 distinct white lines; calcification of the walls of the carotid artery. *The carotid artery bifurcation is about 6 mm in diameter. *coronal view: lateral to anterior tubercle of cervical vertebrae(C3-5)
  12. 12. CAC: axial view (a) as single rice grain (b), (c) multiple "rice grains", linear, curvilinear homogeneous opacifications (d) increased number of ipsilateral opacifications, forming larger coalescing masses Soft Tissue Calcifications In The Neck: Maxillofacial CBCT Presentation And Significance Dr. William C. Scarfe BDS, FRACDS, MS, Dr. Allan G. Farman BDS, PhD, MBA, DSc Dept. of Surgical/Hospital Dentistry, University of Louisville School of Dentistry Louisville, Kentucky From the Spring 2010 AADMRT Newsletter
  13. 13. Hyoid Bone Netterimages.com
  14. 14. sagittal view: CAC: latero-inferior to hyoid bone posterior to GCHB medial-inferior to angle of mandible CSC: Isolated calcified stylohyoid chain GCHB: Greater cornu of the hyoid bone Soft Tissue Calcifications In The Neck: Maxillofacial CBCT Presentation And Significance Dr. William C. Scarfe BDS, FRACDS, MS Dr. Allan G. Farman BDS, PhD, MBA, DSc Dept. of Surgical/Hospital Dentistry University of Louisville School of Dentistry Louisville, Kentucky From the Spring 2010 AADMRT Newsletter
  15. 15. Soft Tissue Calcifications In The Neck: Maxillofacial CBCT Presentation And Significance Dr. William C. Scarfe BDS, FRACDS, MS Dr. Allan G. Farman BDS, PhD, MBA, DSc Dept. of Surgical/Hospital Dentistry University of Louisville School of Dentistry Louisville, Kentucky From the Spring 2010 AADMRT Newsletter CAC & CSC: coronal view Stylohyoid ligament connects the tip of the Styloid process to the Lessor Cornu of the Hyoid bone
  16. 16. Calcified Stylohyoid Chain(CSC), Eagle’s Syndrome Discrete, circular, corticated opacity; Normal length 20-30mm; 40mm considered elongated 1.4% - 30% of population(75% bilateral), mostly asymptomatic
  17. 17. Soft Tissue Calcifications In The Neck: Maxillofacial CBCT Presentation And Significance Dr. William C. Scarfe BDS, FRACDS, MS Dr. Allan G. Farman BDS, PhD, MBA, DSc Dept. of Surgical/Hospital Dentistry University of Louisville School of Dentistry Louisville, Kentucky From the Spring 2010 AADMRT Newsletter Calcified Stylohyoid Chain: CSC
  18. 18. Enlarged Styloid Process Detection of Incidental Findings in CBCT Imaging & Their Clinical Implications, E. Benavides, DDS, Ph.D, P. Edwards, MSc, DDS, Pocket Dentistry, Chapter 10 Asymmetry in the left & right styloid process enlarged left styloid process
  19. 19. Triticeous Cartilage: A cartilaginous nodule in the thyrohyoid ligament Gray’s anatomy, 1918
  20. 20. Dr. Douglas K Benn DDS PhD DDR (RCR, England) Oral & Maxillofacial Radiologist panoramic view: 1. Calcified Stylohyoid Chain(CSC) 2. Submandibular Gland Sialolith 3. Calcified Triticeous Cartilage(CTC) (ovoid, homogeneous, dense) *CAC is irregular in shape and density.
  21. 21. Calcified Triticeous Cartilage(CTC) Axial: single ‘rice grain’, ovoid, homogeneous, dense medio-posterior to the most distal extent of GCHB *GCHB(greater cornu of hyoid bone) at C2, C3 Coronal: inferior to GCHB & at C3 & C4 Sagittal: immediately inferior to the maximal extension of GCHB Soft Tissue Calcifications In The Neck: Maxillofacial CBCT Presentation And Significance Dr. William C. Scarfe BDS, FRACDS, MS, Dr. Allan G. Farman BDS, PhD, MBA, DSc Dept. of Surgical/Hospital Dentistry, University of Louisville School of Dentistry, Louisville, Kentucky From the Spring 2010 AADMRT Newsletter
  22. 22. CTC: Calcified Triticeous Cartilage Soft Tissue Calcifications In The Neck: Maxillofacial CBCT Presentation And Significance Dr. William C. Scarfe BDS, FRACDS, MS, Dr. Allan G. Farman BDS, PhD, MBA, DSc Dept. of Surgical/Hospital Dentistry, University of Louisville School of Dentistry, Louisville, Kentucky From the Spring 2010 AADMRT Newsletter Panoramic Radiograph: CTC immediately inferior to the tip of GCHB
  23. 23. CT: Calcified Tonsils Axial - (a) Clusters, ovoid homogeneous dense opacification antero-lateral to the oro-pharyngeal airway space Coronal - (b) Superimposed over the anterior tubercle of the cervical spine; Span supero-inferiorly linearly in line with the pterygoid plates Sagittal - (c) Superimposed over the shadow of the oro-pharyngeal airway space or anterior to it Clinical symptom: asymptomatic or persistent throat irritation, foul taste, odor or otalgia Soft Tissue Calcifications In The Neck: Maxillofacial CBCT Presentation And Significance Dr. William C. Scarfe BDS, FRACDS, MS, Dr. Allan G. Farman BDS, PhD, MBA, DSc Dept. of Surgical/Hospital Dentistry, University of Louisville School of Dentistry, Louisville, Kentucky From the Spring 2010 AADMRT Newsletter
  24. 24. Calcified Tonsils: Tonsilar calculi or Tonsiloliths Dystrophic calcification caused by repeated bouts of inflammation Affects 20-68, age related Treatments: None if small, surgery for larger lesion or elderly patients with deglutition disorder, or immunocompromised patients due to the risk of aspiration pneumonia
  25. 25. Palatine Tonsiloliths Detection of Incidental Findings in CBCT Imaging & Their Clinical Implications, E. Benavides, DDS, Ph.D, P. Edwards, MSc, DDS, Pocket Dentistry, Chapter 10
  26. 26. Palatine Tonsiloliths Omami G (2016) Soft Tissue Calcification in Oral and Maxillofacial Imaging: A Pictorial Review. Int J Dentistry Oral Sci. 03(4), 219-224
  27. 27. Pharyngeal Tonsilolith Detection of Incidental Findings in CBCT Imaging & Their Clinical Implications, E. Benavides, DDS, Ph.D, P. Edwards, MSc, DDS, Pocket Dentistry, Chapter 10
  28. 28. Tonsilolith Sialolith: lingual aspect of mandible Incidental findings on cone beam computed tomography: Relate and relay, Suhas P Pande, Subhash P Kumbhare, Amit R Parate Department of Oral Medicine and Radiology, Government Dental College and Hospital, Nagpur, Maharashtra, India, Journal of Indian Academy of Oral Medicine & Radiology, 2015, vol 27, issue 1, pg 48-54
  29. 29. Superior Cornu of Thyroid Cartilage en.wikipedia.org
  30. 30. Calcified Superior Cornu of the Thyroid Cartilage: CSCT Soft Tissue Calcifications In The Neck: Maxillofacial CBCT Presentation And Significance Dr. William C. Scarfe BDS, FRACDS, MS, Dr. Allan G. Farman BDS, PhD, MBA, DSc Dept. of Surgical/Hospital Dentistry, University of Louisville School of Dentistry, Louisville, Kentucky From the Spring 2010 AADMRT Newsletter Age related; immediately below hyoid bone, suspended by thyrohyoid membrane Axial: single distinct circular opacification, Posterior to GCHB (CTC is medial to GCHB) Coronal: linear cylindrical opacification extending inferiorly from GCHB
  31. 31. Salivary Gland: sagittal view
  32. 32. Conventional sialography of submandibular gland(A) parotid gland(B) showing ductal system Rastogi R, Bhargava S, Mallarajapatna GJ, Singh SK. Pictorial essay: Salivary gland imaging. Indian J Radiol Imaging 2012;22:325-33
  33. 33. Sialolith: stone in the salivary gland Sialolith adjacent to the lingual cortical plate in the right submandibular region Solitary, ‘onion shaped’, linear or globular homogeneous, medial to the angle of the mandible Mostly in submandibular gland near hilum or Wharton’s duct
  34. 34. Sialolith in the Submandibular gland Detection of Incidental Findings in CBCT Imaging & Their Clinical Implications, E. Benavides, DDS, Ph.D, P. Edwards, MSc, DDS, Pocket Dentistry, Chapter 10
  35. 35. Sialolith in the right Wharton’s duct Capaccio P, Marciante GA, Gaffuri M, Spadari F. Submandibular swelling: Tooth or salivary stone?. Indian J Dent Res 2013;24:381-3
  36. 36. Sialoliths In the left Wharton’s duct Omami G (2016) Soft Tissue Calcification in Oral and Maxillofacial Imaging: A Pictorial Review. Int J Dentistry Oral Sci. 03(4), 219-224
  37. 37. Lymph nodes in the head & neck 300 of total 800 lymph nodes in our body found in the head & neck
  38. 38. Calcified Lymph Nodes Dystrophic calcification due to chronic inflammation Lymphoid tissue replaced by hydroxyapatite-like calcium salts Causes: TB, bacille Calmette-Guerin vaccination, sarcoidosis, cat-scratch disease Rheumatoid arthritis, systemic sclerosis, fungal infections lymphoma previously treated with radiation therapy malignancy(Hodgkin’s lymphoma, metastatic thyroid carcinoma) Asymptomatic Most common sites: submandibular, superficial or deep cervical nodes; less commonly preauricular & submental nodes Well defined irregular ‘cauliflower-like’ shape; hard, lumpy, round or oblong masses Treatment: none but underlying cause should be established Laurie C. Carter, DDS, Ph.D, pocketdentistry.com, Chapter 28, Soft Tissue Calcifications and Ossifications
  39. 39. Calcification in the Submandibular lymph nodes
  40. 40. Calcification in the Submental lymph nodes Detection of Incidental Findings in CBCT Imaging & Their Clinical Implications, E. Benavides, DDS, Ph.D, P. Edwards, MSc, DDS, Pocket Dentistry, Chapter 10
  41. 41. Tuberculous Lymphadenitis
  42. 42. Phlebolith Calcified vascular thrombus, result of vascular anomaly, multiple laminated spherical radiopacities with onion-like appearance(concentric radiopaque & radiolucent rings) Chava VR, Shankar AN, Vemanna NS, Cholleti SK. Multiple Venous Malformations with Phleboliths: Radiological-Pathological Correlation. J Clin Imaging Sci 2013;3, Suppl S1:13
  43. 43. Phlebolith Omami G (2016) Soft Tissue Calcification in Oral and Maxillofacial Imaging: A Pictorial Review. Int J Dentistry Oral Sci. 03(4), 219-224
  44. 44. Intradermal Calcification Small calcium deposits under the skin, result of injury or surgical incision; or due to systemic disease involving alteration of calcium metabolism Calcification & scar tissue in the chin after plastic surgery Detection of Incidental Findings in CBCT Imaging & Their Clinical Implications, E. Benavides, DDS, Ph.D, P. Edwards, MSc, DDS, Pocket Dentistry, Chapter 10
  45. 45. Cutaneous Ossification - Osteoma Cutis Primary(15%) Secondary(85%): develop within pre-existing neoplastic or inflammatory skin lesion Small Well-defined Single or Multiple High density area within skin Detection of Incidental Findings in CBCT Imaging & Their Clinical Implications, E. Benavides, DDS, Ph.D, P. Edwards, MSc, DDS, Pocket Dentistry, Chapter 10
  46. 46. Osteoma Cutis Safi, Yaser; Valizadeh, Solmaz; Vasegh, Sahra; Aghdasi, Mohammad Mahdi; Shamloo, Nafiseh; & Azizi, Zeynab. (2016). Prevalence of osteoma cutis in the maxillofacial region and classification of its radiographic pattern in cone beam CT.Dermatology Online Journal, 22(1). doj_29781 148 of 6500 CBCT(2.27%) scans showed osteoma cutis.
  47. 47. Osteoma Cutis Dr. Shawneen Gonzalez, Director of Radiology, Legacy 3D Imaging
  48. 48. Osteoma Cutis - Osseous Choristoma of Tongue Rare, benign, normally matured bony tissue Radiograph: doughnut-shaped radiopacity & radiolucent centers representing central marrow cavities
  49. 49. Osseous Choristoma Sandy Cheng-Yu Chen, M.D., Taipei Medical University Hospital, Taipei, American Journal of Neuroradiology, February 2014
  50. 50. Osseous Choristoma: Masseter muscle Priscilla Suassuna Carneiro Lúcio, et al. An unusual presentation of multiple osseous choristomas in masseter muscle. Musculoskelet Regen 2015; 2: e905. doi: 10.14800/mr.905
  51. 51. Osseous Choristoma: Mandibular Buccal Vestibule Gregoire C, Davis C, Bullock M, Steeves T (2015) Recurrent Osseous Choristoma Involving the Mandibular Buccal Vestibule: A Case Report. Int J Oral Dent Health 1:004
  52. 52. Cysticercosis Caused by Parasite, Taenia Solium(pork tapeworm) Larval form penetrate mucosa, blood vessels, lymphatics Dead larvae causes granuloma, scarring, calcification Calcification seen years after the infection Intraorally: palpable, well-circumscribed, soft fluctuant swelling multiple, small nodules in tongue, buccal mucosa, lip, masseter & suprahyoid muscles Radiograph: homogeneous, ‘grain of rice’ radiopacity smaller, widespread dissemination in brain, muscles Laurie C. Carter, DDS, Ph.D, Soft Tissue Calcifications and Ossifications, pocketdentistry.com, Chapter 28
  53. 53. Cysticercosis Indian Journal of Medical Microbiology Anil Khosla, MBBS, MD Assistant Professor, Department of Radiology, St Louis University School of Medicine, Veterans Affairs Medical Center of St Louis R Meher, A Sabherwal. Cysticercosis Of The Cheek. The Internet Journal of Tropical Medicine. 2004 Volume 2 Number 2.
  54. 54. Myositis Ossificans Temporal muscle & tendon at the lower part of the coronoid process Caused by hemorrhage within the interstitial tissue of the muscle after trauma or heavy muscle strain Runs in the same direction of muscle fibers Associated with trismus, limited opening
  55. 55. Myositis Ossificans Fernanda Trautmann, Paula de Moura, Tito L. Fernandes, Rogério O. Gondak, Julio C. de M. Castilho, Edmundo Medici Filho, Myositis ossificans traumatica of the medial pterygoid muscle: a case report Journal of Oral Science, Vol. 52, No. 3, 485-489, 2010 myositis ossificans traumatica (MOT) of the medial pterygoid muscle, developed after mandibular block anesthesia administered for endodontic treatment of the lower right second molar
  56. 56. Myositis Ossificans: the left masseter muscle after trauma Elitsa G. Deliverska, Department of Oral and Maxillofacial surgery, Faculty of dental medicine, Medical University, Sofia, Bulgaria, MYOSITIS OSSIFICANS TRAUMATICA OF THE MASSETER MUSCLE- review of the literature and case report, Journal of IMAB - Annual Proceeding (Scientific Papers) 2013, vol. 19, issue 4
  57. 57. Myositis Ossificans of Temporalis & Medial Pterygoid Reddy SD, Prakash AP, Keerthi M, Rao BJ. Myositis ossificans traumatica of temporalis and medial pterygoid muscle. J Oral Maxillofac Pathol 2014;18:271-5
  58. 58. Calcific Longus Colli or Retropharyngeal Calcific Tendinitis Calcium hydroxyapatite deposition in the longus colli muscle Inflammatory response Acute onset of neck pain, dysphagia, odynophagia, low-grade fever Self-limiting, resolves after 1-2 wks large, oval, nodular calcification of longus colli tendon Macrorad Teleradiology Services
  59. 59. EVALUATION OF SOFT TISSUE CALCIFICATIONS: RADIOGRAPHIC CRITERIA Calcified lymph node lobulated, cauliflower shaped; may appear in a chain fashion (sagittal view) Sialolith may appear as a smooth, cylindrical entity lingual to the mandible (axial view) Tonsillolith multiple small ill-defined, punctate; may appear in clusters (coronal view) OSHC long, linear thin extension from base of skull to hyoid (sagittal view) CAC multiple, irregular entities in the carotid space C3-C4 region lateral to greater cornu of hyoid (axial view) Triticeous cartilage round, well defined, smooth; medial to the greater cornu of hyoid (axial view) Superior cornu of thyroid calcification linear, thin finger-like projection; below the hyoid bone (coronal view) WHITE, STUART C., MICHAEL PHARAOH. ORAL RADIOLOGY: PRINCIPLES AND INTERPRETATION, 7TH EDITION. MOSBY, 2014
  60. 60. References: 1. Dr. William C. Scarfe BDS, FRACDS, MS, Dr. Allan G. Farman BDS, PhD, MBA, DSc, Soft Tissue Calcifications In The Neck: Maxillofacial CBCT Presentation And Significance, Dept. of Surgical/Hospital Dentistry, University of Louisville School of Dentistry, Louisville, Kentucky, From the Spring 2010 AADMRT Newsletter 2. Khan et ai, Soft tissue calcifications in CBCT, 3. Suhas P Pande, Subhash P Kumbhare, Amit R Parate, Incidental findings on cone beam computed tomography: Relate and relay, Department of Oral Medicine and Radiology, Government Dental College and Hospital, Nagpur, Maharashtra, India, Journal of Indian Academy of Oral Medicine & Radiology, 2015, vol 27, issue 1, pg 48-54 4. Laurie C. Carter, DDS, Ph.D, Soft Tissue Calcifications and Ossifications, pocketdentistry.com, Chapter 28 5. E. Benavides, DDS, Ph.D, P. Edwards, MSc, DDS, Detection of Incidental Findings in CBCT Imaging & Their Clinical Implications, Pocket Dentistry, Chapter 10 6. Omami G (2016) Soft Tissue Calcification in Oral and Maxillofacial Imaging: A Pictorial Review. Int J Dentistry Oral Sci. 03(4), 219-224 7. Rastogi R, Bhargava S, Mallarajapatna GJ, Singh SK. Pictorial essay: Salivary gland imaging. Indian J Radiol Imaging 2012;22:325-33 8. Safi, Yaser; Valizadeh, Solmaz; Vasegh, Sahra; Aghdasi, Mohammad Mahdi; Shamloo, Nafiseh; & Azizi, Zeynab. (2016). Prevalence of osteoma cutis in the maxillofacial region and classification of its radiographic pattern in cone beam CT. Dermatology Online Journal, 22(1). Doj_29781 9. WHITE, STUART C., MICHAEL PHARAOH. ORAL RADIOLOGY: PRINCIPLES AND INTERPRETATION, 7TH EDITION. MOSBY, 2014 10. Shawneen Gonzalez, DDS, MS, Interpretation Basics of CBCT 11. Gregoire C, Davis C, Bullock M, Steeves T (2015) Recurrent Osseous Choristoma Involving the Mandibular Buccal Vestibule: A Case Report. Int J Oral Dent Health 1:004 12. Priscilla Suassuna Carneiro Lúcio, et al. An unusual presentation of multiple osseous choristomas in masseter muscle. Musculoskelet Regen 2015; 2: e905. doi: 10.14800/mr.905
  61. 61. References: 13. Sandy Cheng-Yu Chen, M.D., Taipei Medical University Hospital, Taipei, American Journal of Neuroradiology, February 2014 14. Fernanda Trautmann, Paula de Moura, Tito L. Fernandes, Rogério O. Gondak, Julio C. de M. Castilho, Edmundo Medici Filho, Myositis ossificans traumatica of the medial pterygoid muscle: a case report Journal of Oral Science, Vol. 52, No. 3, 485-489, 2010 15. Elitsa G. Deliverska, Department of Oral and Maxillofacial surgery, Faculty of dental medicine, Medical University, Sofia, Bulgaria, MYOSITIS OSSIFICANS TRAUMATICA OF THE MASSETER MUSCLE- review of the literature and case report, Journal of IMAB - Annual Proceeding (Scientific Papers) 2013, vol. 19, issue 4 16. Reddy SD, Prakash AP, Keerthi M, Rao BJ. Myositis ossificans traumatica of temporalis and medial pterygoid muscle. J Oral Maxillofac Pathol 2014;18:271-5

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