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Soft tissue calcification of head and neck

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This presentation will give u a brief idea of different soft tissue lesions and their diagnosis

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Soft tissue calcification of head and neck

  1. 1. DR ARAVIND B S SECOND YEAR PG DEPT. OF ORAL MEDICINE AND RADIOLOGY Guided by Dr. TATU .E. JOY PROFESSOR AND HOD DEPT OF ORAL MEDICINE AND RADILOGY
  2. 2. DYSTROPHIC CALCIFICATION  CALCIFICATION IDIOPATHIC CALCIFICATION METASTATIC CALCIFICATION  MINERALISATION  Soft tissue calcifications in the orofacial region are uncommon and are usually asymptomatic in nature.
  3. 3. Classification A .Dystrophic Calcifications • General dystrophic calcification of the oral regions • Calcified lymph nodes • Dystrophic calcification in the tonsils • Cysticercosis • Arterial calcification - Monckerberg's medial calcinosis (Arteriosclerosis) - Calcified Atherosclerotic plaque B. Idiopathic calcifications • Sialoliths • Phleboliths • Laryngeal cartilage calcifications • Rhinolith/Antrolith C. Metastatic calcifications • Ossification of the styloid ligament • Osteoma cutis Myositis ossificans
  4. 4. GENERAL DYSTROPHIC CALCIFICATION OF ORAL REGIONS  -Precipitation of calcium salts into primary sites of chronic inflammation or dead and dying tissue.  Associated with a high concentration of phosphatase  Increase in local alkalinity.  Common location -long standing chronically inflamed cyst
  5. 5. CLINICAL FEATURES  COMMON SITES – Gingiva, tongue, lymph nodes and cheek  COMMONLY FOUND IN DISEASES - Tuberculosis - Necrosis - Atherosclerosis -Scars And Areas Of Fatty Degeneration Occasionally the area Is Enlarged, ulcerated Or Palpable.
  6. 6. Radiographic features  common sites -long standing chronically inflamed cysts.  Appearance- varies from fine grains of radiopacities to larger irregular radiopaque particles that rarely exceed 0.5 cm in diameter.  One or more of the radiopacities may be seen, homogenous or may contain punctate areas.  The outline is usually irregular or indistinct.
  7. 7. Calcified Lymph Nodes  Calcification occurs in lymph nodes that have been chronically inflamed because of various diseases (usually granulomatous disorders).  The lymphoid tissue is replaced by hydroxyapatite, like calcium salts nearly effacing all of the nodal architecture.  The common disease that cause calcified lymph nodes are, tuberculosis (scrofula or cervical tuberculous adenitis),BCG vaccination, sarcoidosis, cat-scratch disease, lymphoma treated with radiation therapy, fungal infections, and metastases from distant calcifying neoplasms.
  8. 8. Clinical Features
  9. 9. Clinical Features  The most commonly involved nodes are submandibular and cervical nodes (superficial and deep) and less commonly the preauricular and submental nodes.  There are no significant signs or symptoms.  They are most often detected as an incidental finding during panoramic radiographic examination.  • On palpation these nodes, which may be single or multiple or sometimes chain of nodes, which are found to be mobile, hard, round or oblong masses, whose outline is well contoured and well defined.
  10. 10.  The most common site is the submandibular region, either at or below the inferior border of the mandible near the angle, or between the posterior border of the ramus and cervical spine.  The image of the calcified node may sometimes overlap the inferior aspect of the ramus.  The node calcification may be single, or a series of nodes called lymph node chaining. Radiographic Features
  11. 11.  The periphery may be well-defined, irregular and sometimes may even have a lobulated appearance (cauliflower like). The irregular outline helps to differentiate lymph node calcification from other potential soft tissue calcification in the area.  It may have a varying degree of radiopacity, giving an impression of a collection of spherical or irregular masses, which may look like mass of coral.  Occasionally the lesion may have a laminated appearance.
  12. 12. Radiographic Features  Calcified lymph nodes located inferior to the angle of the mandible. Prior chronic infection of the lymph nodes may result in calcification of the nodes. A history of successfully treated tuberculosis is often associated with this calcification. This asymptomatic condition may involve a single node or a chain of nodes.
  13. 13. OPG showing two calcified lymph nodes in the left cervical chain (solid arrows). Note also the ghost shadows of the lymph nodes on the right premolar/canine region (open arrows)
  14. 14.  A lateral cervical radiograph shows a chain of calcified lymph nodes.
  15. 15. Management Usually require no treatment, but the underlying cause should be determined in case treatment is required; as in the case of lymphoma.
  16. 16. Dystrophic Calcification in the Tonsils (tonsillar calculi, tonsil concretions, tonsilloliths)  Tonsillar calculi are formed when repeated bouts of inflammation enlarge the tonsillar crypts. Incomplete resolution of dead bacteria and pus serve as the nidus for dystrophic calcification.
  17. 17. Clinical Features  Age group - 20 to 68 years of age, more in the older age group.  Tonsilloliths are usually hard, round, white or yellow objects projecting from the tonsillar crypts.  The small calculi may not produce any signs or symptoms.  In case of larger calcifications, pain, swelling, fetor oris dysphagia and a foreign body feeling on swallowing has been reported.  In rare cases there may be giant tonsilloliths, which stretch the lymphoid tissue, resulting in ulcerations and extrusion
  18. 18. Clinical Features
  19. 19. Radiographic Features  On the panoramic film, tonsilloliths appear as single or multiple radiopacities that overlap the mid portion of the mandibular ramus in the region where the image of the dorsal surface of the tongue crosses the ramus in the palatoglossal air spaces.  It appears as clusters of multiple small ill-defined radiopacities. This may vary from 0.5 cm to 14.5 cm in diameter.  The radiopacity is of the same density as that of cortical bone, and a little more radiopaque than cancellous bone.
  20. 20.  Digital panoramic radiography with image suggesting multiple tonsilloliths in the lower one third of the mandibular ramus on both sides.
  21. 21. Left side of an OPG showing the typical appearance of tonsillar calcifications (arrowed) overlying the ramus of the mandible
  22. 22. NOTE:- A right angled view to the panoramic field such as a posterior skull view or an open Towne's view may help to differentiate whether the calcification lies to the medial aspect of the ramus.  Management Larger calcifications with associated symptoms should be removed surgically.
  23. 23. Cysticercosis  When eggs or gravid proglottids from Taenia Solium (pork tapeworm) are ingested by human, their covering is digested in the stomach and the larval form cysticercus cellulosae) of the parasite is hatched. These larvae penetrate the mucosa, enter the blood vessels and lymphatics and are distributed in the tissues all over the body, but preferentially locate to the brain, muscle, skin and heart. They are also found in the oral and perioral tissues, especially the muscles of mastication. After the larva die, they are treated as foreign bodies causing granuloma formation, scarring and calcification, this takes approximately 3 months. These areas in the tissues are called cysticerci.
  24. 24. Clinical Features  Multiple small nodules may be felt in the region of the masseter and suprahyoid muscles and in the buccal mucosa and lip.  Examination of the head and neck region may disclose palpable, well circumscribed soft fluctuant swellings, which resemble a mucocele.  Mild cases are completely asymptomatic.  Moderate cases have symptoms that range from mild to severe gastrointestinal upset with epigastric pain and severe nausea and vomiting.  Invasion of the brain may result in seizures, headaches, visual disturbances, acute obstructive hydrocephalus, irritability and loss of consciousness.
  25. 25. Clinical Features
  26. 26. Radiographic Features  When alive the larva is not visible radiographically.  They are usually found in the muscles of mastication and facial expression, the suprahyoid muscle, and the postcervical musculature.  They appear as multiple, well-defined, elliptical, homogeneous, radiopacities, which resemble grains of rice.
  27. 27. Cysticercosis proglottids— A. Shows calcified nodules near the inferior border of the mandible, which represents calcific degeneration of the larval stage. B. Shows similar ovoid calcifications of the shoulder and thoracic region
  28. 28. Radiograph of a patient with cysticercosis. Thevcalcified encysted larvae are clearly seen in the soft tissues. A single calcification in the area of the Whartons duct may be easily mistaken for a sialolith on an intraoral film
  29. 29. Management  Medical management by using an antihelmintic, in the initial stage.  After the larvae have settled and calcified in the oral tissues, they are harmless.
  30. 30. Arterial Calcification  There are two different patterns of arterial calcifications which can be identified both radiographically and histologically; Monckerberg's Medial Calcinosis and Calcified Atherosclerotic Plaque.  Monckerberg's Medial Calcinosis (Arteriosclerosis)  This is characterized by the fragmentation, degeneration and eventual loss of elastic fibers followed by the deposition of calcium within the medial coat of the vessel.
  31. 31. Clinical Features  • Initially most patients are asymptomatic.  Eventually they may develop cutaneous gangrene, peripheral vascular disease and myositis due to vascular insufficiency.  • Patients with Sturge-Weber syndrome also develop intracranial arterial calcifications.
  32. 32. Radiographic Features  • Those involving the facial or the carotid artery may be seen on the panoramic radiographs.  • The 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, that may have a straight or tortuous path (pipe stem or tram track appearance).  • In cross section the involved vessels display a circular ring like pattern.
  33. 33.  Calcification of the facial artery. It may occur in arteriosclerosis and represents an inflammatory process.
  34. 34. Facial artery calcification
  35. 35. Management  Evaluation of the patient for occlusive arterial disease, and in some cases hyperparathyroidism should be considered as medial calcinosis frequently develops as a metastatic calcification in these patients.
  36. 36. Calcified Atherosclerotic Plaque  This is found in the extracranial carotid vasculature and is a major contributing source of cerebrovascular embolic and occlusive disease.  Dystrophic calcifications can occur in the evolution of plaque within the intima of the involved vessel.
  37. 37. Radiographic Features  • This first develops at the arterial bifurcation as a result of increased endothelial damage at these sites.  • When calcification occurs, these lesions may be visible on the panoramic radiograph in the soft tissues of the neck adjacent to the greater cornu of the hyoid bone and the cervical vertebrae C3, C4 or the intervertebral space between them.  • The soft tissue calcifications are usually seen as heterogeneous radiopacities, which are multiple and irregular in shape, sharply defined from the surrounding soft tissues and have a vertical linear distribution.
  38. 38. Digital panoramic radiography with images suggesting the presence of atheroma on both sides.
  39. 39. Digital panoramic radiography with image suggesting the presence of atheroma on left side.
  40. 40. Management  The patient should be referred to the physician for cerebrovascular and cardiovascular workup.
  41. 41. Idiopathic Calcification (or calcinosis)  This results from deposition of calcium in normal tissue despite normal serum calcium phosphate levels. (e.g. chondrocalcinosis, phleboliths)  Sialoliths (Salivary Gland Stone, Salivary Gland Calculus)  Sialolithiasis is the formation of calcified obstruction within the salivary duct resulting in chronic retrograde infection because of a decreased salivary flow.  Sialoliths may also form in any of the major or minor salivary glands (glandular sialolith) or their ducts (ductal sialolith), usually only one gland is involved.
  42. 42.  Mechanical conditions contributing to the slow flow rate and physiochemical characteristics of the gland secretions both contribute to the formation of a nidus and subsequent precipitation of calcium and phosphate salts.  Accordingly, the submandibular gland and ductal system lie in a dependent position. The Wharton duct is long and has an irregular tortuous course, an uphill flow in the proximal portion and the orifice is much smaller than the lumen. The salivary secretion of the submandibular gland is more viscous and has higher mineral content.
  43. 43.  The sialolith is made up of laminated layers of organic material covered with concentric shells of calcified material, which is crystalline in structure (Hydroxyapatite crystals with octacalcium and phosphate).  The chemical composition is principally of calcium phosphate and carbon with traces of magnesium, potassium, chloride and ammonium.
  44. 44.  • These are common in the middle age with a slight predilection for men.  • The submandibular gland and the Wharton duct are by far the most frequently involved (83% of the cases), followed by the parotid (10%) and sublingual (7%) glands. About half of the submandibular stones lie in the distal portion of the Wharton's duct, 20% in the proximal portion, and 30% in the gland. Clinical Features
  45. 45.  • The patient may be asymptomatic, or they may history of pain and swelling in the floor of the mouth and in the involved gland. Intra glandular stones cause less severe symptoms than the extra glanular or the intraductal types.  • The discomfort may intensify at meal times, when the salivary flow is stimulated.
  46. 46.  • If the blockage is partial, then the pain and swelling gradually subsides.  • 9% of patients have recurrent sialolithiasis and 10% have nephrolithiasis.  • Pus may exude from the duct orifice, the surrounding soft tissue may be inflamed, and tender, and the overlying mucosa may ulcerate.  • Stones in the more peripheral portion of the duct may be palpated, if it is of sufficient size.  • Sialolithiasis of minor salivary gland is a rare occurrence, the most common site being buccal mucosa either near the commissure or in the proximity to the mandibular mucobuccal fold.
  47. 47.  The sialoliths located in the duct of the submandibular glands are usually cylindrical. But they may vary in shape from long cigar shapes to oval or round shapes.  • Stones that form in the hilus of the submandibular gland tend to be larger and more irregularly shaped.  • The stones are homogeneously radiopaque, and show evidence of multiple layers.  • Less than 20% of the submandibular gland and 40% of the parotid gland sialoliths are radiolucent because of the low mineral content of parotid secretions. Radiographic Features
  48. 48.  CT: also helps to detect minimally calcified sialoliths which are not visible on plain films.  USG: is of limited use in the diagnosis of inflammatory and obstructive diseases, but if the stone is large (2 mm), it will be detected as a characteristic acoustic shadow showing echodense spots.
  49. 49.  • A periapical film, placed in the buccal vestibule, with reduced exposure and time and the central ray directed through the cheek, helps to demonstrate stones in the parotid gland duct.  • An anteroposterior skull view, of the patient with "blow- out" cheek , or an open-mouth lateral skull projection, helps to demonstrate stones in the parotid duct. When producing radiographs to detect sialoliths, the exposure time should be reduced to about half of normal, this helps to detect stones that are highly calcified.
  50. 50.  If non calcified stone are suspected, then Sialography; is helpful in locating obstructions that are undetectable with plain radiography. The contrast agent usually flows around the sialolith, filling the duct proximal to the obstruction. The ductal system is frequently dilated proximal to the obstruction and infers the presence of an obstruction even when is not visible. The contrast agent that flows around the sialolith is more radiopaque and may obscure small sialoliths.  Radiolucent sialoliths appear as ductal filling defects.  Sialography should not be performed if the radiopaque stone is shown by plain radiography to be in the distal portion of the duct, because the procedure may displace it proximally into the ductal system, complicating its subsequent removal.
  51. 51. Additional Imaging  • On the periapical view, there may be superimposition of the stone over the mandibular premolar and molar apices.  • A standard mandibular occlusal view, using half the usual exposure time, displays the floor of the mouth without overlap of the mandible and is the best view for visualizing stones in the distal portion of the Wharton's duct.  • A lateral oblique view or a panoramic view, helps to visualize stones in a more posterior location.
  52. 52. Radiographic Features  Mandibular occlusal projection shows a sialolith (salivary calculus) in the duct of the submandibular gland (Wharton's duct).
  53. 53. Calcifications in the parotid gland
  54. 54. Sialolith with in Stensons duct of the parotid gland. Other calcifications such as phleboliths or osteoma on the pterygoid process can occur in the region. With the help of a tangential zygoma projection (phleboliths) or an axial skull film or with CT (osteoma on the pterygoid process), the differential diagnosis can be determined
  55. 55. On periapical radiographs, the radiopacity may be misdiagnosed as osteosclerosis. To differentiate an osteosclerosis from a sialolith, take two radiographs using different vertical (or horizontal) angulations of the x-ray beam. If the radiopacity changes its position in relation to the adjoining teeth, as shown here, the radiopacity is a sialolith in the floor of the oral cavity (Clark's rule: same lingual, opposite buccal). Another method to identify a submandibular sialolith is to take an occlusal projection.
  56. 56.  A sialolith on a panoramic radiograph may be misdiagnosed as a calcified lymph node. In the absence of clinical signs and symptoms it is difficult to differentiate the two types of calcifications unless a sialogram is made.
  57. 57. A. Right side of an OPG showing a large radiopacity in the lower premolar region (arrowed). B. Lower 90° occlusal of the same patient showing the opacity to be a large stone in the right submandibular duct
  58. 58.  Sialogram showing an obstruction in the Wharton's duct preventing the flow of the radiopaque dye into the submandibular salivary gland. The stone (arrow) is blended with the radiopaque dye.
  59. 59.  Digital panoramic radiography with image suggesting a single sialolith in the right submandibular gland.
  60. 60.  Digital panoramic radiography showing a image suggesting a calcification in the right parotid gland and in its duct.
  61. 61.  Digital panoramic radiography with image suggesting multiple microliths in the parotid gland on both sides.
  62. 62. Differential Diagnosis  • Gas bubble; these are more easily removed and are more circular than sialoliths.  • Hyoid bone; these are seen bilaterally on the panoramic film.  • Myositis ossificans; there will be restriction of mandibular movements.  • Phleboliths; there will be no sialadenitis, and these are more or less rounded and contain laminations or central dark (radiolucent) areas.  • Calcific submandibular lymph nodes; if there is presence of pain then it is suggestive of a sialolith. The calcified lymph nodes appear to be cauliflower shaped.
  63. 63.  • Chondrodystrophia calcificans congenita; this is associated with calcifications in the neck which resemble the submaxillary calculi in the radiographs.  • Palatine tonsillitis; on the panoramic image it has a similar location to parotid sialoliths, superimposed over the ramus, but can be differentiated in that they are typically multiple and punctate.
  64. 64. Other Causes of Obstructions  • Mucous plugs; these are incompletely mineralized sialoliths.  • Strictures and Stenosis; this may be papillary or ductal obstruction due to chronic irritation, acute trauma or presence of intra ductal growth or tumor.  • Foreign bodies; food particles, toothbrush bristles, tooth picks.  • Extra ductal causes; like muscle pressure, tumors, lymph nodes and denture flanges.
  65. 65.  Parotid fistula; this may open into the oral cavity or on to the exterior of the face. It may be due to trauma, rupture of parotid abscess or complication of superficial parotidectomy.  Management: It is best to encourage spontaneous discharge through the use of sialogogues or piezoelectric extracorporeal shock wave lithotripsy or surgical removal is indicated.
  66. 66. Pheboliths  Intravascular thrombi, which arise secondary to venous stagnation, may get organized or mineralized. The mineralization begins at the core of the thrombus and consists of crystals of apatite with calcium phosphate and calcium carbonate. Phleboliths are calcified thrombi found in veins, venulae, or the sinusoidal vessels of hemangiomas (especially the cavernous type).
  67. 67. Clinical Features  • In the head and neck region , phleboliths always indicate the presence of a hemangioma.  • In an adult it may be the sole residua of a childhood hemangioma, which has long since regressed.  • The involved soft tissue may be swollen, throbbing or discolored by the presence of veins or a soft tissue hemangioma, which often fluctuate in size, associated with changes in body position or during a Valsalva maneuver. The vascular nature may be confirmed by the presence of blanching or change in color on applying pressure.  Auscultation may reveal bruit in case of cavernous hemangioma but not in the capillary type.
  68. 68. Radiographic Features Multiple phleboliths superimposed on the mandibular ramus. Phleboliths are calcified thrombi. These calcified masses in blood vessels are associated with hemangiomas found in the cheek.
  69. 69.  Multiple phleboliths of various sizes in cavernous hemangioma of the face. The radiograph is of the patient's cheek.
  70. 70. Oblique lateral showing multiple phleboliths (arrowed) associated with a hemangioma. Note the typical target appearance of some of the calcifications
  71. 71.  Panoramic radiography with image suggesting multiple phleboliths on the right side.
  72. 72.  • These are commonly found in hemangiomas.  • In cross section the shape is round or oval, up to 6 mm in diameter with a smooth periphery. If the involved blood vessel is viewed from the side, the phlebolith may resemble a straight or a slightly curved sausage.  It may be homogeneously radiopaque but more commonly has the appearance of laminations, giving phleboliths a bull's eye or target appearance. A radiolucent center may be seen, which may represent the remaining patent portion of the vessel. Radiographic Features
  73. 73. Differential Diagnosis  • Sialolith; these usually occur singly, if multiple sialoliths are present, they are usually oriented in a single line, whereas phleboliths are usually multiple and have a more random, clustered distribution, and is usually associated with a vascular lesion.
  74. 74. Laryngeal Cartilage Calcifications  Both the thyroid and the triticeous (means grain of wheat) cartilages (found within the lateral thyrohyoid ligaments) consist of hyaline cartilage, which has a tendency to calcify or ossify with advancing age.
  75. 75. Clinical Features  • Has no clinical features and usually is an incidental radiographic finding.  Radiographic Features  • The calcified cartilage is located on a lateral view within the pharyngeal air space inferior to the greater cornu of the hyoid bone and adjacent to the superior border of C4. The superior cornu of a calcified thyroid cartilage appears medial to C4 and is superimposed on the prevertebral soft tissue.  • The triticeous cartilage measures 7 to 9 mm in length and 2 to 4 mm in width. The periphery is well defined and smooth, and only the top 2 to 3 mm of the calcified thyroid cartilage is visible at the lower edge of a panoramic radiograph.  • The calcified tracheal cartilages usually present a homogeneous radiopacity, with an occasional outer cortex.
  76. 76.  Calcification of the thyroid cartilage. It is asymptomatic.
  77. 77.  Ossified thyroid and cricoid cartilages in a 40-year-old female patient demonstrated on a lateral cephalometric radiograph.
  78. 78.  Digital panoramic radiography with image suggesting triticeous cartilage on both sides (between the greater horn of the hyoid and superior horn of the thyroid cartilage).
  79. 79. Differential Diagnosis  • Calcified Atheromatous Plaque in the carotid bifurcation, the calcified triticeous cartilage has a solitary nature and an extremely uniform shape and size.  Management: No treatment required.
  80. 80. Rhinolith/Antrolith  Hard calcified bodies or stones that occur in the nose (rhinoliths) or the antrum (antroliths) arise from the deposition of mineral salts such as calcium phosphate, calcium carbonate, and magnesium around a nidus.  In case of a rhinolith the nidus is usually an exogenous foreign body (coin, beads etc) whereas the nidus for an antrolith is usually endogenous (root tip, bone fragment, masses of stagnated mucus, etc.).
  81. 81. Clinical Features  • The patient may be asymptomatic initially.  • With the increase in size of the expanding mass, it may impinge on the mucosa, producing pain, congestion and ulceration.  • The patient may develop a unilateral purulent rhinorrhea, sinusitis, headache, epistaxis, nasal obstruction, anosmia, fetor, fever and facial pain.
  82. 82. Radiographic Features  • These stones have a variety of shapes and sizes. They have well-defined smooth or irregular borders.  • They may be homogeneous or heterogeneous radiopacities, depending on the nature of the nidus and sometimes have laminations. Occasionally the density may exceed the surrounding bone.  • Antroliths occur within the maxillary sinus above the floor of the antrum and may be seen on the periapical, occlusal and panoramic radiographs.  • Rhinoliths are seen in the nasal fossae. A posteroanterior skull view will help to identify the location of a rhinolith.
  83. 83.  Antrolith (stone in maxillary sinus) on the floor of the sinus.  It is asymptomatic.
  84. 84.  A. Rhinolith in the maxillary sinus, seen on an OPG. The rhinolith is seen located at the posterior wall of the right maxillary sinus (arrow), B. Rhinolith in the maxillary sinus of the same patient, seen on Waters Projection, this projection also reveals the presence of chronic sinusitis
  85. 85. Differential Diagnosis  • Osteoma  • Healing odontogenic cyst  • Mycolith  • Root fragments; should be differentiated from antroliths by the presence of the root anatomy and presence of a root canal. A displaced fragment in the sinus will move when the radiography is performed with the head in different positions, unless it is lodged between the bone and the sinus lining.
  86. 86. Management  Patients should be referred to an otorhinolaryngologist for the removal of the stone.  Metastatic calcification results when minerals precipitate into normal tissue as a result of higher than normal serum calcium (e.g. hyperparathyroidism, hypercalcemia of malignancy) or phosphate (e.g. chronic renal failure).  Metastatic calcifications usually occur bilaterally and symmetrically. The deposits of calcium occur in the kidney, lung, gastric mucosa and media of blood vessels.
  87. 87. Ossification of the Styloid Ligament  Ossification of the styloid ligament usually extends downwards from the base of the skull and commonly occurs bilaterally. In rare cases the ossification begins at the lesser horn of the hyoid or in the central area of the ligament. The associated conditions are Eagle's Syndrome, Styloid Syndrome and Styloid Chain Ossification.
  88. 88. Clinical Features  • Patients are more than 40 years of age and are usually clinically symptom less.  • It may be detected by palpation over the tonsil as a hard pointed structure.  • The patient may present with a complaint of a vague nagging to intense pain in the pharynx on swallowing, turning the head or opening the mouth, especially on yawning.
  89. 89.  • The elongated styloid process and local scar tissue probable cause symptoms by impinging on the glossopharyngeal nerve.  • Similar clinical findings without a history of neck trauma constitute stylohyoid (carotid artery) syndrome.  – The patient may also describe attacks of otalgia, tinnitus, temporal headache and vertigo or transient syncope.  – The pain may be produced by mechanical irritation of sympathetic nerve tissue in the arterial wall, producing regional carotidynia.  – This condition is more prevalent than Eagle's syndrome.
  90. 90. Radiographic Features  • The styloid ligament ossification is quite common in individuals of any age and may be detected as an incidental feature on any panoramic radiograph.  • In the panoramic image it is seen as 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. The hyoid bone is positioned approximately parallel to or superimposed on the posterior aspect of the inferior cortex of the mandible.
  91. 91.  • The ossified ligament has a more or less straight outline, but it may sometimes show irregularity in the outer surface. The further the radiopaque ossified ligament extends towards the hyoid bone, the more likely it is that it will be interrupted by radiolucent, joint like junctions (pseudo articulations).  • Small ossifications of the styloid ligament appear homogeneously radiopaque. As the ossification increases in length and girth, the outer cortex of this bone appears as a radiopaque band at the periphery.
  92. 92.  Calcified stylohyoid ligament.
  93. 93. Patient with Eagle’s syndrome. The stylohyoid ligaments are bilaterally calcified.
  94. 94. Differential Diagnosis  • Temporomandibular joint dysfunction; there is no radiographic evidence of ligament ossification.  Management: Amputation of the stylohyoid process.
  95. 95. Osteoma Cutis  These are sites of normal bone formation in abnormal locations. It is a rare soft tissue calcification in the skin.  It may develop secondary to acne of long duration. In a scar or chronic inflammatory dermatosis.  Histologically these are seen as areas of dense viable bone in the dermis or subcutaneous tissue. They are occasionally found in diffuse scleroderma, replacing the altered collagen in the dermis and subcutaneous septa.
  96. 96. Clinical Features  • It may occur on the face (extraoral) in the cheek and lip region, and tongue (intraoral) where it may be called osteoma mucosae or osseous choristoma.  • It does not cause any visible change in the overlying skin, except in some cases where the color may change to yellowish white.  • It varies in size from 0.1 mm to 5 cm in diameter, if the lesion is large. The individual osteoma may be palpated. A needle inserted into one of the papules usually meets with stone like resistance.
  97. 97.  • Osteoma may be single or multiple.  • Some patients develop numerous lesions (dozens to hundreds)  Usually on the face in females and on the scalp or chest in males. This is known as multiple miliary osteoma cutis.
  98. 98. Radiographic Features  • An intraoral film placed between the cheek and the alveolar bone gives accurate localization.  • A posteroanterior skull view with the cheek blown outward using a soft tissue technique of 60 kVp helps localize osteomas of the skin.  • If present in the cheek or lip region the shadow may be superimposed over a tooth root or alveolar process, giving the appearance of dense bone.  • The osteoma cutis appears as smoothly outlined, radiopaque, washer-shaped images.
  99. 99.  •The single or multiple radiopacities of various sizes.  • It appears as a homogeneous radiopacity with a radiolucent center that represents normal fatty marrow, giving the lesion a dough-nut appearance radiographically.  • Trabeculae usually develop in the marrow cavity of the larger osteomas.  • Lesions of calcified cystic acne resemble a snowflake radiopacity which corresponds to the clinical location of the scar.
  100. 100. Differential Diagnosis  • Myositis ossificans; is of greater proportions, in some cases causing noticeable deformity of the facial contour.  • Calcinosis cutis  • Osteoma mucosae; if the blown out cheek technique is used, the lesions of osteoma cutis. appear much more superficial than mucosal lesions.
  101. 101. Management:  They may be removed for cosmetic reasons. The methods used are excision, resurfacing of the skin with erbium:YAG laser using tretinoin cream (especially in cases of multiple miliary osteomacutis).
  102. 102. Myositis Ossificans  In this case, the fibrous tissue and heterotopic bone form within the interstitial tissue of the muscle and associated tendons and ligaments. There is secondary destruction and atrophy of the muscle as the fibrous tissue and bone interdigitate and separate the muscle fibers. It is of two types:  – Localized myositis ossificans  – Progressive myositis ossificans
  103. 103. Localized Myositis Ossificans (post-traumatic myositis, myositis ossificans, Solitary myositis)  This results due to acute or chronic trauma, heavy muscular strain, muscle injury which may lead to considerable hemorrhage into the muscle or associated tendons or fascia. The hemorrhage organizes and undergoes progressive scarring.  During the healing process, heterotopic bone and in some cases cartilage is formed. There is no inflammation (the term myositis is thus misleading).  The fibrous tissue and bone form within the interstitial tissue of the muscle, there is no actual ossification of the muscle fibers.
  104. 104. Clinical Features  • It may develop at any age, in either gender, but is more common in young men who engage in vigorous activities. The commonly involved oral sites are, the masseter, sterno-cleidomastoid and lateral pterygoid muscle.  • The site of the precipitating trauma remains swollen, tender and painful for a long time. The overlying skin may be red and inflamed.  • If the lesion involves a muscle of mastication, opening the jaw may be difficult.  • After a period of 2-3 weeks the area of ossification may become apparent, as a firm, intramuscular palpable mass, which enlarges slowly, but eventually stops growing. The lesion may appear fixed or may be freely movable on palpation.
  105. 105. Radiographic Features  • A radiolucent band may be seen between the areas of ossification and adjacent bone, and the heterotopic bone may lie along the long axis of the muscle. The periphery is more radiopaque than the internal structure. The shape may vary from irregular, oval to linear streaks (psuedotrabeculae) running in the same direction as the normal muscle fibers.  • The internal structure varies with time:  – In the third or fourth week after injury, the appearance is faintly homogeneous radiopacity.
  106. 106.  – By the second month, it is organized and appears as delicate lacy or feathery radiopaque internal structure, which indicate the formation of bone. This bone does not have a normal appearing trabecular pattern.  – Gradually the image becomes denser and better defined, maturing fully in about 5-6 months.  – After this the lesion may shrink.
  107. 107.  Myositis Ossificans , this could be due to trauma or repeatedly occurring inflammatory events. In this case there is ossification of the masseter muscle causing limited ability to open the mouth. A. shows a section of an OPG (arrow). B. shows the massive ossification in a tangential zygoma projection (arrow)
  108. 108.  Ossification of muscle attachments on the mental spine; the genioglossus muscle and the geniohyoid muscle may become ossified where they attach to the mental spine, and this may provide difficulties for denture wearers. This may represent a form of myositis ossificans, which is a heterotopic accumulation of the bone at the attachment of the musculature
  109. 109.  Myositis ossificans involving the masseter muscle
  110. 110. Differential Diagnosis  •Ossification of the stylohyoid ligament, dystrophic calcifications in areas of necrosis, pathological calcifications, phleboliths. The form and location of myositis ossifications and the presence of psuedotrabeculae are enough to differentiate it from them.  • Bone forming tumors; although tumors like osteogenic sarcoma can form a linear bone. pattern, the tumor is contiguous with the adjacent bone and signs of bone destruction are present.  Management: Sufficient rest to the injured part, and if necessary excision.
  111. 111. Progressive Myositis Ossificans  This is a rare disease of unknown cause that usually affects children before 6 years of age, and occasionally as early as infancy.  Progressive formation of heterotopic bone occurs within the interstitial tissue of muscles, tendons, ligaments and fascia, and the involved muscle atrophies.  This condition may be inherited or may be a spontaneous mutation affecting the mesenchyma.
  112. 112. Clinical Features  • It usually affects children before 6 years of age, and occasionally as early as infancy, males are more affected.  It may affect the striated muscles including the heart and diaphragm.  • It starts in the muscles of the neck and upper back and moves to the extremities.  • It begins as a soft tissue swelling that is tender and painful and may show redness and heat, indicating the presence of inflammation.  • As the acute symptoms subside, a firm mass remains in the tissue.
  113. 113.  •Sometimes the spread of ossification is limited, in other cases it may be very extensive; affecting, almost all the muscles of the body, resulting in stiffness and limitation of motion of the neck, chest, back and extremities (especially the shoulders), which gradually increases.  • Advanced stages of the disease result in the “petrified man” like appearance.  • During the third decade the process may spontaneously arrest, however most of the patients die young during the 3rd or 4th decade, due to respiratory embarrassment or from inanition through the involvement of the muscles of mastication.
  114. 114. Radiographic Features  • The radiographic appearance is similar to that of localized myositis ossificans.  • The heterotopic bone more commonly is oriented along the long axis of the involved muscle, with coarser linear striae of increased density which represent new bone formation, and there is evidence of dense osseous replacement of the greater part or whole of the muscle.  • The bone that is laid down does not show normal bone structure, and appears as a rather structure less mass of variable density.  • Osseous malformations of the regions of muscle attachment, such as the mandibular condyles, may also be seen.  • Skeleton becomes osteoporotic because of lack of function as muscles atrophy and joints become ankylosed.
  115. 115. Differential Diagnosis  • Rheumatoid arthritis; in the initial stage it may be difficult but as the disease progresses specific anomalies confirm the diagnosis.  • Calcinosis; the deposists of amorphous calcium salts frequently resorb, but in progressive myositis ossificans that bone never disappears.  Management: There is no effective treatment. The treatment is symptomatic and supportive as per the requirement of each case. Nodules that are traumatized and then ulcerate should be excised.
  116. 116. References  Shenoy N, Ahme J, Sumanth K N, Srikant N S, Rai S, Yadiyal M . Prevalence of Laryngeal Cartilage Calcifications in Mangalore population; a Radiographic Study.Otolaryngology online journal.2014;4(4):74-80  Mupparapu M, Vuppalapati A. Ossification of Laryngeal Cartilages on Lateral Cephalometric Radiographs. Angle orthod.2005;75(2):196-201  White SC, Pharoa MJ. Oral Radiology: Principles and Interpretation. 6th ed. Saint Louis: Mosby; 2007  Haring JI, Jansen L. Dental radiography: principles and techniques. 2nd ed. Philadelphia:Saunders; 2000. 569 p.  Langland OE, Langlais RP, Preece JW. Principles of dental imaging. 2nd ed. LippincottWilliams & Wilkins; 2002. 459 p.

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