Radiographic Features of Soft Tissue Calcifications

1. SOFT TISSUE CALCIFICATIONS
Dr. Hadi Munib
Oral and Maxillofacial Surgery Resident

2. OUTLINE
• Introduction
• Clinical Features
• Radiographic Features
• Arterial Calcifications
• Metastatic Calcifications
• References

3. INTRODUCTION
• The deposition of calcium salts, primarily calcium phosphate,
usually occurs in the skeleton.
• Heterotopic Calcifications; When it occurs in an unorganized
fashion in soft tissue and it may develop in a wide variety of
unrelated disorders and degenerative processes.
• Heterotopic calcifications may be divided into three categories:
• Dystrophic calcification
• Idiopathic calcification
• Metastatic calcification

4. DYSTROPHIC CALCIFICATIONS
• Calcification that forms in degenerating, diseased, and dead tissue despite
normal serum calcium and phosphate levels.
• The soft tissue may be damaged by blunt trauma, inflammation, injections,
the presence of parasites, soft tissue changes arising from disease, and many
other causes.
• This calcification usually is localized to the site of injury.
• Idiopathic calcification (or calcinosis) results from deposition of calcium in
normal tissue despite normal serum calcium and phosphate levels.
• Examples include chondrocalcinosis and phleboliths.
• Metastatic calcification results when minerals precipitate into normal tissue
as a result of higher than normal serum levels of calcium or phosphate (e.g.,
chronic renal failure).
• Metastatic calcification usually occurs bilaterally and symmetrically.

5. DYSTROPHIC CALCIFICATIONS
• Heterotopic Ossifications; When the mineral is deposited in soft tissue
as organized, well-formed bone.
• Heterotopic indicates that bone has formed in an extra-skeletal location.
• The heterotopic bone may be all compact bone, or might show some
trabeculae and fatty marrow.
• May range from 1 mm to several centimeters in diameter and it could be
multiple
• The causes range from post-traumatic ossification, bone produced by
tumors, and ossification caused by diseases such as progressive myositis
ossificans and ankylosing spondylitis.

6. CLINICAL FEATURES
• Sites of heterotopic calcification or ossification may not cause
significant signs or symptoms.
• They most often are detected as incidental findings during
radiographic examination.

7. RADIOGRAPHIC FEATURES
• Soft tissue opacities are fairly common, present on about 4% of
panoramic radiographs.
• In most cases the goal is to identify the calcification correctly to
determine whether treatment or further investigation is required.
• Some soft tissue calcifications require no intervention or long-term
surveillance, whereas others may be life threatening and the underlying
cause requires treatment.
• When the soft tissue calcification is adjacent to bone another
radiographic view at right angles is useful.
• The important criteria to consider in arriving at the correct
interpretation are the anatomic location, number, distribution and
shape of the calcifications

8. DYSTROPHIC CALCIFICATIONS
• GENERAL DYSTROPHIC CALCIFICATION OF THE ORAL
REGIONS
• Precipitation of calcium salts into primary sites of chronic
inflammation or dead and dying tissue.
• Usually associated with a high local concentration of
phosphatase, as in normal bone calcification.
• An increase in local alkalinity and anoxic conditions within the
inactive or devitalized tissue.
• A longstanding chronically inflamed cyst is a common location of
dystrophic calcification.

9. DYSTROPHIC CALCIFICATIONS
• Clinical Features
• Common soft tissue sites include the gingiva, tongue, lymph nodes, and cheek.
• May produce no signs or symptoms, although occasionally enlargement and
ulceration of overlying soft tissues may occur.
• Solid mass of calcium salts sometimes can be palpated.
• Radiographic Features
• Barely perceptible, fine grains of radiopacities to larger, irregular radiopaque
particles that rarely exceed 0.5 cm in diameter.
• One or more of these radiopacities may be seen, and the calcification may be
homogeneous or may contain punctate areas.
• The outline of the calcified area usually is irregular or indistinct.
• Common sites are long-standing chronically inflamed cysts and polyps.

12. CALCIFIED LYMPH NODES
• Lymph nodes that have been chronically inflamed because of various
diseases, frequently granulomatous disorders.
• The lymphoid tissue becomes replaced by hydroxyapatite nearly
effacing all of nodal architecture.
• The presence of calcifications in lymph nodes implies disease, active or
Previously treated
• Tuberculosis was the most common disease causing calcified lymph
nodes (scrofula or cervical tuberculous adenitis).
• Other well-known causes include bacille Calmette-Gu é rin
vaccination, sarcoidosis, cat-scratch disease, rheumatoid arthritis
and systemic sclerosis, lymphoma previously treated with
radiation therapy, fungal infections, and metastases from distant
calcifying neoplasms, most notably metastatic thyroid carcinoma.

13. CALCIFIED LYMPH NODES
• Generally asymptomatic.
• Discovered as an incidental finding on a panoramic radiograph.
• The most commonly involved nodes are the submandibular and
superficial and deep cervical nodes and the preauricular and
submental nodes.
• When these nodes can be palpated, they are hard, lumpy, round
to oblong masses.

14. CALCIFIED LYMPH NODES
• Radiographic Features
• Location; The most common location 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 sometimes overlaps the inferior aspect of
the ramus. Lymph node calcifications may affect a single node or a linear
series of nodes in a phenomenon known as lymph node “chaining”
• Periphery. The periphery is well defined and usually irregular, occasionally
having a lobulated appearance similar to the outer shape of cauliflower.
• This irregularity of shape is of great significance in distinguishing node
calcifications from other potential soft tissue calcifications in the area.
• Internal Structure. The internal aspect is without pattern but may vary in
the degree of Radiopacity, giving the impression of a collection of spherical
or irregular masses. Eggshell Calcifications

15. CALCIFIED LYMPH NODES
• Differential Diagnosis
• Sialolith in the hilar region of the submandibular gland; a
smooth outline, whereas a calcified lymph node is usually
irregular and sometimes lobulated.
• Phlebolith; are usually smaller and multiple, with concentric
radiopaque and radiolucent rings, and their shape may mimic a
portion of a blood vessel.
• Management; do not require treatment; however, the
underlying cause should be established in case treatment is
required.

18. DYSTROPHIC CALCIFICATION IN THE TONSILS
• Tonsillar calculi, tonsil concretions, and tonsilloliths
• Formed when repeated bouts of inflammation enlarge the
tonsillar crypts.
• Incomplete resolution of organic debris can serve as the nidus
for dystrophic calcification.
• Usually present as hard, round, white or yellow objects
projecting from the tonsillar crypts, usually of the palatine tonsil.
• Small calcifications usually produce no clinical signs or
symptoms.
• Pain, swelling, fetor oris, dysphagia, or a foreign body sensation
on swallowing - reported with larger calcifications.

19. DYSTROPHIC CALCIFICATIONS IN THE TONSILS
• Giant tonsilloliths stretching lymphoid tissue resulting in ulceration
and extrusion are much less common.
• Occur between 20 and 68 years of age more often in older age groups.
• Radiographic Features
• Location. In the panoramic film, they 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 oropharyngeal air spaces,
immediately inferior to the mandibular canal
• Periphery; cluster of multiple small, ill-defined radiopacities.
• Internal Structure; more radiopaque than cancellous bone and
approximately the same as cortical bone.

20. DYSTROPHIC CALCIFICATIONS IN THE TONSILS
• Differential Diagnosis
• Calcified granulomatous disease, syphilis, mycosis, or
lymphoma,
• The essential radiographic differential diagnosis is a radiopaque
lesion within the mandibular ramus, such as a dense bone
island.
• When in doubt, a right-angle view such as a posteroanterior
skull view or an open Towne’s view will be helpful
• No treatment is required.

22. CYSTICERCOSIS
• When humans ingest eggs or gravid proglottids from the parasite Taenia solium
(pork tapeworm), the covering of the eggs is digested in the stomach and the larval
form (Cysticercus cellulosae) of the parasite is hatched.
• The larvae penetrate the mucosa, enter the blood vessels and lymphatics, and are
distributed in the tissues all over the body but preferentially locate to brain, muscle,
skin, liver, lungs, and heart.
• They are also found in the oral and perioral tissues, especially the muscles of
mastication.
• In tissues other than the intestinal mucosa, the larvae eventually die and are treated as
foreign bodies, causing granuloma formation, scarring, and calcification
approximately 3 months later.
• These areas in the tissues are called cysticerci.
• There is currently an increased incidence in the American Southwest and urban
Northeast, especially among Koreans and Hispanics.
• It is much worse in developing countries where there is fecal contamination of
agricultural soil and pork is a valued food.

23. CYSTICERCOSIS
• Mild cases of are completely asymptomatic.
• More severe 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, headache, visual
disturbances, acute obstructive hydrocephalus, irritability, loss of
consciousness and death.
• Examination of the oral mucosa may disclose palpable, well-
circumscribed soft fluctuant swellings, which resemble a mucocele or
benign mesenchymal neoplasm.
• Multiple small nodules may be felt in the region of the masseter and
suprahyoid muscles and in the tongue, buccal mucosa, or lip.

24. CYSTICERCOSIS
• Radiographic Features
• While alive, larvae are not visible radiographically.
• Death of the parasites and development of calcifications in
subcutaneous and muscular sites occurs approximately 5 years after the
initial infection.
• Location; the muscles of mastication and facial expression, the
suprahyoid muscle, and the Post-cervical musculature, as well as in the
tongue, buccal mucosa, or lip.
• Periphery and Shape; Multiple well-defined elliptic radiopacities
resembling grains of rice.
• Internal Structure; homogeneous and radiopaque.

25. CYSTICERCOSIS
• Differential Diagnosis
• Sialolith; small size of the calcified nodules of cysticerci and
their widespread dissemination,
• Management
• Although basic sanitation is needed to extinguish this source of
infection.
• The symptoms that accompany the initial infestation are best
treated by a physician using an anti-helminthic such as
praziquantel.

29. ARTERIAL CALCIFICATIONS
• Monckeberg’s medial calcinosis and calcified atherosclerotic plaque.
• MONCKEBERG’S MEDIAL CALCINOSIS (ARTERIOSCLEROSIS)
• The hallmark of arteriosclerosis is the fragmentation, degeneration,
and eventual loss of elastic fibers
• Followed by the deposition of calcium within the medial coat of the
vessel.
• Most patients are asymptomatic initially.
• May have clinical pathosis such as cutaneous gangrene, peripheral
vascular disease, and myositis as a result of vascular insufficiency.
• Patients with Sturge-Weber syndrome also develop intracranial arterial
calcifications.

30. MONCKEBERG’S MEDIAL CALCINOSIS
(ARTERIOSCLEROSIS)
• Location; Medial calcinosis involving the facial artery or less
commonly, the carotid artery, may be viewed on panoramic
radiographs.
• Periphery and Shape; The calcific deposits in the wall of the artery
outline an image of the artery.
• From the side, the calcified vessel appears as a parallel pair of thin,
radiopaque lines that may have a straight course or a tortuous path
and is described as a “pipe stem” or “tram-track” appearance.
• In cross-section, involved vessels will display a circular or ring-like
pattern.
• Internal Structure; no internal structure because the diffuse, finely
divided calcium deposits occur solely in the medial wall of the vessels

31. • Differential Diagnosis
• The radiographic appearance of arteriosclerosis is so distinctive
as to be pathognomonic of the condition.
• Management
• Evaluation of the patient for occlusive arterial disease and
peripheral vascular disease may be appropriate.
• Hyperparathyroidism may be considered because medial
calcinosis frequently develops as a metastatic calcification in
patients with this condition.
MONCKEBERG’S MEDIAL CALCINOSIS
(ARTERIOSCLEROSIS)

33. CALCIFIED ATHEROSCLEROTIC PLAQUE
• Atheromatous plaque in the extracranial carotid vasculature is the major
contributing source of cerebrovascular embolic and occlusive disease.
• Dystrophic calcification can occur in the evolution of plaque within the intima
of the involved vessel.
• Radiographic Findings
• Location; first develops at arterial bifurcations as a result of increased
endothelial damage from shear forces at these sites, may be visible in the
panoramic radiograph in the soft tissues of the neck either superior or
inferior to the greater cornu of the hyoid bone and adjacent to the cervical
vertebrae C3, C4, or the intervertebral space between them
• Periphery and Shape; multiple and irregular in shape and sharply defined
from the surrounding soft tissues and they have a vertical linear distribution.
• Internal Structure; heterogeneous Radiopacity with radiolucent voids.

34. CALCIFIED ATHEROSCLEROTIC PLAQUE
• Differential Diagnosis
• Calcified triticeous cartilage may be mistaken for atheromatous
plaque, although the uniform size, shape, and location of
calcified triticeous cartilage in the laryngeal cartilage skeleton
identify this innocuous condition.
• Management
• Patients especially those with established risk factors for
cerebrovascular and cardiovascular disease, should be referred
to their physicians for further investigation.

37. IDIOPATHIC CALCIFICATIONS - SIALOLITH
• Stones found within the ducts of salivary glands
• Mechanical conditions contributing to a slow flow rate and physiochemical
characteristics of the gland secretion.
• Contribute to the formation of a nidus and subsequent precipitation of calcium
and phosphate salts.
• Most common in the submandibular glands of men in their middle and later
years.
• They usually occur singly (70% to 80%) but may be multiple, especially in the
parotid gland.
• Usually have a history of pain and swelling, the discomfort may intensify at
mealtimes, when salivary flow is stimulated.
• Because the stone usually does not block the flow of saliva completely.
• As many as 9% of patients have recurrent sialolithiasis, and about 10% of
patients with sialolithiasis also have nephrolithiasis.

38. SIALOLITH
• Radiographic Features
• Location; The submandibular gland is involved more often (83%
to 94% of cases) than the parotid gland (4% to 10%) or the
sublingual gland (1% to 7%).
• About half of submandibular stones lie in the distal portion of
Wharton’s duct.
• 20% in the proximal portion
• 30% in the gland itself.

39. SIALOLITH
• Periphery and Shape; duct of the submandibular gland usually
are cylindric and very smooth in their outlines.
• Hilus of a submandibular gland tend to be larger and more
irregularly shaped.
• Internal Structure; homogeneously radiopaque, and others
show evidence of multiple layers of calcification
• Less than 20% of submandibular gland Sialoliths and 40% of
those in the parotid gland are radiolucent.

40. SIALOLITH
• Applied Radiology
• Periapical views; superimposed over the mandibular premolar and
molar apices
• Mandibular Occlusal Radiograph; The best view for visualizing
stones in the distal portion of Wharton’s using half the usual exposure
time, which displays the floor of the mouth without overlap
• Lateral Oblique view/ Panoramic Film; Stones in a more posterior
location are
• Periapical Film in Buccal Vestibule; To demonstrate stones in the
parotid gland duct, reduces the exposure time, and orients x-ray beam
through the cheek.

41. SIALOLITH
• Differential Diagnosis
• Other soft tissue calcifications; Sialoliths usually are
associated with pain or swelling of the involved salivary gland.
• Management; Small stones often may be “Milked out ” through
the duct orifice by bimanual palpation.
• If the stone is too large or located in the proximal duct, non-
surgical or minimally invasive sialolithotomy may be used

46. PHLEBOLITH
• Calcified thrombi found in veins, venulae, or the sinusoidal vessels of
hemangiomas (especially the cavernous type).
• Intravascular thrombi - arise from venous stagnation- sometimes
become organized or even mineralized.
• Beginning in the core of the thrombus and consists of crystals of
apatite with calcium phosphate and calcium carbonate.
• In the head and neck, phleboliths nearly always signal the presence of a
hemangioma.
• In an adult, phleboliths may be the sole residua of a childhood
hemangioma that has long since regressed.
• The involved soft tissue may be swollen, throbbing, or discolored by
the presence of veins or a soft tissue hemangioma.

47. PHLEBOLITH
• Hemangiomas often fluctuate in size, associated with changes in body position or during a
Valsalva maneuver.
• Applying pressure to the involved tissue should cause a blanching or change in color if the
lesion is vascular in nature.
• Auscultation may reveal a bruit in cases of cavernous hemangioma but not in the capillary
type.
• Radiographic Features
• Location; most commonly are found in hemangiomas
• Periphery and Shape; 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 slightly curved sausage.
• Internal Structure; 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

48. PHLEBOLITH
• Differential Diagnosis
• Sialolith; usually occur singly; if more than one is present, they
usually are oriented in a single line, whereas phleboliths are
usually multiple and have a more random, clustered distribution.
• Correct Diagnosis identifies a vascular problem
• This is critical if surgical procedures are contemplated.

50. LARYNGEAL CARTILAGE CALCIFICATIONS
• The small, paired triticeous cartilages are found within the lateral
thyrohyoid ligaments.
• Both the thyroid and triticeous cartilages consist of hyaline cartilage,
which has a tendency to calcify or ossify with advancing age.
• Calcification of tracheal cartilages is an incidental radiographic finding
with no clinical features.
• Location; located on a lateral skull or panoramic radiograph within the
soft tissues of the pharynx 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

51. LARYNGEAL CARTILAGE CALCIFICATIONS
• Periphery and Shape; The word triticeous means “grain of
wheat” and the cartilage measures 7 to 9 mm in length and 2 to 4
mm in width.
• The periphery of the calcified triticeous cartilage is well defined
and smooth, and the geometry is exceedingly regular.
• Usually only the top 2 to 3 mm of a calcified thyroid cartilage will
be visible at the lower edge of a panoramic radiograph with 6-
inch systems.
• Internal Structure. Calcified tracheal cartilages generally present
a homogeneous Radiopacity but may occasionally demonstrate an
outer cortex.

52. LARYNGEAL CARTILAGE CALCIFICATIONS
• Differential Diagnosis
• Calcified atheromatous plaque in the carotid bifurcation; the
solitary nature and extremely uniform size and shape of LCC should
be discriminatory.
• Management
• No treatment is needed for calcified tracheal cartilages.
• Careful attention to the differences in morphology and location
enable the clinician to distinguish between calcified triticeous
cartilage and calcified carotid atheromata

54. RHINOLITH/ ANTROLITH
• Calcareous concretions that occur in the nose (Rhinoliths) or the
antrum of the maxillary sinus (antroliths)
• Arise from the deposition of nasal, lacrimal, and inflammatory
mineral salts such as calcium phosphate, calcium carbonate, and
magnesium by accretion around a nidus.
• In cases of Rhinolith, the nidus is usually an exogenous foreign
body especially in the pediatric population.
• The route of entry is usually anterior, but some may enter the
choanae posteriorly during sneezing, coughing, or emesis.
• The nidus for an Antrolith is usually endogenous especially in
the adult population.

55. RHINOLITH/ ANTROLITH
• The patient may be asymptomatic for extended periods of time.
• The expanding mass may impinge on the mucosa, producing pain, congestion, and
ulceration.
• The patient may have a unilateral purulent rhinorrhea, sinusitis, headache, epistaxis,
anosmia, fetor, and fever.
• Location; Rhinoliths develop in the nose whereas antroliths develop in the antrum
of the maxillary sinus.
• Periphery and Shape; variety of shapes and sizes, depending on the nature of the
nidus.
• Internal Structure; may present as homogeneous or heterogeneous radiopacities,
depending on the nature of the nidus, and may sometimes have laminations.
• Occasionally the density will exceed the surrounding bone.
• Differential Diagnosis; osteoma, Odontoma, surgical ciliated cyst, and mycolith.
• Management; referred to an Otorhinolaryngologist for endo-nasal surgical removal
of the mass. Lithotripsy has been used to debulk large rhinoliths.

57. METASTATIC CALCIFICATIONS
• Calcification of the soft tissues in the oral region caused by conditions
involving elevated serum calcium and phosphate levels, such as
hyperparathyroidism or hypercalcemia of malignancy, are extremely
rare.

58. HETEROTOPIC BONE – STYLOHYOID LIGAMENT
• Embryologically, the styloid process arises from the second
branchial arch (Reichert cartilage).
• Which consists of four sections that give rise to the stylohyoid
complex.
• Ossification of the stylohyoid ligament usually extends downward
from the base of the skull and commonly occurs bilaterally.
• Rare cases; the ossification begins at the lesser horn of the hyoid
and in fewer still in a central area of the ligament.
• Detected by palpation over the tonsil as a hard, pointed structure.

59. STYLOHYOID LIGAMENT CALCIFICATIONS
• Eagle’s Syndrome; Symptoms related to this ossified ligament
• Expressed as one of two subtypes:
• Classic Eagle syndrome; from cranial nerve impingement, this entity
is associated with discomfort and the patient has a recent history of
neck trauma (typically tonsillectomy).
• Carotid artery syndrome; from impingement on the carotid vessels,
Clinical findings without a history of neck trauma
• The ossified stylohyoid complex and local scar tissue are thought to
cause symptoms by impinging on cranial nerves V, VII, IX, X, or XII, all
of which pass in close proximity to the styloid process.
• Symptoms may include vague, nagging to intense pain in the
pharynx on swallowing, turning the head, or opening the mouth,
especially on yawning, and tinnitus or otalgia.

60. STYLOHYOID LIGAMENT CALCIFICATIONS
• When the ECA is impinged and stimulated, the patient may feel
suborbital facial pain.
• Symptoms when the ICA is affected may include eye pain,
temporal or parietal headache, aphasia, visual symptoms,
weakness, and transient hemispheric ischemia with vertigo
or syncope, notably on turning the head to the ipsilateral side.
• Pain is produced by mechanical irritation of sympathetic nerve
tissue in the arterial wall, producing regional carotidynia.

61. STYLOHYOID LIGAMENT CALCIFICATIONS
• Radiographic Features
• Commonly as an incidental feature on panoramic radiographs.
• In one study, approximately 18% of a population examined showed
ossification of more than 30 mm of the stylohyoid ligament.
• The ligament may have at least some calcification in individuals of any
age.
• Location. In a panoramic image the linear ossification extends
forward from the region of the mastoid process and crosses the
posteroinferior aspect of the ramus toward the hyoid bone.
• The hyoid bone is positioned roughly parallel to or superimposed on
the posterior aspect of the inferior cortex of the mandible.

62. STYLOHYOID LIGAMENT CALCIFICATIONS
• Shape. The styloid process appears as a long, tapering, thin, radiopaque
process that is thicker at its base and projects downward and forward.
• It normally varies from about 0.5 to 2.5 cm in length.
• The farther the radiopaque ossified ligament extends toward the hyoid
bone, the more likely it is that it will be interrupted by radiolucent,
• Joint-like junctions (pseudo-articulations).
• Internal Structure. Small ossifications of the stylohyoid ligament
appear homogeneously radiopaque.
• As the ossification increases in length and girth, the outer cortex of this
bone becomes evident as a radiopaque band at the periphery.

63. STYLOHYOID LIGAMENT CALCIFICATIONS
• Differential Diagnosis
• The symptoms generally are vague.
• When they occur with the distinctive radiographic evidence of ligament
ossification, little chance exists that the complaint will be confused
• Temporomandibular Joint Dysfunction.
• Management
• Asymptomatic  no treatment is required.
• Vague symptoms  a conservative approach of reassurance and steroid or
lidocaine injections into the tonsillar fossa would be recommended initially.
• Persistent or intense symptoms  amputation of the stylohyoid process
(stylohyoidectomy).

65. OSTEOMA CUTIS
• Rare soft tissue ossification in the skin.
• Approximately 85% of cases occur as a result of acne of long duration,
developing in a scar or chronic inflammatory dermatosis.
• Histologically these lesions are areas of dense viable bone in the
dermis or subcutaneous tissue.
• They occasionally are found in diffuse scleroderma, replacing the
altered collagen in the dermis and subcutaneous septa.
• Can occur anywhere, but the face is the most common site.
• The tongue is the most common intraoral site (osteoma mucosae or
osseous choristoma).
• Does not cause any visible change in the overlying skin other than an
occasional color change that may appear yellowish white.

66. OSTEOMA CUTIS
• If the lesion is large, the individual osteoma may be palpated.
• A needle inserted into one of the papules is met with stone-like
resistance.
• Multiple Miliary osteoma cutis; patients have numerous
(dozens to hundreds) of lesions, usually on the face in females
and on the scalp or chest in males.

67. OSTEOMA CUTIS
• Radiographic Features
• Location; osteoma cutis most commonly appears in the cheek and lip regions, can
be superimposed over a tooth root or alveolar process, giving the appearance of an
area of dense bone.
• Posteroanterior skull view with the cheek blown outward by use of a soft tissue
technique of 60 peak kilovolts helps localize osteomas in the skin.
• Periphery and Shape; smoothly outlined, radiopaque, washer-shaped images.
These single or multiple radiopacities usually are very small, although the size can
range from 0.1 to 5 cm.
• Internal Structure; homogeneously radiopaque but usually has a radiolucent
center that represents normal fatty marrow, giving the lesion a donut appearance
radiographically.
• Trabeculae occasionally develop in the marrow cavity of larger osteomas.
• Individual lesions of calcified cystic acne resemble a snowflake like Radiopacity,
which corresponds to the clinical location of the scar.

68. OSTEOMA CUTIS
• Differential Diagnosis
• Myositis ossificans, calcinosis cutis, and osteoma mucosae.
• If the blown-out cheek technique is used, the lesions of osteoma
cutis appear much more superficial than mucosal lesions.
• Myositis ossificans is of greater proportions, in some cases
causing noticeable deformity of the facial contour.
• Management; No treatment is required, but these osteomas
occasionally are removed for cosmetic reasons.

70. MYOSITIS OSSIFICANS
• Fibrous tissue and heterotopic bone form within the interstitial
tissue of muscle and associated tendons and ligaments.
• Secondary destruction and atrophy of the muscle occur as this
fibrous tissue and bone interdigitate and separate the muscle
fibers.
• There are two principal forms: localized and progressive

71. LOCALIZED MYOSITIS OSSIFICANS - TRAUMATIC
• Post-traumatic myositis ossificans and solitary myositis
• Results from acute or chronic trauma or from heavy muscular strain caused
by certain occupations and sports.
• Muscle injury from multiple injections (occasionally from dental anesthetic)
also may be a cause.
• Skeletal muscle has limited capacity for regeneration after significant
physical trauma.
• Proposed that exuberant proliferation of vascular granulation tissue
subsequently undergoes metaplasia to cartilage and bone during the healing
process.
• The term myositis is misleading because no inflammation is involved.
• The fibrous tissue and bone form within the interstitial tissue of the muscle;
no actual ossification of the muscle fibers occurs.

72. LOCALIZED MYOSITIS OSSIFICANS
• Occurs most often in young men who engage in vigorous activity.
• The site remains swollen, tender, and painful much longer than
expected.
• When the lesion involves a muscle of mastication, opening the jaws
may be difficult.
• After about 2 or 3 weeks, the area of ossification becomes apparent
in the tissues; a firm intramuscular mass can be palpated.
• May enlarge slowly, but eventually it stops growing.
• The lesion may appear fixed, or it may be freely movable on
palpation.

73. LOCALIZED MYOSITIS OSSIFICANS
• Radiographic Features
• Location; The most commonly involved muscles of the head and
neck are the masseter and sternocleidomastoid.
• Other muscles involved such as the medial and lateral pterygoid
and the temporalis muscles.
• The anterior attachments of the temporalis and the medial
pterygoid muscles are at risk of injury on administration of
mandibular block anesthesia.
• Usually a radiolucent band can be seen between the area of
ossification and adjacent bone.

74. LOCALIZED MYOSITIS OSSIFICANS
• Periphery and Shape; commonly is more radiopaque than the internal
structure, irregular oval to linear streaks (pseudo-trabeculae) running in the
same direction as the normal muscle fibers.
• These pseudo-trabeculae are characteristic of myositis ossificans and
strongly imply a diagnosis.
• Internal Structure; varies with time, within the third or fourth week after
injury, the radiographic appearance is a faintly homogeneous Radiopacity.
• By 2 months a delicate lacy or feathery radiopaque internal structure
develops.
• These changes indicate the formation of bone; it does not have a normal-
appearing trabecular pattern.
• Gradually the image becomes denser and better defined, maturing fully in
about 5 to 6 months.
• After this period the lesion may shrink.

75. LOCALIZED MYOSITIS OSSIFICANS
• Ossification of the stylohyoid ligament
• Other soft tissue calcifications
• Both the form and location of myositis ossificans often are enough to
make the differential diagnosis.
• Bone-forming tumors; osteogenic sarcoma can form a linear bone
pattern, the tumor is contiguous with the adjacent bone, and signs of
bone destruction often are present.
• Management; Rest and limitation of use are recommended to diminish
the extent of the calcific deposit.
• Surgical excision of the entire calcified mass with intensive
physiotherapy to minimize postsurgical scarring is the recommended
treatment.

77. PROGRESSIVE MYOSITIS OSSIFICANS
• Rare hereditary disease with autosomal dominant transmission, but less
commonly it arises as a result of spontaneous mutation.
• It is more common in males and causes symptoms from early infancy.
• Progressive formation of heterotopic bone occurs within the interstitial
tissue of muscles, tendons, ligaments and fascia, and the involved muscles
atrophy
• Starts in the muscles of the neck and upper back and moves to the
extremities.
• The disease commences with soft tissue swelling that is tender and painful
and may show redness and heat, indicating the presence of inflammation.
• The acute symptoms subside, and a firm mass remains in the tissues.
• This may affect any of the striated muscles, including the heart and
diaphragm

78. PROGRESSIVE MYOSITIS OSSIFICANS
• Some cases the spread of is limited; in others it may affect almost all
the large muscles of the body.
• Stiffness and limitation of motion of the neck, chest, back, and
extremities (especially the shoulders) gradually increase.
• Functional deficits are progressive and handicapping.
• Advanced stages of the disease result in the “petrified man” condition.
• During the third decade the process may spontaneously arrest.
• Most patients die during the third or fourth decades.
• Premature death usually results from respiratory embarrassment or
from inanition through the involvement of the muscles of mastication

79. PROGRESSIVE MYOSITIS OSSIFICANS
• Radiographic Appearance is similar to that described for the limited
form.
• The heterotopic bone more commonly is oriented along the long axis
of the involved muscle.
• Osseous malformation of the regions of muscle attachment, such as
the mandibular condyles, also may be seen.
• Differential Diagnosis
• In the initial stages of the disease; Rheumatoid arthritis.
• The presence of specific anomalies suggests the diagnosis. In the case
of calcinosis, the deposits of amorphous calcium salts frequently
resorb.
• Progressive myositis ossificans, the bone never disappears.

80. PROGRESSIVE MYOSITIS OSSIFICANS
• Management
• No effective treatment exists for progressive myositis ossificans.
• Nodules that are traumatized and that ulcerate frequently should
be excised.
• If interference with respiration or respiratory infection occurs in
the later stages of the disease, supportive therapy may be
required.

83. REFERENCES
• Chapter 28: Soft Tissue Calcifications and Ossifications

84. THANK YOU!