Soft tissue calcifications of the head and neck

Question 1

What is a heterotopic calcification vs heterotopic ossification?

Answer 1

heterotopic calcification = when deposition of calcium salts occurs in the skeleton in an unorganised fashion

heterotopic ossification = “” organised (e.g. ossification of stylohyoid ligament, osteoma cutis, myositis ossificans)

Question 2

What are the 3 types of heterotopic calcification? (DIM acronym)

Answer 2

dystrophic

idiopathic

metastatic

Question 3

Define and give examples for dystrophic, idiopathic and metastatic calcification. (6)

Answer 3

Dystrophic = calcification that forms in degenerating, diseased and dead tissue despite normal serum calcium and phosphate levels (DDD,D) → calcified lymph nodes, tonsilloliths, atherosclerotic plaque

Idiopathic = deposition of calcium in normal tissue depsite normal serum and phosphate levels → sialoliths, phleboliths, triteceous cartilage calcifications, rhinolith, antrolith

Metastatic = when minerals precipitate into normal tissue as a result of higher than normal serum levels of calcium → hyperparathyroidism, chronic renal failure

Question 4

What is a General dystrophic calcification of oral region? (1) Gives its radiographic features (site, size appearance) (3)

Answer 4

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

site: long standing chronically inflamed cysts
size: rarely exceed 0.5cm diameter
appearance: varies from fine grains of ROs to large irregular radioopacities

Question 5

What is shown in the image

Answer 5

large residual cyst with ill-defined calcifications → general dystrophic calcification of oral regions

Question 6

What is shown in the image

Answer 6

large residual cyst with ill-defined calcifications → general dystrophic calcification of oral regions

Question 7

What causes calcified lymph nodes? give some examples of conditions

Answer 7

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

e.g. TB, sarcoidosis, cat-scratch disease, lymphoma treated with radiotherapy, fungal infections, metastases from distant calcifying neoplasms

Question 8

What are the clinical features of calcified lymph nodes? (4) (which nodes, signs/symptoms, how its found, palpation)

Answer 8

• submd and cervical (superficial and deep) most commonly involved
• no signficant signs or symptoms
• usually incidental finding
• upon palpation - may be single/multiple, mobile, hard/round whose outline is well contoured and defined

Question 9

What are the radiographic features of calcified lymph nodes? (location, periphery, internal structure, size)

Answer 9

location: below inferior border of mandible near angle OR between posterior border of ramus and cervical spine
periphery: well-defined, irregular and lobulated (cauliflower-like)

internal structure: may have a varying degree of radioopacity, giving impression of collection of spherical or irregular masses, looks like mass of coral

size: big or small

Question 10

What are the differential diagnoses of calcified lymph nodes?

Answer 10

sialolith

phlebolith

Question 11

What is the management for a calcified lymph node?

Answer 11

usually requires no tx, but the underlying cause should be determined in case tx is required

Question 12

How are tonsilloliths (dystrophic calcification) formed? (2)

Answer 12

when there are repeated bouts of inflammation enlarge the tonsilar crypts, incomplete resolution of dead bacteria and pus serve as the nidus for dystrophic calcification

Question 13

What are the clinical features of tonsilloliths? (5)

Answer 13

• hard, round, white or yellow objects projecting from the tonsillar crypts
• small calculi are usually asymptomatic
• large carger calcifications: pain, swelling, fetor oris, dysphagia and foreign body feeling on swallowing
• in rare cases with giant tonsilloliths, may stretch the lymphoid tissue, resulting in ulcerations and extrusion
• 20-68 years, more common in older

Question 14

What are the radiographic features of tonsilloliths? (location, periphery shape and size, internal structure)

Answer 14

location: single or multiple radioopacities that overlap the mid-portion of the mandibular ramus in the region where the image where the dorsal surface of the tongue crosses the ramus in palatoglossal air spaces

periphery, shape, size: clusters of multiple or single small ill-defined radioopacities

size: 0.5-1.5cm in diameter

internal structure: the radioopacity is of the same density as that of cortical bone and a little more radiopaque than cancellous bone

Question 15

What is the differential diagnosis for tonsilloliths?

Answer 15

enostosis

Question 16

What is the management for tonsilloliths?

Answer 16

smaller: no tx required
larger: ones associated with symptoms are surgically removed (refer to ENT)

Question 17

What are the 2 types of arterial calcifications which can be identified both radiographically and histologically?

Answer 17

Monckerberg’s Medial Calcinosis (Arteriosclerosis)

Calcified Atherosclerotic Plaque

Question 18

What is Monckerberg’s Medial Calcinosis?

Answer 18

characterised by the fragmentation degeneration and eventual loss of elastic fibres followed by deposition of calcium within the medial coat of the vessel

Question 19

What are the clinical features of Monckerberg’s Medial Calcinosis

Answer 19

• initially most patients asymptomatic
• eventually may develop cutaneous gangrene, peripheral vascular disease and myositis due to vascular insufficiency
• EXTREMELY rare

Question 20

What are the radiographic features of Monckerberg’s Medial Calcinosis? (site, periphery, internal structure)

Answer 20

site: those involving facial (pic) or carotid artery may be seen on panoramic radiographs
periphery: calcific deposits in walls of artery outline an image of the artery, from the side it may appear as a parallel pair of thin, RO lines that have a straight or tortuous path (pipe stem or tram track appearance), in cross section the involved vessels display a circular ring like pattern

internal structure: no specific internal structure

Question 21

How do you manage Monckerberg’s Medial Calcinosis?

Answer 21

evaluation of patient for occlusive arterial disease or peripheral vascular disease - refer to GP or cardiologist

Question 22

What is a calcified atherosclerotic plaque? Why is it dangerous?

Answer 22

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

forms at bifurcation of common carotid artery, which has high blood pressure, if the atherosclerotic plaque is dislodged it may go into the vessels of brain and cause stroke

Question 23

What are the radiographic features of calcified atherosclerotic plaque? (site, periphery, shape and size, internal structure)

Answer 23

site: at bifurcation of common carotid artery adjacent to greater cornu of hyoid bone and cervical vertebrae C3, C4 or intervertebral space between them

periphery, shape, size: multiple and irregularly shaped, sharply-defined from surrounding soft tissues and vertical linear distribution

internal structure: heterogenous radioopacity

Question 24

What is a differential diagnosis of calcified atherosclerotic plaque?

Answer 24

calcified triticeous cartilage -uniform size, shape and location

Question 25

What is the management for calcified atherosclerotic plaque?

Answer 25

URGENT referral to GP for cerebrovascular and cardiovascular assessment

Question 26

What causes idiopathic calcification? give some examples of idiopathic calcifications

Answer 26

deposition of calcium in normal tissue despite normal serum calcium and phosphate levels e.g. sialolith, phleboliths, triteceous cartilage calficiations, rhinolith, antrolith

Question 27

What are sialoliths? Where are they commonly found?

Answer 27

stones found within salivary glands ducts can form in any major or minor salivary gland (glandular sialolith) or ducts (ductal sialolith) common in submd glands

Question 28

Where are sialoliths most commonly found? (1) Explain why (4) \*exam q

Answer 28

submandibular salivary glands 1. **gland and ductal system** lie in a **dependent position** 2. **Wharton's** duct is **long** and has **irregular, tortuous** course 3. An **uphill flow** in **proximal portion** 4. salivary secretion is more **viscous** and has **higher mineral content**

Question 29

Which age and gender do sialoliths have more incidence in?

Answer 29

age: common in middle age, slight predilection for men

Question 30

What proportion of submd sialoliths are found in different areas?

Answer 30

half in distal portion of Wharton's duct 20% in proximal portion 30% in gland

Question 31

When can sialoliths be palpated?

Answer 31

if in more peripheral portion of duct if of sufficient size

Question 32

What are signs and symptoms of sialoliths? What difference is noticed between intra and extraglandular stones?

Answer 32

may be **asymptomatic** OR may have hx of **pain and swelling** in FOM and involved gland **intraglandular stones** cause **less severe symptoms** than extraglandular discomfort may **intensify at meal times** when salivary flow is stimulated if blockage is only partial, then pain and swellig gradully subside **pus** may excude from duct orifice, the surrounding soft tissue may be **inflamed** and **tender** and overlying mucosa may **ulcerate**

Question 33

What are the radiographic features of sialoliths? (shape, internal structure, how many are RL in submd and parotid)

Answer 33

in submd gland: **cylindrical** or **long cigar shaped** to **oval or round shaped** stones are **homeogenously radioopaque** and show evidence of **multiple layers** less than 20% of submd and 40% of parotid gland sialoliths are **radiolucent** because of **low mineral content**

Question 34

What must you do when taking a radiograph in order to be able to see a sialolith?

Answer 34

* reduce exposure to almost half (half of iopa 1.6s)

Question 35

Which types of radiographs are better to visualise differently positioned sialoliths and why? (3)

Answer 35

PA: there may be superimposition of stone over md premolar and molar apices standard Md occlusal view: best view for visualising stones in distal portion of Wharton's duct panoramic view: to view stones in more posterior location

Question 36

What do these radiographs show?

Answer 36

sialolith in submandibular gland duct

Question 37

What does this radiograph show?

Answer 37

sialolith in right submandibular gland

Question 38

What does this radiograph show?

Answer 38

calcification in right parotid gland and its duct

Question 39

What is shown in this radiograph?

Answer 39

multiple microliths in parotid gland on both sides

Question 40

Which two types of radiographs may be used to view parotid gland duct sialolith and how?

Answer 40

1. **PA** film placed in buccal sulcus with reduced exposure and time and central ray directed through cheek 2. **A-P skull view** with “blow out” cheek or an **open-mout lat ceph**

Question 41

What can be done to help detect non-calcified salivary gland stones?

Answer 41

sialography helpful in locating obstructions that are undetectable w plain radiography

Question 42

What is the management for sialoliths of different sizes? (3)

Answer 42

small stones: milked out through duct orifice by TA + bimanual palpation larger stones: minimally invasive sialolithotomy using intracorporeal lithotripters exceedingly large stones: surgical removal of the stone or gland

Question 43

What are pheboliths?

Answer 43

calcified thrombi found in the veins, venulae or sinusoidal vessels of hemangiomas (especially the cavernous type)

Question 44

What are the clinical features of a phlebolith?

Answer 44

in the H + N region, phleboliths always indicate the **presence of a hemangioma** the involved soft tissue may be **swollen, throbbing or discoloured** by the presence of veins or a soft tissue hemangioma

Question 45

What is shown in the radiograph?

Answer 45

multiple phleboliths on the right side

Question 46

What are the radiographic features of phleboliths? (site, periphery and shape, internal structure)

Answer 46

site: commonly found in hemangiomas periphery and shape: **round or oval**, up to **6mm** in diameter with a **smooth periphery** internal structure: may be **homogenously radioopaque** but more commonly appearance of **laminations**, giving a **bull's eye/target** appearance **radiolucent centre** may be seen, which may represent the patent portion of the vessel

Question 47

What is the differential diagnosis of a phlebolith?

Answer 47

sialolith

Question 48

What does correctly identifying phleboliths depend on? And why is this important to dentists?

Answer 48

identification of possible vascular lesion such as haemangioma critical if surgical procedures being contemplated

Question 49

What is a triticeous cartilage calcification?

Answer 49

calcification of cartilages within **lateral thyrohyoid ligaments** have tendency to calcify or ossify with advancing age triticeous means grain of wheat

Question 50

What are the radiographic features of triticeous cartilage calfications? (how is it found, site, periphery and shape, internal structure)

Answer 50

incidental finding within panoramic radiograph site: **within pharyngeal air space** **inferior to the greater cornu** of hyoid bone and **adjacent to superior border of C4** size: **7-9mm** in length and **2-4mm** in width periphery: **well defined** and **smooth** internal structure: **homogenous** radiopacity with **occasional outer cortex**

Question 51

What is shown in the image below?

Answer 51

bilateral tricticeous cartilage calcification and calcification of superior horn of thyroid cartilage

Question 52

What is the differential diagnosis for triticeous cartilage calcification?

Answer 52

adjacent vs inferior to greater cornu of hyoid bone multiple and irregular vs well defined and smooth heterogenous radiopacity, homogenousradiopacity with occasional outer cortex

Question 53

What is the management for triticeous cartilage calcifications?

Answer 53

none

Question 54

What is shown in this image?

Answer 54

Question 55

What is a rhinolith/antrolith and what are they caused by?

Answer 55

hard, calcified bodies or stones that occur in nose (rhinolith) or antrum (antroliths) arising from the deposition of mineral salts around a nidus rhinolith: nidus usually exogenous foreign body (coins, beads etc) antrolith: endogenous (root tip, bone fragment, masses of stagnated mucus etc)

Question 55

What is a rhinolith/antrolith and what are they caused by?

Answer 55

hard, calcified bodies or stones that occur in nose (rhinolith) or antrum (antroliths) arising from the deposition of mineral salts around a nidus rhinolith: nidus usually exogenous foreign body (coins, beads etc) antrolith: endogenous (root tip\*, bone fragment, masses of stagnated mucus etc) \*could be P root of upper molars

Question 56

What are the signs/symptoms of rhinolith/antrolith?

Answer 56

may be asymptomatic initially with increasing size of expanding mass, it may **impinge on mucosa →** causing **pain**, **congestion** and **ulceration** patient may develop **unilateral purulent rhinorrhea**, **sinusitis**, **headache**, **epistaxis** (nosebleed), **nasal obstruction** (may have **difficulty breathing**), **anosmia** (partial-full loss of smell), **fetor** (foul smell), **fever and facial pain**

Question 57

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

Answer 57

site: rhinoliths - nose, antrolith - antrum periphery and shape: **variety of shapes and sizes**, **well-defined smooth or irregular borders** internal structure: **homogenous OR heterogenous** radioopacigties

Question 58

What are the 2 differential diagnoses for rhinolith/antrolith?

Answer 58

osteoma root fragments (should be differentiated from antroliths by presence of root anatomy and root canal)

Question 59

What is the management for rhinolith/antrolith?

Answer 59

refer to GP then ENT for removal of stone

Question 60

Where does ossification of styloid ligament usually occur and is it usually bilateral or unilateral? At which length is it considered abnormal?

Answer 60

usually extends downwards from base of skull commonly bilateral if \>30mm considered abnormal

Question 61

What are the associated conditions of ossified styloid ligament? Give brief signs & symptoms/or lack thereof of each

Answer 61

Styloid Chain Ossification (asymptomatic) Eagle's Syndrome (symptomatic and hx of tonsilectomy or surgery to neck) Styloid Syndrome aka carotid artery syndrome (symptomatic and no hx of neck trauma + ear symptoms)

Question 62

Give the clinical features of styloid chain ossification. (age group, symptoms, how is it detected intraorally?)

Answer 62

\>40yrs usually symptomless (95%) may be detected by **palpation over tonsil** as a hard pointed structure

Question 63

What are the signs/symptoms and relevant medical history of Eagle's Syndrome?

Answer 63

**vague nagging to intense pain** in **pharynx** on **swallowing**, **turning head** or **opening mouth**, **especially yawning** above symptoms + recent hx of neck trauma (e.g. tonsilectomy)

Question 64

What is the probable cause of pain in Eagle's syndrome?

Answer 64

**elongated styloid process** and **local scar tissue** probably cause symptoms by **impinging** on **glossopharyngeal** nerve (CN9)

Question 65

What are the symptoms of stylohyoid (carotid artery) syndrome

Answer 65

similar to Eagles syndrome but WITHOUT hx of neck trauma additionally may have attacks of **otalgia** (ear pain), **tinnitus**, **temporal headache** and **vertigo** or **transient syncope**

Question 66

What may be the cause of pain in Stylohyoid (carotid artery) Syndrome?

Answer 66

**mechanical irritation** of **sympathetic nerve tissue** in **arterial wall**, producing ***regional carotidynia*** (**unilateral** tenderness of carotid artery)

Question 67

What are the radiographic features of Stylohyoid Syndrome? (site, shape, internal structure)

Answer 67

site: **linear, long, tapering, thin** radioopaque process that is **thicker at its base**, **extending forward** from **region of mastoid process** and **crosses the posteroinferior aspect of ramus** towards **hyoid bone** shape: may have bilateral radiolucent joint like junctions (**pseudarticulations**) internal structure: **homogenously** radioopaque

Question 68

What is the differential diagnosis and management for stylohyoid ligament ossification?

Answer 68

temporomandibular joint dysfunction (no radiographic evidence of ligament ossification) refer to ENT for amputation of stylohyoid process

Question 69

Label this diagram

Answer 69

Question 70

What do these images show?

Answer 70

range of NORMAL positions of the mx sinus relative to premolar and molar teeth

Question 71

What does this radiograph show?

Answer 71

left mx sinus mimicking a benign space-occupying lesion

Question 72

Name 4 intrinsic diseases of the maxillary sinus

Answer 72

mucositis maxillary sinusitis retention pseudocyst mucocele

Question 73

Name extrinsic diseases of the maxillary sinus

Answer 73

periostitis cysts

Question 74

What are the symptoms, treatment and radiographic appearance of mucositis?

Answer 74

asymptomatic, discovered as incidental finding (can follow up after 6 months) non-corticated band paralleling the bony wall of the sinus 2-4mm is normal, greater than 4mm considered pathology

Question 75

What is maxillary sinuitis and what is it caused by?

Answer 75

generalised inflammation of sinus mucosa caused by allergen, bacteria or virus in 10% of cases inflammation from dental origin

Question 76

What are the 3 types of sinusitis?

Answer 76

acute - less than 2 weeks chronic - more than 3 months pansinusitis - all sinuses involved

Question 77

What are the clinical features of acute sinusitis vs chronic sinusitis?

Answer 77

Acute: * **clear nasal discharge** or **pharyngeal drainage** * **nasal stuffiness** * **pain** and tenderness to **pressure or swelling** over the involved **sinus** * may have **referred pain to pm or m** on affected side * teeth may be **TTP** * may have pain on jumping or stomping * ask patient to bend down for 2-3 minutes and ask if they have pain in that particular mx sinus area and palpate Chronic: * no external signs occur except during **periods of acute exacerbations when increased pain and discomfort** are apparent

Question 78

What are different radiographic appearances of maxillary sinusitis?

Answer 78

* localised mucosal thickening along sinus floor * generalised thickening of mucosal lining around entire wall of sinus * complete radiopacity of the sinus * uniform cloudiness of the maxillary sinus * fluid level seen (usually in the lowest portion of the sinus)

Question 79

Give the etiology, predominant gender and symptoms and treatment of retention pseudocysts

Answer 79

blockage of secretory ducts of seromucous males asymptomatic - incidental finding BUT symptomatic when it completely fills the mx sinus no tx - self limiting (if small and asymptomatic/ incidental finding tx may not be necessary, recommended to moniter with periodic imaging, if large tx may be required, advise CBCT, may be removed by minor endoscopic surgery that includes either enucleation - difficult or curreettage - more common)

Question 80

Why is a retention pseudocyst considered a pseudocyst?

Answer 80

no epithelial lining

Question 81

What are the radiographic features of retention pseudocysts? (bi/unilateral, size, periphery and shape)

Answer 81

bilateral (sometimes unilateral aswell) size: ranges from finger tip size to large enough to completely fill sinus periphery and shape: non-corticated, dome-shaped radiopacity in the antrum

Question 82

What is shown in the images below?

Answer 82

retention pseudocyst (bottom image fills about ¼ of mx sinus)

Question 83

What is a mucocele: type of lesion, which sinus, etiopathogenesis, radiographic appearance, treatment

Answer 83

expanding and destructive lesion when **sinus ostium** is blocked and causes excrutiating pain in **ethmoidal**, **frontal** sinuses and **maxillary** sinus highly symptomatic R/F: radioopacity, causing **thinning and expansion of sinus walls** tx: urgent referral to GP/ENT \*sinus ostium (opening of mx sinus - at middle meatus)

Question 84

What is periostitis?

Answer 84

when mx 1st or 2nd molar has periapical inflammation and it ‘lifts’ the periosteum and floor of mx sinus as a result of inflammation, once recedes it will drop down to normal level

Question 85

How do you different a cyst from normal floor of the maxillary antrum? (borders-2, aspiration)

Answer 85

borders: cyst will be **smooth, straight and clear** outline whereas normal sinus has **irregular, scalloped outline** **+ cortical border wider in cyst** than sinus aspiration: in cyst yields **yellow straw coloured fluid** but **nothing from sinus** + subsequent **injection of radioopaque contrast** medium will **remain in cyst rather than drain out through ostium**

Question 86

What is the radiographic appearance of a periapical cyst?

Answer 86

**uniform** **radiolucency** bordered by **thin, well-defined radioopaque margin** that _displaces the maxillary sinus upward + non-vital teeth_