Soft Tissue Calcifications and Ossifications

Soft Tissue Calcifications and Ossifications1Outline Disease mechanismsHeterotopic calcifications Dystrophic calcificationIdiopathic calcificationMetastatic calcification

Heterotopic ossifications ossification of the styloid ligamentOsteoma cutisMyositis ossificans

Disease mechanisms

Heterotopic calcifications :when this deposition occurs in unorganized fashion in soft tissue . Heterotopic ossifications: When minerals deposited in soft tissue as organized fashion.Heterotopic = indicate that bone has formed in abnormal extra skeleton location .Diameter rang from 1mm to several cms .

Imaging features(IN GENERAL)ST opacities are common 4% of panoramic RGThe goal is to determine the need of :treatment or further investigations.Another RG at right angle is useful if the calcification close to the bone.Focus on :the anatomic location ,number ,distribution and shape to have correct interpretation. Knowledge of Soft Tissue anatomy is required.

Dystrophic calcification

Disease mechanism: precipitation of calcium salts into primary site of chronic inflammation or dead and dying tissue e.g. long-standing chronically inflamed cyst. Associate with high local concentration of phosphate ,increase local alkalinity and anoxic conditions within the inactive or devitalized tissue.Clinical features: common sites are gingiva ,tongue, lymph node and cheek. Signs and symptoms: may not present at all ,but we may see: * enlargement ,ulceration of the underling soft tissues. * solid mass of calcium salts can be palpated sometimes.

Imaging features of dystrophic calcificationvaries from fine radiopaque grains to large irregular radiopaque particles rarely exceed 0.5cm in diameterOne or more Homogeneous or punctate The Outline =irregular or indistinct Common sites: long standing chronically inflamed cysts and polyps.Imaging features of dystrophic calcification

Calcified lymph nodesCalcfication occur in the lymph nodes = chronically inflamed because of various diseases (either active or result of former treated pathosis ) frequently granulomatous disorder.Lymph tissue > > Replaced by hydroxyapetite like Ca salts.

Most known causes= TB (scrofula or cervical tuberculosis adenitis(Bacille Calmette-Guerin vaccination sarcoidosis cat-scratch disease rheumatoid arthritis systemic sclerosis fungal infections lymphoma previously treated with radiation malignancy like treated hogkins lymphoma metastases from distant calcifying neoplasms mostly thyroid cancer.

Calcified lymph nodesClinical features: Asymptomatic Incidental finding on panorama RGWhen these nodes can be palpated >Most common nodes involved >Less commonly preauricular and submental They are hard, lumpy and round to oblong masses submandibular, superficial and deep cervical

Calcified lymph nodesRadiographic features: Location:the most common =submandibular either Below or at the inferior border of mandible near the angle or Between the posterior border of the ramus and cervical spine.Chaining : when linear series of lymph nodes are affected.Periphery: well defined, irregular and occasionally lobulated (cauliflower shape) Internal structure: Without a patternand not reliably distinguish between benign and malignant disease .may vary in degree of radiopacity Collection of spherical or irregular masses Laminated appearance ( occasionally)Radiopacity on surface of node ( egg-shell calcifications)

Calcified lymph nodes

Calcified lymph nodes* Differential diagnosis: Sialolith = smooth outline ,symptoms , sialography Phlebolith = smaller ,multiple ,concentric RO and RL rings, may mimic a portion of blood vessels .

* Management: - Usually do not need treatment- Underplaying cause should be eliminated in the case of active disease

Dystrophic calcification in the TonsilsSynonyms : tonsillar calculi ,tonsil concretions and tonsilloliths .Disease mechanism: Formed when repeated bouts of inflammation enlarge the tonsillar crypts . Incomplete resolutions of organic debris > serve as the nidus for dystrophic calcificationClinical features :Hard, round , white or yellow objects projecting from tonsillar crypts ( usually the palatine tonsil )Small calcification > No clinical signs or symptomsLarger calcification > Pain, swelling, fetor oris and dysphagia or foreign body sensation on swallowing. Giant tonsiloliths >stretch the lymphoid tissue and resulting in ulceration +extrusion less commoncalcification occur in individuals between ( 20-68years), more often in older age group Dystrophic calcification in the TonsilsRadiographic features:

Location: in the panoramic RG: mid portion of the mandibular ramus+ exactly inferior to the mandibular canal.in axial CT they appear in the soft tissue medial to mandibular ramus and next to the lateral wall of the oropharyngeal space. - Periphery: multiple small ill defined radiopacities rarely large.- Internal structure: more radiopaque than cancellous bone and approximately the same as cortical bone.

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Dystrophic calcification in the TonsilsDifferential diagnosis : 1- clinical :calcified granulomatous disease, Syphilis, mycosis or lymphoma may >firm tonsillar masses2- radiographic: any RO lesion within the mandibular ramus e.g. dens bone island ***When in doubt>> right angle view e.g. Posterior anterior skull view or open Townes view ALSO 3D like MDCT or CBCT may be necessary for precise localization. Management: mostly no treatment Symptomatic patients > sedation + express manually Large calcification with symptoms > removed surgically Elderly with mechanical deglutition disorders and immunocompromised > consider treatment even if asymptomatic because of the risk of aspiration pneumonia .

CysticercosisDisease mechanism when human ingest eggs from parasite taena solium larvae of egg is released to the rest of the body and tend to attach to muscles of in the oral region, they die in tissues other than intestinal mucosa causing granuloma > scar > calcify 3 months later. Increase incidence > American south west & urban northeast Korean + hespanic .it is endemic problem in developing countries central and south America , asia and Africa where there is fecal contamination in agriculture soil and pork is valued food .

CysticercosisClinical features: Mild cases > asymptomatic Severe cases > gastrointestinal upset, epigastric pain, severe nausea and vomiting Invasion of brain > seizures, headache, visual disturbances, acute obstructive hydrocephalus, irritability, loss of consciousness and death.Oral mucosa: palpable, well circumscribed soft fluctuant swelling resemble > mucocele or benign mesenchymal neoplasm Multiple small nodules may be felt in : masseter + suprahyoid muscle + tongue + buccal mucosa +lip

CysticercosisRadiographic features: -note : alive larvae is not visible radio graphically .Location: muscles of mastication& facial expression, suprahyoid muscle, post cervical musculature, tongue, buccal mucosa or lipPeriphery & shape: multiple well defined elliptic radiopacities ( resemble grains of rice) - Internal structure: homogeneous and radiopaque

Cysticercosis

Cysticercosis * Differential diagnosis :- Sialolith ,, BUT cysticercosis =small sized calcification , widespread disseminated in brain and muscle. *Management:Basic Sanitation > to get rid of the source of infection (prober preparation of pork +avoid fecal contamination ) the symptoms that accompany the initial infestation treated by antihelminthic ( albendazole or praziquantel) +adjunct corticosteroid and anticonvulsant Seriological testing

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