Soft tissue calcifications of the oral cavity

soft tissue calcifications ppt

1. SOFT TISSUE CALCIFICATIONS PRESENTED BY N.NARMATHA

2. INTRODUCTION The deposition of calcium salts - occurs in the skeleton. U norganized fashion in soft tissue - heterotopic calcification. Heterotopic calcifications •  Dystrophic calcification • Idiopathic calcification • Metastatic calcification

3. Term   heterotopic   - bone formed in an abnormal location - compact bone, or it may exhibit some trabeculae and fatty marrow - 1  mm to several cms in diameter. CAUSES Post traumatic ossification bone produced by tumours ossification caused by diseases such as progressive myositis ossificans and ankylosing spondylitis . CLINICAL FEATURES No significant signs or symptoms I ncidental findings during radiographic examination.

4. GENERAL RADIOGRAPHIC FEATURES • S een in 4% of panoramic radiographs. • If calcification is adjacent to bone - difficult to determine - another radiographic view at right angles is useful .

5. CLASSIFICATION A.Dystrophic Calcifications • General dystrophic calcification of the oral regions • Calcified lymph nodes • C alcification 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

6. DYSTROPHIC CALCIFICATION Calcification that forms in degenerating, diseased and dead tissue despite normal serum calcium and phosphate levels. S oft tissue - damaged by blunt trauma, inflammation, injections, the presence of parasites Localized to the site of injury.

7. Disease Mechanism A high local concentration of phosphatase, An increase in local alkalinity Anoxic conditions within the inactive or devitalized tissue. A long-standing chronically inflamed cyst is a common location of dystrophic calcification .

8. CLINICAL FEATURES S oft tissue sites - gingiva, tongue, lymph nodes, and cheek. N o signs or symptoms, Occasionally enlargement and ulceration of overlying soft tissues may occur A solid mass of calcium salts can be palpated.

9. IMAGING FEATURES Fine grains of radiopacities to larger, irregular radiopaque particles R arely exceed 0.5 cm in diameter. homogeneous or may contain punctate areas. Outline - irregular or indistinct.

10. IDIOPATHIC CALCIFICATION (OR CALCINOSIS) Results from deposition of calcium in normal tissue despite normal serum calcium and phosphate levels.

11. METASTATIC CALCIFICATION O ccurs bilaterally and symmetrically . Minerals precipitate into normal tissue as a result of higher than normal serum levels of calcium Examples: hyperparathyroidism

12. DYSTROPHIC CALCIFICATION CALCIFIED LYMPH NODES Chronically inflamed lymph nodes - granulomatous disorders. L ymphoid tissue replaced by hydroxyapatite-like calcium salts, nearly effacing all nodal architecture. C alcifications in lymph nodes implies disease

13. CAUSES: T uberculosis - most common BCG vaccination S arcoidosis C at-scratch disease R heumatoid arthritis S ystemic sclerosis L ymphoma previously treated with radiation therapy F ungal infections M alignancy

14. Clinical Features: Asymptomatic I ncidental finding on panoramic radiograph. I nvolved nodes most common - submandibular , superficial and deep cervical nodes . pre auricular and submental nodes (least) On palpation - hard, lumpy, round to oblong masses.

15. IMAGING FEATURES Location: M ost common location – 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.

16. I mage of the calcified node sometimes overlaps the inferior aspect of the ramus. may affect a single node or a linear series of nodes in a phenomenon known as lymph node chaining

17. PERIPHERY: W ell defined and usually irregular O ccasionally - lobulated appearance similar to cauliflower

18. Internal Structure: V ary in the degree of radiopacity - collection of spherical or irregular masses. Occasionally – laminated appearance or eggshell calcification. Differential Diagnosis: Sialolith Phlebolith Management: Do not require treatment , the underlying cause should be established

19. DYSTROPHIC CALCIFICATION IN THE TONSILS (tonsillar calculi, tonsil concretions, tonsilloliths .) Disease Mechanism: F ormed when repeated bouts of inflammation enlarge the tonsillar crypts Incomplete resolution of organic debris Clinical Features: H ard , round, white or yellow objects projecting from the tonsillar crypts, usually of the palatine tonsil.

20. Smaller calcifications - No clinical signs or symptoms. Pain, swelling, fetor oris , dysphagia, or a foreign body sensation on swallowing - larger calcifications.

21. IMAGING FEATURES Location: S ingle or multiple radiopacities that overlap the midportion of the mandibular ramus I nferior to the mandibular canal

22. PERIPHERY: C luster of multiple small, ill-defined radiopacities INTERNAL STRUCTURE : M ore radiopaque than cancellous bone and approximately the same as cortical bone. DIFFERENTIAL DIAGNOSIS: Syphilis Mycosis Lymphoma D ense bone island.

23. MANAGEMENT: No treatment Large calcifications - removed surgically. Treatment of asymptomatic tonsilloliths - considered in elderly patients

24. CYSTICERCOSIS Disease Mechanism : The larvae penetrate the mucosa - enter the blood vessels and lymphatics - distributed as cysticerci in the tissues all over the body F ound in oral , perioral tissues, muscles of mastication. L arvae die years after infection and are treated as foreign bodies - strong inflammatory reaction - granuloma formation, scarring, and calcification.

25. Clinical Features: Mild cases - asymptomatic. More severe cases - mild to severe gastrointestinal upset with epigastric pain and severe nausea and vomiting. Invasion of the brain - seizures , headache, visual disturbances, acute obstructive hydrocephalus, irritability, loss of consciousness, and death.

26. Oral mucosa disclose palpable, well-circumscribed soft fluctuant swellings Multiple small nodules - masseter and suprahyoid muscles,tongue , buccal mucosa, or lip. Imaging Features: Alive larvae not visible radiographically. Death of the parasites and development of calcifications in subcutaneous and muscular sites occurs years after the initial infection .

27. Periphery and Shape: Multiple well-defined elliptic radiopacities Internal Structure - homogeneous and radiopaque .

28. Management: Basic sanitation Anthelmintic such as albendazole or praziquantel . Adjunctive corticosteroids Anticonvulsants After the larvae have settled and calcified in the oral tissues, they are harmless.

29. MONCKEBERG’S MEDIAL CALCINOSIS : C haracterized by fragmentation, degeneration and eventual loss of elastic fibers - deposition of calcium within the medial coat of the vessel. CLINICAL FEATURES: A symptomatic

30. IMAGING FEATURES Location : Involve the facial artery or carotid artery Periphery and Shape: The calcific deposits in the wall of the artery outline an image of the artery.

31. P arallel pair of thin, radiopaque - straight course or a tortuous path - “pipe stem” or “tram-track” appearance. In cross section - circular or ringlike pattern.

32. CALCIFIED ATHEROSCLEROTIC PLAQUE Disease Mechanism: Found in the extracranial carotid vasculature - source of cerebrovascular embolic and occlusive disease . Location: A rterial bifurcations I n the soft tissues of the neck either superior or inferior to the greater cornu of the hyoid bone adjacent to the cervical vertebrae C3 , C4, or the intervertebral space

33. Periphery and Shape: Multiple, irregular and sharply defined from the surrounding soft tissues, and have vertical linear distribution . Internal Structure: H eterogeneous radiopacity with radiolucent voids. Differential Diagnosis: Atheromatous Plaque

34. IDIOPATHIC CALCIFICATION D eposition of calcium in normal tissue despite normal serum calcium phosphate levels. • Sialoliths • Phleboliths • Laryngeal cartilage calcifications • Rhinolith / Antrolith

35. SIALOLITHS Formation of calcified obstruction within the salivary duct - chronic retrograde infection. G landular sialolith D uctal sialolith Mechanical conditions Slow flow rate and physiochemical characteristics gland secretions formation of a nidus precipitation of calcium and phosphate salts .

36. CLINICAL FEATURES • Common in middle age • Submandibular gland ,Wharton duct ( 83 %), parotid (10%) and sublingual (7 %) About half - lie in the distal portion of the Wharton's duct, proximal portion (20 % ) and 30% in the gland. •Asymptomatic , or history of pain and swelling

37. • Stones in peripheral portion - palpated, if it is of sufficient size. • Sialolithiasis of minor salivary gland is rare -common site – buccal mucosa

38. RADIOGRAPHIC FEATURES • S ialoliths – cylindrical, long cigar shapes to oval or round shapes. • Stones in hilus of the submandibular gland - larger and irregularly shaped.

39. • Homogeneously radiopaque, and show evidence of multiple layers . • Mandibular occlusal view - best view for visualizing stones in the distal portion of the Wharton's duct. • lateral oblique view or a panoramic view - to visualize stones in a more posterior location.

40. • Periapical film & Anteroposterior skull view - to demonstrate stones in the parotid duct. To detect sialoliths the exposure time should be reduced to about half of normal - detect stones that are highly calcified.

41. If non calcified stone – Sialography is helpful • CT: detect minimally calcified sialoliths which are not visible on plain films. • USG: is of limited use, but if the stone is large (2 mm), it will be detected as characteristic acoustic shadow showing echodense spots .

42. DIFFERENTIAL DIAGNOSIS • Hyoid bone • Myositis ossificans • Phleboliths • Calcific submandibular lymph nodes • Palatine tonsillitis.

43. MANAGEMENT: Use of sialogogues Piezoelectric extracorporeal shock wave lithotripsy Indication: smaller than 10 mm calculi Surgical removal

44. PHLEBOLITHS Calcified thrombi found in veins, venulae , or the sinusoidal vessels of hemangiomas CLINICAL FEATURES • In the head and neck region - phleboliths indicate hemangioma . • Soft tissue may be swollen, throbbing or discolored ,fluctuate blanching or change in colour on applying pressure. Auscultation reveal bruit

45. RADIOGRAPHIC FEATURES • common in hemangiomas . • In cross section - round or oval, 6 mm in diameter with smooth periphery . If blood vessel is viewed from the side, the phlebolith resemble straight or a slightly curved sausage . • homogeneously radiopaque bull's eye or target appearance . A radiolucent center may be seen DIFFERENTIAL DIAGNOSIS • Sialolith

46. LARYNGEAL CARTILAGE CALCIFICATIONS Both the thyroid and the triticeous cartilages consist of hyaline cartilage - calcify or ossify with advancing age . RADIOGRAPHIC FEATURES - homogeneous radiopacity , with an occasional outer cortex. DIFFERENTIAL DIAGNOSIS • Calcified Atheromatous Plaque.

47. RHINOLITH ANDANTROLITH Hard calcified bodies or stones that occur in the nose – rhinoliths or antrum - antroliths In rhinolith the nidus is exogenous foreign body (coin, beads) T he nidus for an antrolith is endogenous ( root tip , bone fragment, masses of stagnated mucus, etc )

48. CLINICAL FEATURES • asymptomatic initially. • With increase in size - pain,congestion and ulceration. • M ay develop unilateral purulent rhinorrhea , sinusitis, headache, epistaxis, nasal obstruction , anosmia, fetor, fever and facial pain

49. RADIOGRAPHIC FEATURES • well-defined smooth or irregular borders . • homogeneous or heterogeneous radiopacities – density may exceed the surrounding bone. • Antroliths seen on the periapical , occlusal and panoramic radiographs. • A posteroanterior skull view - locate rhinolith .

50. DIFFERENTIAL DIAGNOSIS • Osteoma • Healing odontogenic cyst • Mycolith • Root fragments. MANAGEMENT: R eferred to an otorhinolaryngologist for the removal of the stone .

51. OSSIFICATION OF THE STYLOID LIGAMENT Extends downwards from the base of the skull occurs bilaterally. The associated conditions are Eagle's Syndrome , Styloid Syndrome and Styloid c hain o ssification . Clinical Features • >40 years, a symptomatic. • D etected over the tonsil as a hard pointed structure.

52. • Vague nagging to intense pain Neck trauma - eagle's syndrome. • Without history of neck trauma - stylohyoid (carotid artery) syndrome. Otalgia, tinnitus, temporal headache and vertigo or transient syncope.

53. RADIOGRAPHIC FEATURES L inear , long, tapering , thin, radiopaque process 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 . 0.5 to 2.5 cm .

54. DIFFERENTIAL DIAGNOSIS • Temporomandibular joint dysfunction MANAGEMENT Amputation of the stylohyoid process.

55. OSTEOMA CUTIS Rare soft tissue calcification – focal development of bone within the dermis Secondary to acne of long duration, in a scar ,chronic inflammatory dermatosis.

56. CLINICAL FEATURES • Extraoral – cheek and lip region, Intraoral - tongue - osteoma mucosae or osseous choristoma . • Color - yellowish white. • 0.1 mm to 5 cm in diameter, A needle inserted into one of the papules usually meets with stone like resistance. • Single or multiple. • Numerous lesions - multiple miliary osteoma cutis.

57. RADIOGRAPHIC FEATURES • A PA skull view with the cheek blown outward using a soft tissue technique of 60 kvp - localize osteomas of the skin. Smooth , radiopaque, washer-shaped images. • Single or multiple homogeneous radiopacity with a radiolucent center – normal fatty marrow- dough-nut appearance • Calcified cystic acne – snowflake radiopacity

58. DIFFERENTIAL DIAGNOSIS • Myositis ossificans MANAGEMENT Excision, Resurfacing of the skin with erbium:yag laser using tretinoin c ream

59. MYOSITIS OSSIFICANS F ibrous tissue and heterotopic bone form within the interstitial tissue of the muscle ,tendons and ligaments S econdary destruction and atrophy of the muscle Etiology : Acute or chronic trauma, Heavy muscular strain, Muscle injury - hemorrhage into the muscle or associated tendons or fascia - organizes and undergoes progressive scarring - heterotopic bone / cartilage.

60. CLINICAL FEATURES • Common sites - the masseter, sternocleidomastoid and lateral pterygoid muscle • Muscle of mastication involvement - Jaw opening difficult. • 2-3 weeks later - apparent , firm, intramuscular palpable mass, which enlarges slowly , but eventually stops growing, fixed or freely movable

61. RADIOGRAPHIC FEATURES • A radiolucent band may be seen between the areas of ossification and adjacent bone, and the heterotopic bone lie along the long axis of the muscle.

62. periphery - radiopaque. shape - irregular , oval to linear streaks running in the same direction as the normal muscle fibers . INTERNAL STRUCTURE: T hird or fourth week after injury – homogeneous radiopacity . S econd month - delicate lacy or feathery radiopaque internal structure - formation of bone . Gradually denser and better defined, maturing fully in about 5-6 months– After this the lesion shrink .

63. DIFFERENTIAL DIAGNOSIS Ossification of the stylohyoid ligament, Dystrophic calcifications Pathological calcifications, Phleboliths Bone forming tumors

64. PROGRESSIVE MYOSITIS OSSIFICANS Rare disease of unknown cause affects children before 6 years of age Occurs within the interstitial tissue of muscles, tendons, ligaments and fascia, and the involved muscle atrophies Inherited or may be a spontaneous mutation affecting the mesenchyma .

65. CLINICAL FEATURES Affect the striated muscles - heart and diaphragm. It starts in the muscles of the neck and upper back and moves to the extremities. Begins as soft tissue swelling , tender and painful redness and heat - inflammation - firm mass in the tissue .

66. DIFFERENTIAL DIAGNOSIS • Rheumatoid arthritis • MANAGEMENT: No effective treatment E xcision Affecting all the muscles of the body - stiffness and limitation of motion of the neck, chest, back and extremities Advanced stages - “petrified man” like appearance. • Third decade - spontaneously arrest - patients die young during the 3rd or 4th decade,

67. REFERENCES: Textbook of Dental and Maxillofacial Radiology - Freny R Karjodkar 2 nd edition Mehta A, Beall DP. Radiology: The Oral Boards Primer. Humana Press. (2006) ISBN:1588293572 2. Weissleder R, Wittenberg J, Harisinghani MM et-al. Primer of Diagnostic Imaging, Expert Consult- Online and Print. Mosby Inc. (2011) ISBN:0323065384.