Phleboliths

Disease Mechanism

Intravascular thrombi, which arise from venous stagnation, sometimes become

organized or mineralized.
Mineralization begins in the core of the thrombus and consists of crystals of
calcium carbonate-fluorohydroxyapatite.
Phleboliths: calcified thrombi found in veins, venulae, or the sinusoidal vessels of
hemangiomas (esp. the cavernous type).

Clinical Features

In H&N, it signal the presence of hemangioma.

In adults, it might be the sole residue of a childhood hemangioma.
Involved soft tissue >> swollen, throbbing, or discolored.
Hemangiomas often fluctuant in size.
Applying pressure >> blanching or change in color if the lesion is vascular in
nature.
Auscultation >> reveal a bruit in cases of cavernous hemangioma NOT in the
capillary type.

Radiographic Features

Location
Most commonly found in hemangiomas.
Periphery and Shape
Cross section >> shape is round or oval.
Up to 6 mm in diameter.
Smooth periphery.
If the involved blood vessel is viewed from the side >> phlebolith may resemble a
straight or slightly curved sausage.
Internal Structure
Homogeneously radiopaque.
More commonly has the appearance of laminations >> bull's-eye or targetoid
appearance.
Radiolucent flow voids >> the remaining patent portions of the vessel.

D/D

Sialolith

Laryngeal Cartilage Calcifications

Disease Mechanism
A. Fibroelastic cartilages > epiglottis & vocal process of the arytenoid cartilages.
B. Hyaline cartilage > all the remaining laryngeal cartilages.
- Endochondral calcification and ossification of the hyaline cartilages is a
physiologic process.
- The most frequently demonstrated laryngeal cartilages on OPGs are
>> Calcified triticeous.
>> Thyroid cartilages.

Clinical Features
> No clinical features, it is just an incidental radiographic finding.

Radiographic Features
Location
A. Calcified triticeous cartilage:
1. On a lateral skull or panoramic image within the soft tissues of the pharynx.
2. Inferior to the greater cornu of the hyoid bone.
3. Adjacent to the superior border of C4.
B. Calcified thyroid cartilage:
- The superior cornu appears medial to C4 and is superimposed on the prevertebral
soft tissue.
Periphery and shape
Triticeous = grain of wheat
The cartilage measures 7 to 9 mm in length and 2 to 4 mm in width.
Periphery is well defined and smooth with regular geometry.
Only the top 2 to 3 mm of calcified thyroid cartilage is visible at the lower edge of
a panoramic RG with 6-inch systems.
Internal structure
Homogeneous radiopacity.
May occasionally demonstrate an outer cortex.

D/D

Calcified atheromatous plaque in the carotid bifurcation. (But the solitary nature
and uniform size & shape should be discriminatory)

Management

No treatment.

Rhinoliths and Antroliths

Disease Mechanism

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.

Rhinoliths >> nidus is exogenous foreign body (coins, beads, seeds & fruit pits)
in children mainly.
Antroliths >> nidus is endogenous (root tip, bone fragment, blood clot, ectopic
tooth) in adults mainly.

Dystrophic calcification may occur within chronically inflamed mucosa of the

maxillary sinus in long-standing sinusitis with a small scattered appearance and
faint calcifications in the thickened mucosal lining.

Patients with chronic sinus disease may develop a noninvasive aspergillosis

mycetoma in the antrum that may manifest as a muddy, necrotic fungus ball, or
calcarious deposits may transform it into a hard mycolith.

Clinical Features

Asymptomatic for extended periods.

Expanding mass may impinge on mucosa producing: pain, congestion and
ulceration.
Nasal obstruction.
Unilateral purulent or blood-stained rhinorrhea.
Sinusitis.
Headache.
Epistaxis.
Anosmia.
Fetor.
Fever.

Radiographic Features
Location
Rhinoliths >> nose
Antroliths >> antrum of the maxillary sinus
Periphery and shape
Various shapes and sizes depending on the nature of nidus.
Internal structure
Homogeneous or heterogeneous radiopacities.
Occasionally, the density exceeds the surrounding bone.
D/D
Osteoma.
Odontoma.
Calcified polyp.
Surgical ciliated cyst.
Management
Referral to an otorhinolaryngologist for endonasal or sinus surgical removal of the
mass.
In some cases, lithotripsy has been used to debulk large rhinoliths.

Metastatic Calcification

Caused by conditions involving elevated serum calcium and phosphate levels,

such as hyperparathyroidism or hypercalcemia of malignancy.
These calcifications are extremely rare.

Heterotopic Ossifications
Ossification of the Stylohyoid Ligament
Disease Mechanism

Embryologically, styloid process arises from the 2nd branchial arch, which consists
of 4 sections that give rise to the stylohyoid complex.
Ossification of the stylohyoid ligament >> extends downward from the base of the
skull bilaterally.
In rare cases, ossification begins at the lesser horn of the hyoid and in fewer still in
a central area of the ligament.

Clinical Features
Ossified ligament detected by palpation over the tonsil as a hard, pointed structure.
Only a few patients have symptoms.
Symptoms are termed Eagle's syndrome:
A. Classic Eagle's syndrome >> resulting from cranial nerve impingement.
Associated with discomfort and patient has recent history of neck trauma (tonsillectomy).
Ossified stylohyoid complex + local scar tissue = symptoms by impingement on cranial nerves
5,7,9,10, or 12 that pass in close proximity to styloid process.
Symptoms: vague, nagging to intense pain in the pharynx on speaking, chewing, swallowing,
turning the head, or opening the mouth widely (singing or yawning); foreign body sensation in
throat on swallowing; and tinnitus or otalgia.

B. Carotid artery syndrome >> resulting from impingement on the carotid vessels.
Clinical findings WITHOUT a history of neck trauma.
Patient may describe referred pain along the distribution of the external or internal carotid artery.
Pain is the result of mechanical impingement of the involved artery & stimulation to its
sympathetic nerve plexus.
External carotid artery affected >> suborbital facial pain.
Internal carotid artery affected >> eye pain, temporal or parietal headache, migraines, aphasia,
visual symptoms, weakness, and transient hemispheric ischemia with vertigo or syncope, on
turning the head to the ipsilateral side.
Older than 40 years.
More prevalent than classic Eagle's syndrome.

Radiographic Features

Incidental feature on panoramic images.

Ligament may have at least some calcifications in individuals of any age.

Location
In OPG, the linear ossification extends forward from the region of the mastoid
process & crosses the posteroinferior aspect of the ramus toward the hyoid bone.
Hyoid bone is parallel or superimposed on posterior aspect of the inferior cortex of
mandible.
Shape
Styloid process: long, tapering, thin, radiopaque, thicker at its base & projects
downwards & forward.
Ranges from 0.5 to 2.5 cm in length.
Ossified ligament: straight outline (some irregularity in the outer surface in some
cases).
The farther the radiopaque ossified ligament extends toward the hyoid bone, the
more likely that it will be interrupted by radiolucent, jointlike junctions
(pseudoarticulations).

Internal Structure
Small ossifications appear homogeneously radiopaque.
As it increases in length & girth >> outer cortex becomes evident as a
radiopaque band at the periphery.

D/D

Occasionally, the symptoms may be similar to symptoms seen in

temporomandibular joint dysfunction (TMD).
Diagnostic conformation: topical anesthesia to suppress the gag reflex, palpation
of the tonsillar fossa to reproduce the symptoms & detect the hard submucosal
mass.

Management

Asymptomatic >> NO treatment.

Vague symptoms >> conservative approach of reassurance & steroid or
lidocaine injections into the tonsillar fossa.
Persistent or intense symptoms >> amputation of the stylohyoid process
(stylohyoidectomy).

Osteoma Cutis
Disease Mechanism

Rare soft tissue ossification the skin or subcutaneous tissues.

Manifests as focal development of bone within the dermis physically removed from any
original osseous tissue.
Primary >> occur in normal tissue without any preexisting condition.
Secondary >> developing in damaged or disrupted skin.
85% of cases are secondary & occur as a result of acne of long duration, developing in a
scar or chronic inflammatory dermatosis.
Occasionally found in diffuse scleroderma, replacing the altered collagen in the dermis
and subcutaneous septa.

Clinical Features

Can occur anywhere.

Most common site is the face.
Tongue is the most common intraoral site (osteoma mucosae or osseous choristoma).
Does not cause color change in the skin usually.
Occasional color change >> yellowish white.
If large lesion >> palpable individual osteoma.
A needle inserted into one of the papules is met with stonelike resistance.
Some patients have numerous lesions (face in females & scalp or chest in males) >>
multiple miliary osteoma cutis.

Radiographic Features

Location
Most commonly in the cheek & lips.
Image can be superimposed over a
tooth or alveolar process >> area of
dense bone.
Accurate localization >> intraoral
film between cheek & alveolar
process to image the cheek alone.
Posteroanterior skull view with cheek
blown outward by use of soft tissue
technique of 60 kVp >> localize
osteomas in the skin.

Periphery and Shape

Smoothly outlined.
Radiopaque.
Washer-shaped images.
Single or multiple.
Very small.
Size can range from 0.1 - 5 cm.
Internal Structure
Homogeneously radiopaque.
Usually has radiolucent centre (normal fatty marrow).
Donut appearance radiographically.
Trabeculae develop in marrow cavity of larger osteomas.
Snowflake-like radiopacity >> Individual lesions of calcified cystic acne
corresponds to clinical location of acne.

D/D

Myositis ossificans.
Calcinosis cutis.
Osteoma mucosae.

Management

No treatment.
Primary osteoma cutis >> removed for cosmetic reasons.
Multiple miliary osteoma cutis >> needle microincision-extirpation technique.

Myositis Ossificans

Fibrous tissue and heterotopic bone form within the interstitial tissue of muscle and
associated tendons and ligaments.
As this fibrous tissue and bone interdigitate and separate the muscle fibers >>
Secondary destruction and atrophy of the muscle occur.

Localized (Traumatic) Myositis Ossificans

Synonyms: posttraumatic myositis ossificans & solitary myositis.
Disease Mechanism

Results from acute or chronic trauma or from heavy muscular strain caused by
certain occupations and sports.
Muscle injury from multiple injections.
The term myositis is misleading because no inflammation is involved.
No actual ossification of the muscle fibers occurs.

Clinical Features

At any age in either sex.

Most often in young men (vigorous activity).
Site of trauma remains swollen, tender, & painful much longer than expected.
Overlying skin >> red & inflamed.
If lesion involve muscle of mastication >> difficulty in opening the jaws.
After 2-3 weeks >> palpable firm intramuscular mass.
Enlarge slowly but eventually it stops growing.
Fixed or freely movable on palpation.

Radiographic Features
Location
Most commonly masseter & sternocleidomastoid muscles.
Other muscles: medial & lateral pterygoid, buccinator, & temporalis.
Radiolucent band between area of ossification and adjacent bone.
Masses less than 6 cm in greatest dimension.

Periphery and Shape

Periphery more radiopaque than internal structure.
Variation in shape >> irregular oval to linear streaks (pseudotrabeculae).
Pseudotrabeculae >> characteristic of myositis ossificans.
Internal Structure
Varies with time.
3-4 weeks after injury >> faintly homogenous radiopacity.
2 months >> delicate lacy or feathery radiopaque internal structure develops.
5-6 months >> denser, more homogenous and better defined, maturing fully.
Some lesions progress slowly and do not reach maturation until 12 months.

D/D

Ossification of the stylohyoid ligament.

Bone-forming tumors.
Osteogenic sarcoma.

Management

Bone morphogenetic protein type 1 receptor inhibition to reduce the heterotopic

ossifications.
Rest and limitation of use are recommended to diminish the extent of the calcific
deposit.
Lesions that cause functional restriction or neurologic impairment >> surgical
excision of the entire calcified mass + intensive physiotherapy to minimize post
surgical scarring.
Complete maturation of myositis ossificans (6-12months).
Incomplete excision or excision at immature stage >> recurrence.

Progressive Myositis Ossificans

Synonym: Fibrodysplasia ossificans progressiva.

Disease Mechanism

Rare hereditary disease.

Autosomal dominant.
Less commonly, arises as a result of spontaneous mutation.
More common in males.
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.

Clinical Features

Starts in the muscles of the neck and upper back and moves to the extremities.
Soft tissue swelling.
Tender.
Painful.
Redness.
Heat.
Acute symptoms subside and a firm mass remains.
May affect any of striated muscles (heart & diaphragm).
Spread of ossification might be limited or extensive.
Stiffness and limitation of motion of the neck, chest, back, and extremities
(shoulders) gradually increase.
Advanced stages >> "Petrified man" condition.
3rd decade >> process may spontaneously arrest.
Most patients die during 3rd or 4th decades
Premature death >> respiratory embarrassment or from inanition.

Radiographic Features

Similar to appearance
of the limited form.
Heterotopic bone more
commonly oriented
along the long axis of
the involved muscle.
Osseous malformation
of the regions of
muscle attachment
(mandibular condyles).

D/D

Rheumatoid arthritis.
Calcinosis.

Management

No effective treatment.
Traumatized and ulcerated nodules >> excision.
If interference with respiration or respiratory infection occurs in later stages >>
supportive therapy.

Thank You