Soft tissue calcification in the neck observed in cone beam CT scans

1. Soft Tissue
Calcification in the
Neck
Judy H. Oh, D.D.S.
UCLA School of Dentistry, 1992
Preceptorship in Oral & Maxillofacial Radiology, Rutgers School of Dental Medicine, 2016
3D Oral & Maxillofacial Imaging Center, North Bethesda, MD
3DOMI.net

2. Types of Calcification in the Neck
1. Carotid Artery Calcification CAC 0.1 ~ 37%
2. Calcified Stylohyoid Chain CSC 1.4 ~ 30%
3. Calcified Triticeous Cartilage CTC 5 ~ 29%
4. Calcified Tonsils CT 16%
5. Calcified Superior Cornu of Thyroid Cartilage CSCT
6. Sialolith
7. Calcification of Lymph Nodes
8. Phlebolith(calcified vascular thrombus)
9. Intradermal Calcifications
10. Cutaneous Ossifications

3. FREQUENCY OF SOFT TISSUE CALCIFICATIONS
FROM 380 CBCT SCANS
Locations No %
Stylohyoid Chain 144 47.6
Triticeous Cartilage 103 27.1
Tonsils 86 22.6
Superior Cornu of Thyroid Cartilage 76 20.0
Carotid Artery 72 19.0
Salivary glands 10 2.6
Lymph Nodes 2 0.5
Ali Z Syed, PREVALENCE OF CAROTID ATHEROMA AND ITS CONFOUNDERS ON CONE BEAM COMPUTED TOMOGRAPHY, Master thesis for
OMFR program at UNC, Chapel Hill, 2014

4. Location of soft tissue calcification:
panoramic radiograph
Laurie C. Carter, DDS, Ph.D, pocketdentistry.com, Chapter 28, Soft Tissue Calcifications and Ossifications

5. Types of Heterotopic Calcification:
Dystrophic Calcification
Forms in chronic inflammation, cyst, diseased tissue
Due to trauma, infection, inflammation
Normal serum Calcium & Phosphate levels
Localized to the site of injury, Asymptomatic
Irregular or indistinct shape
Found in Residual cyst, Inflammatory fibrous hyperplasia
Idiopathic Calcification
Calcium deposit in normal tissue
Normal serum Calcium & Phosphate levels
Found in Chondrocalcinosis, Phleboliths
Metastatic Calcification
Mineral precipitation into normal tissue due to higher serum level of
Calcium & Phosphate

6. Heterotopic Ossification(vs. calcification)
When mineral is deposited in soft tissue as organized,
well-formed bone
May be all compact bone or may include trabeculae &
fatty marrow
Caused by trauma, tumors, diseases
- myositis ossificans
- ankylosing spondylitis

7. Network of Arteries:
coronal view

8. Network of Arteries:
sagittal view

9. Atheroma in
Internal Carotid Artery at or
just above the bifurcation of
common carotid artery
Bifurcation at lateral &
inferior to Hyoid bone

10. Reference: Metrowestdentalgroup.com
CAC: axial view
single or multiple
semi-circular or ovoid
latero-posterior to GCHB
(greater cornu of hyoid bone)
postero-lateral to
pharyngeal airway

11. Dr. Douglas K Benn DDS PhD DDR (RCR, England)
Oral & Maxillofacial Radiologist
CAC:
71 year old male with CV
disease and hypertension:
a 4 mm opacity with 2 distinct
white lines; calcification of
the walls of the carotid artery.
*The carotid artery bifurcation
is about 6 mm in diameter.
*coronal view:
lateral to anterior tubercle of
cervical vertebrae(C3-5)

12. CAC: axial view
(a) as single rice grain
(b), (c) multiple "rice grains",
linear, curvilinear
homogeneous opacifications
(d) increased number of
ipsilateral opacifications,
forming larger coalescing
masses
Soft Tissue Calcifications In The Neck: Maxillofacial CBCT Presentation And Significance
Dr. William C. Scarfe BDS, FRACDS, MS, Dr. Allan G. Farman BDS, PhD, MBA, DSc
Dept. of Surgical/Hospital Dentistry, University of Louisville School of Dentistry
Louisville, Kentucky
From the Spring 2010 AADMRT Newsletter

13. Hyoid Bone
Netterimages.com

14. sagittal view:
CAC:
latero-inferior to hyoid bone
posterior to GCHB
medial-inferior to angle of
mandible
CSC:
Isolated calcified stylohyoid
chain
GCHB:
Greater cornu of the hyoid bone
Soft Tissue Calcifications In The Neck:
Maxillofacial CBCT Presentation And Significance
Dr. William C. Scarfe BDS, FRACDS, MS
Dr. Allan G. Farman BDS, PhD, MBA, DSc
Dept. of Surgical/Hospital Dentistry
University of Louisville School of Dentistry
Louisville, Kentucky
From the Spring 2010 AADMRT Newsletter

15. Soft Tissue Calcifications In The Neck:
Maxillofacial CBCT Presentation And Significance
Dr. William C. Scarfe BDS, FRACDS, MS
Dr. Allan G. Farman BDS, PhD, MBA, DSc
Dept. of Surgical/Hospital Dentistry
University of Louisville School of Dentistry
Louisville, Kentucky
From the Spring 2010 AADMRT Newsletter
CAC & CSC:
coronal view
Stylohyoid ligament connects
the tip of the Styloid process
to the Lessor Cornu of the
Hyoid bone

16. Calcified Stylohyoid Chain(CSC), Eagle’s Syndrome
Discrete, circular, corticated opacity; Normal length 20-30mm; 40mm considered elongated
1.4% - 30% of population(75% bilateral), mostly asymptomatic

17. Soft Tissue Calcifications In The Neck:
Maxillofacial CBCT Presentation And Significance
Dr. William C. Scarfe BDS, FRACDS, MS
Dr. Allan G. Farman BDS, PhD, MBA, DSc
Dept. of Surgical/Hospital Dentistry
University of Louisville School of Dentistry
Louisville, Kentucky
From the Spring 2010 AADMRT Newsletter
Calcified Stylohyoid
Chain: CSC

18. Enlarged Styloid Process
Detection of Incidental Findings in CBCT Imaging & Their Clinical Implications, E. Benavides, DDS, Ph.D, P. Edwards, MSc, DDS,
Pocket Dentistry, Chapter 10
Asymmetry in the left & right styloid process
enlarged left styloid process

19. Triticeous Cartilage:
A cartilaginous nodule in the thyrohyoid ligament
Gray’s anatomy, 1918

20. Dr. Douglas K Benn DDS PhD DDR (RCR, England)
Oral & Maxillofacial Radiologist
panoramic view:
1. Calcified Stylohyoid Chain(CSC)
2. Submandibular Gland Sialolith
3. Calcified Triticeous Cartilage(CTC)
(ovoid, homogeneous, dense)
*CAC is irregular in shape and density.

21. Calcified Triticeous Cartilage(CTC)
Axial: single ‘rice grain’, ovoid, homogeneous, dense
medio-posterior to the most distal extent of GCHB
*GCHB(greater cornu of hyoid bone) at C2, C3
Coronal: inferior to GCHB & at C3 & C4
Sagittal: immediately inferior to the maximal extension of
GCHB
Soft Tissue Calcifications In The Neck: Maxillofacial CBCT Presentation And Significance
Dr. William C. Scarfe BDS, FRACDS, MS, Dr. Allan G. Farman BDS, PhD, MBA, DSc
Dept. of Surgical/Hospital Dentistry, University of Louisville School of Dentistry, Louisville, Kentucky
From the Spring 2010 AADMRT Newsletter

22. CTC: Calcified Triticeous Cartilage
Soft Tissue Calcifications In The Neck:
Maxillofacial CBCT Presentation And Significance
Dr. William C. Scarfe BDS, FRACDS, MS, Dr.
Allan G. Farman BDS, PhD, MBA, DSc
Dept. of Surgical/Hospital Dentistry, University of
Louisville School of Dentistry, Louisville, Kentucky
From the Spring 2010 AADMRT Newsletter
Panoramic Radiograph:
CTC immediately inferior
to the tip of GCHB

23. CT: Calcified Tonsils
Axial - (a) Clusters, ovoid homogeneous dense opacification
antero-lateral to the oro-pharyngeal airway space
Coronal - (b) Superimposed over the anterior tubercle of the
cervical spine; Span supero-inferiorly linearly in line with the
pterygoid plates
Sagittal - (c) Superimposed over the shadow of the oro-pharyngeal
airway space or anterior to it
Clinical symptom: asymptomatic or persistent throat irritation,
foul taste, odor or otalgia
Soft Tissue Calcifications In The Neck: Maxillofacial CBCT Presentation And Significance
Dr. William C. Scarfe BDS, FRACDS, MS, Dr. Allan G. Farman BDS, PhD, MBA, DSc
Dept. of Surgical/Hospital Dentistry, University of Louisville School of Dentistry, Louisville, Kentucky
From the Spring 2010 AADMRT Newsletter

24. Calcified Tonsils:
Tonsilar calculi or Tonsiloliths
Dystrophic calcification caused by
repeated bouts of inflammation
Affects 20-68, age related
Treatments: None if small,
surgery for larger lesion or elderly
patients with deglutition disorder,
or immunocompromised patients
due to the risk of aspiration
pneumonia

25. Palatine Tonsiloliths
Detection of Incidental Findings in CBCT Imaging & Their Clinical Implications, E. Benavides, DDS, Ph.D, P. Edwards, MSc, DDS,
Pocket Dentistry, Chapter 10

26. Palatine Tonsiloliths
Omami G (2016) Soft Tissue Calcification in Oral and Maxillofacial Imaging: A Pictorial Review. Int J
Dentistry Oral Sci. 03(4), 219-224

27. Pharyngeal Tonsilolith
Detection of Incidental Findings in CBCT Imaging & Their Clinical Implications, E. Benavides, DDS, Ph.D, P. Edwards, MSc, DDS,
Pocket Dentistry, Chapter 10

28. Tonsilolith
Sialolith: lingual aspect of mandible
Incidental findings on cone beam computed tomography: Relate and
relay, Suhas P Pande, Subhash P Kumbhare, Amit R Parate
Department of Oral Medicine and Radiology, Government Dental College
and Hospital, Nagpur, Maharashtra, India, Journal of Indian Academy of
Oral Medicine & Radiology, 2015, vol 27, issue 1, pg 48-54

29. Superior Cornu of Thyroid Cartilage
en.wikipedia.org

30. Calcified Superior Cornu of the Thyroid Cartilage:
CSCT
Soft Tissue Calcifications In The Neck: Maxillofacial CBCT Presentation And Significance
Dr. William C. Scarfe BDS, FRACDS, MS, Dr. Allan G. Farman BDS, PhD, MBA, DSc
Dept. of Surgical/Hospital Dentistry, University of Louisville School of Dentistry, Louisville,
Kentucky From the Spring 2010 AADMRT Newsletter
Age related;
immediately below hyoid bone,
suspended by thyrohyoid membrane
Axial: single distinct circular opacification,
Posterior to GCHB (CTC is medial to GCHB)
Coronal: linear cylindrical opacification
extending inferiorly from GCHB

31. Salivary Gland: sagittal view

32. Conventional sialography of
submandibular gland(A)
parotid gland(B)
showing ductal system
Rastogi R, Bhargava S, Mallarajapatna GJ, Singh SK. Pictorial essay:
Salivary gland imaging. Indian J Radiol Imaging 2012;22:325-33

33. Sialolith: stone in the salivary gland
Sialolith adjacent to the lingual cortical plate in the right submandibular region
Solitary, ‘onion shaped’, linear or globular homogeneous, medial to the angle of the mandible
Mostly in submandibular gland near hilum or Wharton’s duct

34. Sialolith in the Submandibular gland
Detection of Incidental Findings in CBCT
Imaging & Their Clinical Implications, E.
Benavides, DDS, Ph.D, P. Edwards, MSc, DDS,
Pocket Dentistry, Chapter 10

35. Sialolith in the right Wharton’s duct
Capaccio P, Marciante GA, Gaffuri M, Spadari F. Submandibular swelling: Tooth or salivary stone?. Indian J Dent Res
2013;24:381-3

36. Sialoliths
In the left Wharton’s duct
Omami G (2016) Soft Tissue Calcification
in Oral and Maxillofacial Imaging: A
Pictorial Review. Int J Dentistry Oral Sci.
03(4), 219-224

37. Lymph nodes in the head & neck
300 of total 800 lymph nodes in
our body found in the head & neck

38. Calcified Lymph Nodes
Dystrophic calcification due to chronic inflammation
Lymphoid tissue replaced by hydroxyapatite-like calcium salts
Causes: TB, bacille Calmette-Guerin vaccination, sarcoidosis, cat-scratch disease
Rheumatoid arthritis, systemic sclerosis, fungal infections
lymphoma previously treated with radiation therapy
malignancy(Hodgkin’s lymphoma, metastatic thyroid carcinoma)
Asymptomatic
Most common sites: submandibular, superficial or deep cervical nodes;
less commonly preauricular & submental nodes
Well defined irregular ‘cauliflower-like’ shape; hard, lumpy, round or oblong masses
Treatment: none but underlying cause should be established
Laurie C. Carter, DDS, Ph.D, pocketdentistry.com, Chapter 28, Soft Tissue Calcifications and Ossifications

39. Calcification in the Submandibular lymph nodes

40. Calcification in the Submental lymph nodes
Detection of Incidental Findings in CBCT Imaging & Their Clinical Implications, E. Benavides, DDS, Ph.D, P. Edwards, MSc, DDS,
Pocket Dentistry, Chapter 10

41. Tuberculous Lymphadenitis

42. Phlebolith
Calcified vascular thrombus, result of vascular anomaly, multiple laminated spherical
radiopacities with onion-like appearance(concentric radiopaque & radiolucent rings)
Chava VR, Shankar AN, Vemanna NS, Cholleti SK. Multiple Venous Malformations with Phleboliths: Radiological-Pathological
Correlation. J Clin Imaging Sci 2013;3, Suppl S1:13

43. Phlebolith
Omami G (2016) Soft Tissue Calcification in Oral and Maxillofacial Imaging: A Pictorial Review. Int J Dentistry
Oral Sci. 03(4), 219-224

44. Intradermal Calcification
Small calcium deposits under the skin, result of injury or surgical incision;
or due to systemic disease involving alteration of calcium metabolism
Calcification & scar tissue in the chin after
plastic surgery
Detection of Incidental Findings in CBCT Imaging & Their Clinical Implications, E. Benavides, DDS, Ph.D, P. Edwards, MSc, DDS,
Pocket Dentistry, Chapter 10

45. Cutaneous Ossification - Osteoma Cutis
Primary(15%)
Secondary(85%):
develop within pre-existing
neoplastic or inflammatory skin
lesion
Small
Well-defined
Single or Multiple
High density area within skin
Detection of Incidental Findings in CBCT Imaging & Their
Clinical Implications, E. Benavides, DDS, Ph.D, P. Edwards,
MSc, DDS, Pocket Dentistry, Chapter 10

46. Osteoma Cutis
Safi, Yaser; Valizadeh, Solmaz; Vasegh, Sahra; Aghdasi, Mohammad Mahdi; Shamloo, Nafiseh; & Azizi, Zeynab. (2016). Prevalence of osteoma cutis in the
maxillofacial region and classification of its radiographic pattern in cone beam CT.Dermatology Online Journal, 22(1). doj_29781
148 of 6500 CBCT(2.27%) scans showed osteoma cutis.

47. Osteoma Cutis
Dr. Shawneen Gonzalez, Director of Radiology, Legacy 3D Imaging

48. Osteoma Cutis - Osseous Choristoma of Tongue
Rare, benign, normally matured bony tissue
Radiograph: doughnut-shaped radiopacity & radiolucent centers representing
central marrow cavities

49. Osseous Choristoma
Sandy Cheng-Yu Chen, M.D., Taipei Medical University Hospital,
Taipei, American Journal of Neuroradiology, February 2014

50. Osseous Choristoma:
Masseter muscle
Priscilla Suassuna Carneiro Lúcio, et al.
An unusual presentation of multiple
osseous choristomas in masseter
muscle. Musculoskelet Regen 2015;
2: e905. doi: 10.14800/mr.905

51. Osseous Choristoma:
Mandibular Buccal
Vestibule
Gregoire C, Davis C, Bullock M, Steeves T (2015)
Recurrent Osseous Choristoma Involving the
Mandibular Buccal Vestibule: A Case Report. Int J
Oral Dent Health 1:004

52. Cysticercosis
Caused by Parasite, Taenia Solium(pork tapeworm)
Larval form penetrate mucosa, blood vessels, lymphatics
Dead larvae causes granuloma, scarring, calcification
Calcification seen years after the infection
Intraorally:
palpable, well-circumscribed, soft fluctuant swelling
multiple, small nodules in tongue, buccal mucosa, lip,
masseter & suprahyoid muscles
Radiograph:
homogeneous, ‘grain of rice’ radiopacity
smaller, widespread dissemination in brain, muscles
Laurie C. Carter, DDS, Ph.D, Soft Tissue Calcifications and Ossifications, pocketdentistry.com, Chapter 28

53. Cysticercosis
Indian Journal of Medical
Microbiology
Anil Khosla, MBBS, MD Assistant
Professor, Department of
Radiology, St Louis University
School of Medicine, Veterans
Affairs Medical Center of St Louis
R Meher, A Sabherwal.
Cysticercosis Of The Cheek.
The Internet Journal of Tropical
Medicine. 2004 Volume 2
Number 2.

54. Myositis Ossificans
Temporal muscle & tendon at
the lower part of the coronoid
process
Caused by hemorrhage within the
interstitial tissue of the muscle after
trauma or heavy muscle strain
Runs in the same direction of muscle
fibers
Associated with trismus, limited opening

55. Myositis Ossificans
Fernanda Trautmann, Paula de Moura, Tito L. Fernandes, Rogério O. Gondak, Julio C. de M. Castilho, Edmundo Medici Filho,
Myositis ossificans traumatica of the medial pterygoid muscle: a case report Journal of Oral Science, Vol. 52, No. 3, 485-489, 2010
myositis ossificans traumatica (MOT) of the medial pterygoid muscle,
developed after mandibular block anesthesia administered for endodontic
treatment of the lower right second molar

56. Myositis Ossificans:
the left masseter
muscle after trauma
Elitsa G. Deliverska, Department of Oral and Maxillofacial surgery, Faculty of dental medicine, Medical University, Sofia, Bulgaria, MYOSITIS
OSSIFICANS TRAUMATICA OF THE MASSETER MUSCLE- review of the literature and case report, Journal of IMAB - Annual Proceeding
(Scientific Papers) 2013, vol. 19, issue 4

57. Myositis Ossificans of Temporalis & Medial Pterygoid
Reddy SD, Prakash AP, Keerthi M, Rao BJ. Myositis ossificans traumatica of temporalis and medial pterygoid muscle. J Oral
Maxillofac Pathol 2014;18:271-5

58. Calcific Longus Colli or Retropharyngeal Calcific Tendinitis
Calcium hydroxyapatite deposition
in the longus colli muscle
Inflammatory response
Acute onset of neck pain,
dysphagia, odynophagia, low-grade
fever
Self-limiting, resolves after 1-2 wks
large, oval, nodular calcification of longus colli tendon
Macrorad Teleradiology Services

60. EVALUATION OF SOFT TISSUE CALCIFICATIONS: RADIOGRAPHIC CRITERIA
Calcified lymph node
lobulated, cauliflower shaped; may appear in a chain fashion (sagittal view)
Sialolith
may appear as a smooth, cylindrical entity lingual to the mandible (axial view)
Tonsillolith
multiple small ill-defined, punctate; may appear in clusters (coronal view)
OSHC
long, linear thin extension from base of skull to hyoid (sagittal view)
CAC
multiple, irregular entities in the carotid space
C3-C4 region lateral to greater cornu of hyoid (axial view)
Triticeous cartilage
round, well defined, smooth; medial to the greater cornu of hyoid (axial view)
Superior cornu of thyroid calcification
linear, thin finger-like projection; below the hyoid bone (coronal view)
WHITE, STUART C., MICHAEL PHARAOH. ORAL RADIOLOGY: PRINCIPLES AND INTERPRETATION, 7TH EDITION. MOSBY, 2014

61. References:
1. Dr. William C. Scarfe BDS, FRACDS, MS, Dr. Allan G. Farman BDS, PhD, MBA, DSc, Soft Tissue Calcifications In The Neck:
Maxillofacial CBCT Presentation And Significance, Dept. of Surgical/Hospital Dentistry, University of Louisville School of
Dentistry, Louisville, Kentucky, From the Spring 2010 AADMRT Newsletter
2. Khan et ai, Soft tissue calcifications in CBCT,
3. Suhas P Pande, Subhash P Kumbhare, Amit R Parate, Incidental findings on cone beam computed tomography:
Relate and relay, Department of Oral Medicine and Radiology, Government Dental College and Hospital, Nagpur, Maharashtra,
India, Journal of Indian Academy of Oral Medicine & Radiology, 2015, vol 27, issue 1, pg 48-54
4. Laurie C. Carter, DDS, Ph.D, Soft Tissue Calcifications and Ossifications, pocketdentistry.com, Chapter 28
5. E. Benavides, DDS, Ph.D, P. Edwards, MSc, DDS, Detection of Incidental Findings in CBCT Imaging & Their Clinical
Implications, Pocket Dentistry, Chapter 10
6. Omami G (2016) Soft Tissue Calcification in Oral and Maxillofacial Imaging: A Pictorial Review. Int J Dentistry Oral Sci. 03(4),
219-224
7. Rastogi R, Bhargava S, Mallarajapatna GJ, Singh SK. Pictorial essay: Salivary gland imaging. Indian J Radiol Imaging
2012;22:325-33
8. Safi, Yaser; Valizadeh, Solmaz; Vasegh, Sahra; Aghdasi, Mohammad Mahdi; Shamloo, Nafiseh; & Azizi, Zeynab. (2016).
Prevalence of osteoma cutis in the maxillofacial region and classification of its radiographic pattern in cone beam CT.
Dermatology Online Journal, 22(1). Doj_29781
9. WHITE, STUART C., MICHAEL PHARAOH. ORAL RADIOLOGY: PRINCIPLES AND INTERPRETATION, 7TH EDITION. MOSBY, 2014
10. Shawneen Gonzalez, DDS, MS, Interpretation Basics of CBCT
11. Gregoire C, Davis C, Bullock M, Steeves T (2015) Recurrent Osseous Choristoma Involving the Mandibular Buccal
Vestibule: A Case Report. Int J Oral Dent Health 1:004
12. Priscilla Suassuna Carneiro Lúcio, et al. An unusual presentation of multiple osseous choristomas in masseter muscle.
Musculoskelet Regen 2015; 2: e905. doi: 10.14800/mr.905

62. References:
13. Sandy Cheng-Yu Chen, M.D., Taipei Medical University Hospital, Taipei, American Journal of Neuroradiology, February 2014
14. Fernanda Trautmann, Paula de Moura, Tito L. Fernandes, Rogério O. Gondak, Julio C. de M. Castilho, Edmundo Medici Filho,
Myositis ossificans traumatica of the medial pterygoid muscle: a case report Journal of Oral Science, Vol. 52, No. 3, 485-489, 2010
15. Elitsa G. Deliverska, Department of Oral and Maxillofacial surgery, Faculty of dental medicine, Medical University, Sofia,
Bulgaria, MYOSITIS OSSIFICANS TRAUMATICA OF THE MASSETER MUSCLE- review of the literature and case report, Journal
of IMAB - Annual Proceeding (Scientific Papers) 2013, vol. 19, issue 4
16. Reddy SD, Prakash AP, Keerthi M, Rao BJ. Myositis ossificans traumatica of temporalis and medial pterygoid muscle. J Oral
Maxillofac Pathol 2014;18:271-5