Considerations in Detecting Soft Tissue Calcifications on Panoramic Radiography Ibrahim Nasseh 1, Sayde Sokhn 2, Marcel Noujeim 3, Georges Aoun 4

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1 Received: 20 th Jnury 2016 Accepted: 03 rd April 2016 Conflict of Interest: None Source of Support: Nil Cse Report Doi: /jioh Considertions in Detecting Soft Tissue Clcifictions on Pnormic Rdiogrphy Irhim Nsseh 1, Syde Sokhn 2, Mrcel Noujeim 3, Georges Aoun 4 Contriutors: 1 Professor, Deprtment of Orl nd Mxillofcil Rdiology, Fculty of Dentistry, Lenese University, Beirut, Lenon; 2 Clinicl Instructor, Deprtment of Orl nd Mxillofcil Rdiology, Fculty of Dentistry, Lenese University, Beirut, Lenon; 3 Associte Professor, Deprtment of Orl nd Mxillofcil Rdiology, University of Texs Helth Science Center Sn Antonio, Texs, USA; 4 Assistnt Professor, Deprtment of Orl Pthology nd Dignosis, Fculty of Dentistry, Lenese University, Beirut, Lenon Correspondence: Dr. Aoun G. Deprtment of Orl Pthology nd Dignosis, Fculty of Dentistry, Lenese University, Beirut, Lenon. Emil: oungeorges@yhoo.com How to cite the rticle: Nsseh I, Sokhn S, Noujeim M, Aoun G. Considertions in detecting soft tissue clcifictions on pnormic rdiogrphy. J Int Orl Helth 2016;8(6): Astrct: Hed nd neck soft tissues clcifictions cn result from physiologicl or pthologicl minerliztion. Some of these clcifictions my e found on pnormic rdiogrphy ecuse of their proximity to the focl trough nd their superimposition over hrd nd soft tissue structures. Such rdiogrphic imges re common nd crete dignostic chllenge. Differentition of these entities cn e done when rdiogrphic fetures nd loctions re tken into considertion. Since cone-em computed tomogrphy (CBCT) hs een used in dentistry, fortuitous discovery of such clcifictions hs incresed. However, y providing imges in the third dimension, CBCT fcilittes their precise locliztion. Adequte dignosis of these clcifictions my enhnce their pproch nd mngement y clinicins. The im of this rticle is to descrie the rdiogrphic chrcteristics of some hed nd neck clcifictions in dentl prctice on pnormic X-rys nd CBCT. Key Words: Clcifiction, cone-em computed tomogrphy, hed nd neck, pnormic rdiogrphy Introduction Clcifictions of vrious structures locted in the hed nd neck regions re commonly found in ptients seeking dentl cre. These clcifictions my e fortuitously detected on conventionl imging techniques used in dentl prctice such s pnormic rdiogrphy. However, mny of them look like which mke locliztion nd identifiction difficult. 1 These re deposits of clcium slts, mostly clcium phosphte in the soft tissues. 2 In the hed nd neck, they cn e present s physiologic or pthologic minerliztion. 1 The ltest, usully ssocited with chronic inflmmtion or scrs, is more likely to e found in ligments, rticultion s crtilge, glnds, nd vessel tissues. 1,3 There re three types of pthologic clcifictions: Dystrophic clcifiction, generlly occurring in degenerting nd necrotic tissues 2. Metsttic clcifiction, in which clcium nd other slts re deposited in previously undmged tissue s result of excess slts in the circulting lood 3. Clcinosis, which is clcifiction commonly locted in sucutneous tissues. Antomicl loction, distriution, numer, size, nd shpe re mong the most importnt dignostic fetures of these clcifictions. 3 The im of this report is to descrie rdiogrphic findings of some cses of soft tissue clcifictions superimposed over the rmus nd the ngulr region of the mndile nd to help the clinicin estlishing pproprite dignosis nd mngement. Cse Reports Cse 1 The pnormic imge of 21-yer-old mle ptient reveled multiple irregulrs in shpe collection of smll, punctute rdiopque entities, posterior to the inferior third of the right rmus nd ngle of the mndile, projecting the imge of the ody of C3 (Figure 1). Further investigtion reveled history of severe virl protitis (mumps) tht occurred t young ge nd lsted more thn 3 months with residul swelling descried then y the physicin s lymph node rection which would tke long time to dispper without ny mjor concerns. The long-stnding inflmmtion of the protid glnd cn distur the excretory system of the ffected prts of the glnd cusing the slivry flow to slow down nd even completely discontinue. Stgnnt sliv nd post inflmmtory smll firotic res contriute to stsis, mking the slivry system more prone to the development of siloliths. 4 Cone-em computed tomogrphy (CBCT) ws requested to determine the reltionship of the mndiulr cnl with the wisdom teeth. The clcifictions were then evluted: they ppered to e situted t mid-distnce etween the lterl spect of the neck nd the right lterl spect of the irwy (Figure 1). 742

2 Adding medicl history to the rdiogrphic findings might lso suggest the dignosis of clcifiction of one or multiple lymph nodes, normlly emedded within the protid glnd. Cse 2 The pnormic imge of 60-yer-old mle ptient consulting for replcing multiple mxillry, nd mndiulr sent teeth showed round rdiopque structure projecting the imge of the right mndiulr rmus, 2-3 mm inferior to the mndiulr formen. Few smller rdiopcities were noted slightly inferior nd posterior. The ptient ws symptomtic (Figure 2). CBCT showed 5 mm 7 mm high-density structure within the prphryngel soft tissues on the right side with multiple, smller, punctute clcifictions inferior to the lrger one. The clcifictions re within the pltine tonsils region, evoking the dignosis of tonsilloliths. This is rre cse of such ig clcifiction inside the tonsils (Figure 2). Cse 3 An 82-yer-old femle ptient presented for extrction of remining mxillry roots. The medicl history reveled only recurrent tonsil inflmmtion. The pnormic rdiogrph showed multiple smll rdiopcities, ilterlly projecting over, nd spreding long, the whole surfce of the inferior two-thirds of the mndiulr rmus (Figure 3). Before pre-prosthetic surgery, CBCT ws requested, nd it ws eneficil to exctly locte these high densities (Figure 3). The ntomicl loction, distriution, numer, size, nd shpe of theses clcifictions re pthognomonic of tonsillitis s they commonly pper on pnormic. Cse 4 This cse exhiits on the pnormic smooth, single, welldemrcted, kidney-shped structure presenting with multiple lternted lyers of high density nd reltively lower density nds; these fetures re suggestive of long-stnding, over- Figure 1: () Pnormic rdiogrph showing well-limited multiple rdiopcities. () Axil nd sgittl cuts showing hyperdense imge within the codl prt of the protid glnd. Figure 2: () Pnormic rdiogrph showing round rdiopque structure projected over the right mndiulr rmus. () Coneem computed tomogrphy showing high-density structure within the prphryngel soft tissues on the right side with multiple, smller, punctute clcifictions inferior to the lrger one. Figure 3: () Pnormic rdiogrph showing multiple smll rdiopcities, projected ilterlly over the whole surfce of the inferior two-thirds of the mndiulr rmus. () Cone-em computed tomogrphy imging showing multiple clustered rice grin like ovoid high densities, immeditely superficil to the lterl orophryngel irwy spce. 743

3 time uilding slivry glnd clculus situted within the hilum of the glnd (Figure 4). Cse 5 This cse shows rdiopcity with similr size nd shpe thn the former cse; however, the outline is rgged nd irregulr with culiflower ppernce. Multiple, smller in size opcities re noted in chin pttern extending 2-3 cm inferiorly (Figure 5). These fetures re more consistent with clcified lymph nodes usully seen s long-term secondry rection to chronic inflmmtory process in the neighoring re. Cse 6 This is n symptomtic ptient who presented for prosthetic needs (complete denture); the routine pnormic imge reveled the typicl presenttion of clcifiction of the stylohyoid ligment s liner high-density re extending from the sphenoid one to the lesser horn of the hyoid one (Figure 6). Cse 7 This ptient presented for routine dentl tretment; his pnormic imge showed the presence of multiple symptomtic smll, irregulr in shpe nd size, rdiopque res inferior to the ngle of the mndile t the level of C3-C4 (Figure 7). The density is present t the chin-like structures extending in verticl direction with 2-3 cm length. They re <1 cm wide in the nteroposterior direction. The rdiopcities re not homogeneous; they cn present with multiple degrees of density/clcifiction. These re typicl fetures of crotid rtery clcifiction (CAC). Discussion Hed nd neck soft tissue clcifictions re reltively common. They re usully incidentlly detected on routine rdiogrphic exmintion. Clcifictions form, quntity, distriution, nd locliztion re key dignosis fctors to e considered. 3 When superimposed over the one, determintion of whether the clcifiction is locted in either the one or the soft tissue is complex tsk. 5 Among the lesions to e considered for the differentil dignosis re the crotid rtery, lymph nodes, slivry glnd, orophryngel tissues, nd stylohyoid ligment clcifictions. 3,6 According to mny uthors, siloliths re descried s n ggregtion of clcreous structures in the slivry glnds nd their ducts. It is lso referred to s slivry stone or slivry glnd clculus. It is one of the most frequent disorders of slivry glnds, second to virl protitis. Mles re ffected twice s often s femles; however, some uthors found no rce or sex predilection. 7,8 Figure 4: Pnormic showing smooth, single rdiopcity, well-demrcted, kidney-shped structure presenting with multiple lternted lyers of high density nd reltively lower density nds. Figure 6: Pnormic imge showing liner rdiopque structure extending from the sphenoid one to the lesser horn of the hyoid one (clcifiction of the stylohyoid ligment). Figure 5: Pnormic showing rgged outline rdiopcity with culiflower ppernce. Figure 7: Pnormic imge showing the presence of multiple smll rdiopque res inferior to the ngle of the mndile t the level of C3-C4 in verticl direction. 744

4 Aout 80 to 90% of siloliths occur in the sumndiulr glnd, 10-20% in the protid, only 1-7% in the sulingul, nd rrely in minor slivry glnds. This is explined y the thickness, more mucous nture of sumndiulr glnd secretions. 9 Besides the high frequency of siloliths in the sumndiulr glnd, gint ones were descried like the 35 mm length silolith reported y Arsln et l. 9 Two different rdiogrphic spects of tonsilloliths re presented in cses 2 nd 3. Tonsilloliths re common cuse of clcifiction in the phrynx, ut there is generl lck of wreness of this entity mong clinicins nd rdiologists. 10 They re multiple smll opque msses situted within the thickness of the tonsils nd other prphryngel soft tissues. Due to the ngultion of X-ry projection of the pnormic, their imge superimposes t the level of the mid-height of the rmus. 11,12 In cse 3, the pnormic imge shows severl smll opque structures superimposed on the nterior order of the irwy spce tht my occsionlly extend over the rmus. CBCT imge illustrtes multiple congregted rice grin like ovoid homogeneous dense opcities superficilly to the orophryngel irwy spce. 5,6,13,14 These clcified structures tht form in the tonsillr crypts re fortuitously discovered on rdiogrph of up to 16% ptients. 13 They my grow or regroup to rech lrger size. In generlly, the ptients do not present clinicl signs; however, they might t some instnces complin from chronic irrittion of the throt, d tste nd odor, or otlgi. 13 At the neck, lymph nodes re locted in the cervicl, sumndiulr, sumentl, nd preuriculr regions. Most ptients with such clcifictions re symptomtic, with regionl chronic inflmmtion histories such s sinusitis nd tonsillitis. Rdiogrphiclly, these clcifictions re usully distinct, irregulrly shped opcities typiclly descried s culiflowerlike. Since cervicl lymph nodes re rrnged oth superficil nd deep to the neck, differentition is often sed on rdiogrphic spect. 4,7,8,15,16 They re mostly locted in the sumndiulr region, djcent to the mndiulr ngle. The clcified styloid chin (CSC) is n excessive or norml clcifiction component including elongtion of the styloid process nd clcifiction of the stylohyoid ligment. The verge norml length in dult rnges etween 20 to 30 mm nd higher mesurement is considered s n elongtion. 17 It ws first descried y Mrchetti Pietro (1652) 18 nd took the nme of Dr. Wtt Egle (1937) to ecome known s Egle s syndrome. 19 Although symptomtic, 1-10% ptients with CSC my present clinicl signs resulting from the compression of the elongted clcified stylohyoid ligment on the ntomic structures of the region. Among these symptoms, foreign ody senstion during swllowing referred otlgi nd dysphgi. 18 In typicl pnormic rdiogrphy, the stylohyoid ligment ossifiction initites t the mstoid process nd trverses the rmus from its postero-inferior spect towrd the hyoid one. 6 Kusunoki et l. reported cse of elongted styloid reching 8 cm in length. 20 The prevlence of CAC found on pnormic imges during dentl routine exmintion vries etween 0.1 to 3.2% in ptients older thn 50 yers nd increses to 22-37% in popultions hving diseses t high therosclerotic risk such s hypertension, crdiovsculr disese, dietes, hypercholesterolemi, oesity nd physicl inctivity, nd tocco consumers. 12 In ddition to the crotid rteries (common, internl, nd externl), the verterl nd/or lingul rteries my e ffected. 21 Regions of lrge sher forces such s the crotid ifurction locted lterlly nd inferiorly with respect the hyoid one re the most ffected y CAC. 1 The prole moridity nd mortlity induced y the CAC, requires, if suspected, immedite ptient referrl to specilist physicin to confirm the potentil stenosis of the rtery s lumen nd its degree, the ltter eing closely ssocited to stroke risks. 21 CACs re developed t the soft tissue eneth the mndile ngle. On pnormic rdiogrph, they re locted etween the hyoid one nd the cervicl spine. 22 Yeluri et l. found reltionship etween pulp stones nd CAC nd stted tht n dvnced evlution of CAC must e done when multiple pulp stones were detected. 23 Conclusion Multiple clcifictions cn e noted in the hed nd neck re. They present mny fetures tht complicte their differentition for non-experienced oserver. However, close exmintion revels tht ech one of them hs n ppernce typicl enough to mke confident dignosis s such. 745

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