Metastatic Calcifications By Farah Aiman Ahmad Nurulazam

Metastatic Calcifications �  Is when minerals precipitate into normal tissues as

a result of higher serum calcium and phosphate levels in certain conditions *

�  Occurs bilaterally and symmetrically

Heterotopic Bone �  Mineral is deposited in soft tissue (well organized)

�  Formed in an abnormal location (extraskeletal)

Ossification of the Stylohyoid Ligament

�  Usually downward (from base of skull)

�  Bilaterally

�  Rare cases ( ossifications at lesser horn of the hyoid and fewer in central of the ligament)

Clinical Features �  Palpation over tonsil (hard, pointed)

�  Minor patients have symptoms/Most of them symptomless

�  Symptoms of this disease is termed as Eagle Syndrome : 1)Classic Eagle Syndrome

2) Carotid Artery Syndrome

Radiographic Features

Ossifications at stylohyoid cartilage (no symptoms)

�  Incidental in panoramic RG, 18% examined showed 30mm calcification of stylohyoid ligament

�  Calcifications of the in individuals of any age

�  LOCATION: Panoramic- linear ossifications extends forward from mastoid process and cross post-inf aspect of ramus towards hyoid bone. Hyoid bone parallel (roughly) to/ superimposed on post aspect of inferior cortex mandible

�  SHAPE: long, tapering, thin radiopaque process (thicker at base) projects downwards and forward. Length- 0.5-2.5cm. Irregularity may be seen at outer surface. Farther the radiopaque ossified ligaments extend toward the hyoid bone then it will be interupted by radiolucent jointlike junctions (PSUEDOARTICULATIONS)

�  INTERNAL STRUCTURE: Homogenous RO, outer cortex

Differential Diagnosis/ Management

�  TMJ DYSFUNCTION: symptoms alike

�  MANAGEMENT: �  Asymptomatic : NO Rx

�  Symptomatic: vague symptoms- conservative approach of reassurance – steroid/lidocaine injections into tonsillar fossa

�  Persistent/Intense pain- stylohyoidectomy

Osteoma Cutis �  Rare ossification soft tissue in skin

�  85% cases are due to long duration acne, developing scar, chronic inflammatory dermatosis

�  Histologically: dense viable bone in dermis or subcutaneous tissue

�  Found in diffuse scleroderma, replaced altered collagen in dermis and subcutaneous septa

Clinical Features �  Anywhere/ Face (COMMON SITE)

�  Intraoral (Tongue*)- osteoma mucosae or osseous choristoma

�  No visible changes. Colour changes occasionally appear yellowish white

�  Large lesion can be palpated

�  Needle inserted to one of the papules will feel stonelike resistance

�  Numerous in some patients (dozens to hundreds) –multiple osteoma cutis

Radiographic Features �  LOCATION: cheek and lips regions. May

superimposed with tooth root or alveolar process (appearance of dense bone).

�  PERIPHERY AND SHAPE: smoothly outlined, RO, washer shaped image. Single or multiple usually small (0.1 to 5cm)

�  INTERNAL STRUCTURE: �  homogenously RO but usually has RL center (normal

fatty marrow) DONUT APPEARANCE. �  Snow flake like RO- calcified cystic scar

Faint radiopaque calcifications in cheeks

Differential Diagnosis �  Myositis ossificans

�  Calcinosis cutis

�  Osteoma mucosae

�  MANAGEMENT: NO RX. Removed for cosmetics reasons. �  Resurface skin with ERB-Ytrium- Aluminum- Garnet

laser + Tretinoin cream successful in multiple miliary osteoma cutis

�  Needle microincision-extirpation (good cosmetic results)

Myositis Ossificans �  Fibrous tissue + heterotopic bone within the

interstitial tissue of muscle, associated tendons and ligaments

�  Secondary destruction and atrophy to fibrous tissue and bone interdigitate and separate the muscle fibers.

�  Localized and Progressive

Localized (Traumatic) Myositis Ossificans

�  Synonyms: Posttraumatic myositis ossificans and solitary myositis

�  From acute/ chronic trauma or from heavy muscular strain caused by occupations and sports

�  From multiple injections (from dental anesthetic)

�  Skeletal muscle limited capacity for regeneration after significant physical trauma.

Clinical Features �  At any age can develop in either sex ( most often young

men)

�  Site: �  Trauma remains swollen, tender and painful �  Overlying skin red and inflamed �  Opening jaws difficult –(muscle of mastication)

�  The localized lesion may enlarge slowly, will stop growing

�  Fixed/ freely movable on palpation

�  2 to 3 weeks area of ossifications becomes apparent in the tissue , a firm intramuscular mass can be palpated

Radiographic Features �  LOCATION:

�  muscles of the head and neck and muscles of mastication �  RL band can be seen between the area of ossification and adjacent bone. �  Heterotopic bone - long axis of the muscle

�  PERIPHERY AND SHAPE: �  periphery is more RO than the internal structure. �  Variation in shape from irregular oval to linear streaks (pseudotrabeculae)

running same direction as normal muscle fibers

�  INTERNAL STRUCTURE: varies within time. �  3rd-4th week after injury- homogenously radiopacity �  2 months- delicate lacy or feathery radiopacity internal structure develops.

Indicates the formation of bone-not a normal- appearing trabecular pattern. �  5-6 months- denser, well defined and mature fully �  After that, lesion may shrink

Differential Diagnosis �  Ossification of the stylohyoid ligament and other

soft tissue calcification

�  Bone forming tumours-osteogenic sarcoma > tumor is contiguous with the adjacent bone. Have signs of destruction of bone

�  MANAGEMENT: �  Rest and limitation to diminish extent of the calcific

deposit �  Surgical excision of entire calcified mass with

intensive physiotherapy to minimize postsurgical scarring *

Progressive Myositis Ossificans

�  Rare hereditary disease ( Autosommal Dominant transmission)

�  Spontaneous mutation (less common)

�  >Males and symptoms from early infancy

�  Within interstitial tissue of muscles, tendons, ligaments and fascia

�  Muscles atrophy

Clinical features �  Most cases starts in muscles of neck and upper back and moves

to the extremities

�  Soft tissue swelling, tender and painful, redness and heat

�  Firm mass remains

�  Striated muscles affected (heart and diaphragm)

�  Limited to extensive

�  Petrified Men- advance stage of the disease

�  3rd decade- process arrest

�  3rd to 4th decade- mostly patient died

�  Premature death- respiratory embarassment or from initiation of muscles of mastication

Radiographic Features �  Similar to limited form

�  Oriented along long axis of muscles involved

�  Osseous malformation at muscle attachment (mandibular condyles)

Differential Diagnosis �  Initial stage – Rheumatoid Arthritis

�  Calcinosis- deposits of calcium salts will resorb

�  MANAGEMENT: NO AFFECTIVE RX �  Traumatized and ulcerated nodules should be excised �  Interference of respiration or respiratory infection

occurs, supportive therapy needed