Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Contacts Login 
Home Print this page Email this page Users Online: 342



 
 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 8  |  Issue : 2  |  Page : 30-35

“CALCIFIC ISLANDS:” A cone-beam computed tomography review of soft-tissue calcifications in head-and-neck region


1 Department of Oral Medicine and Radiology, Index Institute of Dental Sciences, Indore, MP, India
2 Department of Endodontics and Conservative Dentistry, Index Institute of Dental Sciences, Indore, MP, India
3 Department of Pedodontics and Preventive Dentistry, Index Institute of Dental Sciences, Indore, MP, India
4 Department of Oral Medicine and Radiology, Government College of Dentistry, Index Institute of Dental Sciences, Indore, MP, India
5 Department of Oral and Maxillofacial Surgery, Index Institute of Dental Sciences, Indore, MP, India

Date of Submission02-May-2020
Date of Decision20-May-2020
Date of Acceptance07-Jul-2020
Date of Web Publication5-Oct-2020

Correspondence Address:
Ajay Parihar
Department of Oral Medicine and Radiology, Government College of Dentistry, Indore, Madhya Pradesh
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jomr.jomr_9_20

Rights and Permissions
  Abstract 


Soft-tissue calcification of the head-and-neck region is now commonly seen because of the advent and increased usage of cone-beam computed tomography (CBCT) in dentistry. The purpose of this study is to construe the radiographic characteristics in CBCT of the soft-tissue calcifications in the head-and-neck region. The soft-tissue calcifications of the head-and-neck region may arise from pathological mineralization by deposition of calcium phosphate essentially in an unorganized manner known as “heterotopic calcification.” The three types of heterotopic calcifications are dystrophic calcifications, metastatic calcifications, and idiopathic calcifications (calcinosis). These calcifications can include sialoliths, calcified lymph nodes, carotid artery calcifications, and many more which present themselves with different radiographic presentations. These calcifications can be detected by different two-dimensional and three-dimensional imaging techniques, among which CBCT proves to be the best radiographic tool in most of the cases. The anatomic location, number, distribution, pattern, and size of calcifications are important interpretative criteria in radiographic evaluation of soft-tissue calcifications. Soft-tissue calcifications though usually asymptomatic are quite common in the head-and-neck region. An apt radiographic imaging aids in reaching up to the precise diagnosis which may enhance their approach and management by clinicians.

Keywords: Cone-beam computed tomography, heterotopic calcification, soft-tissue calcifications


How to cite this article:
Parihar A, Shastri A, Jain A, Saxena A, Rawat A, Singh M. “CALCIFIC ISLANDS:” A cone-beam computed tomography review of soft-tissue calcifications in head-and-neck region. J Oral Maxillofac Radiol 2020;8:30-5

How to cite this URL:
Parihar A, Shastri A, Jain A, Saxena A, Rawat A, Singh M. “CALCIFIC ISLANDS:” A cone-beam computed tomography review of soft-tissue calcifications in head-and-neck region. J Oral Maxillofac Radiol [serial online] 2020 [cited 2020 Nov 27];8:30-5. Available from: https://www.joomr.org/text.asp?2020/8/2/30/297221




  Introduction Top


The soft-tissue calcifications of the head-and-neck region may arise from physiological or pathological mineralization by deposition of calcium phosphate essentially in an unorganized manner known as heterotopic calcification. The three types of heterotopic calcifications are dystrophic calcifications, metastatic calcifications, and idiopathic calcifications (calcinosis).[1] According to Kirsch, physiological mineralization is restricted to specific sites in skeletal tissues, including growth plate cartilage, bones, and teeth, while the uncontrolled or pathological mineralization can occur in any soft tissue including articular cartilage, blood vessels, and ligaments.[2] According to Shroff and Shanahan, while the skeletal mineralization is a complex physiological process involving a well-balanced interplay between stimulatory and inhibitory components induced by well-timed developmental cues, an active cell-mediated process resulting from imbalance between the promoters and inhibitors of mineralization induced by dysregulated and inappropriate environmental cues leads to pathological soft-tissue calcifications.[3] The heterotropic calcification occurs when calcium salts are deposited in an unorganized fashion in soft tissue.[4]


  Pathogenesis of Soft-Tissue Calcifications Top


The soft-tissue calcifications can be subdivided into three major classes: dystrophic, metastatic, and idiopathic calcifications.


  Significance of Radiography Top


Soft-tissue calcifications are usually asymptomatic and inevident clinically and are detected incidentally on radiographs only being taken for some other provisional diagnoses or routine radiographic examinations. Furthermore, some of these calcifications (especially dystrophic) may suggest the presence of a systemic condition and represent a manifestation of more potentially ominous sequelae.[5] A thorough knowledge and understanding of anatomy of the head-and-neck region and radiographic appearances of various normal and pathologic structures is, therefore, essential and will aid the dental clinician in the early diagnosis.


  Conventional Radiography and Soft-Tissue Calcification of Head-And-Neck Region Top


Soft-tissue calcifications have usually been identified on panoramic radiographs owing to their greater coverage and higher frequency of use. However, this conventional method of radiography possesses two major drawbacks; one, many of the structures in the head-and-neck region are in close proximity to one another which makes localization and identification difficult. Two, detection and confirmation is complicated on conventional extraoral dental images by the fact that these radiographic images are planar and provide a two-dimensional (2D) representation of a three-dimensional (3D) object. This potentially results in both false-positive and false-negative detection of various calcifications on conventional images.[5]


  Cone-Beam Computed Tomography and Calcifications of Head-And-Neck Region Top


Cone-beam computed tomography (CBCT) is a newer added and important imaging tool in dentistry. It is cost-effective, time-saving, reduced and lesser radiation exposure, and user-friendly in comparison to medical computed tomography or any other ionizing radiographic technique. Its dentistry-driven software gives better 3D reconstructed images. CBCT provides 3D and multiple viewing modalities and increases the frequency and probability of detection of calcified masses. We shall be considering the conventional and CBCT views of each type of calcification in the following text to establish the fact.


  Interpretative Criteria Top


The following are the interpretative criteria in radiographic evaluation of soft-tissue opacities:

  1. Anatomic location
  2. Number
  3. Distribution
  4. Pattern of calcification or appearance
  5. Size of the calcification.[4]



  Classification of Soft-Tissue Calcifications Top


    Dystrophic calcifications


  1. General dystrophic calcifications of oral region
  2. Lymph node calcifications
  3. Tonsiloliths
  4. Arterial calcifications


    • Monckeberg's medial calcification (arteriosclerosis)
    • Intimal calcifications (atherosclerosis)


  5. Cysticercosis


  • Metastatic calcifications


    1. Calcified stylohyoid ligament
    2. Osteoma cutis
    3. Myositis ossificans


  • Idiopathic calcifications


    1. Sialoliths
    2. Phleboliths
    3. Laryngeal cartilage calcification
    4. Triticeous cartilage calcification
    5. Thyroid cartilage calcification
    6. Antroliths
    7. Rhinoliths.



      General Dystrophic Calcifications of Oral Region Top


    General dystrophic calcifications are the precipitations of calcium salts in the primary sites of chronic inflammation or dead and dying tissues, especially the chronically inflamed cysts. Common anatomic locations are gingiva, tongue, lymph nodes, and cheek. They can be single or multiple in number. Their distribution is usually in long-standing chronically inflamed cysts. Their appearance is fine grainy to larger irregular homogeneous or heterogeneous masses. Their size rarely exceeds 0.5 cm in diameter, and the best suitable radiographic tool for dystrophic calcifications is CBCT [Figure 1].
    Figure 1: Cone-beam computed tomography (axial view) showing grainy calcifications within the cystic cavity

    Click here to view



      Lymph Node Calcifications Top


    Lymph nodes in the head-and-neck region usually calcify after chronic inflammation or posttreatment for lymphomas. These lymph nodes usually enlarge during inflammatory processes. Subsequently, the nodes become fibrous, and foci of calcification start to develop.[4] Tuberculous lymphadenitis (scrofula) is probably the most prevalent disease process associated with dystrophic calcification of sclerotic nodes.[6] Submandibular, submental, and cervical lymph nodes[5] are the common anatomic locations. These calcifications can be single or multiple[5] in number and distribute in the region of involved lymph node or along the course of a nodal chain (lymph node chaining) [Figure 2]. Calcification is in the form of radiopacities with irregular borders showing cauliflower-like[5] pattern without a certainly defined size range.
    Figure 2: Cone-beam computed tomography image showing lymph node calcifications

    Click here to view



      Tonsiloliths Top


    Tonsillar calcifications are oropharyngeal concretions formed as sequelae of chronic tonsillitis where residual long-standing inflammation can serve as the nidus for dystrophic calcification.[5] Other school of thought suggests stasis of saliva in the efferent ducts of the accessory salivary gland, secondary to mechanical obstruction arising from posttonsillectomy scars or chronic inflammation[4] as the etiologic factor. The common anatomic locations are tonsils – mid-ramus or lateral oropharyngeal region.[4] The histologic distribution is as follows: tonsillar tissue (69.7%), tonsillar fossa (21.2%), and palate (9%).[5] They can be single or multiple (more often) in number appearing in cluster of multiple rice grain-like[5] small radiopacities. They can be few millimeters to several centimeters[5] in size. CBCT appears to be the best suitable radiographic tool.


      Arterial Calcifications Top


    Monckeberg's medial calcification or arteriosclerosis

    Fragmentation, degeneration, and eventual loss of elastic fibers followed by deposition of the calcium salts in the medial layer of an artery[4] present in the form of arteriosclerosis. The common anatomic location is facial artery. The distribution of usually single lesion is along with the outlines of the affected artery [Figure 3]-4].[4] The pattern of calcification is in the form of parallel radiopaque lines exhibiting tram-track appearance.[4] Size is not certainly defined, and CBCT proves to be the best suitable radiographic tool.
    Figure 3: Calcification of facial artery in cone-beam computed tomography image

    Click here to view


    Intimal calcification or atherosclerosis

    Atherosclerosis occurs by deposition of calcium in the atheromatous plaques within the intima of the arteries. The common anatomic location is carotid artery bifurcation (between the levels of C3 and C4).[4] These calcifications are usually multiple in number with vertical linear distribution. They appear as heterogeneous, irregular, well-demarcated radiopacities in soft tissues of the upper neck.[4] Their size is not certainly defined. These can be detected both by conventional (cephalometric and panoramic) radiography and CBCT.

    A recent study found that arteriosclerosis (63.41%) and calcified atherosclerotic plaques (45.29%) are the most common soft-tissue calcifications. Women have been found to show greater percentage of carotid artery calcifications, especially after menopause as the protective effect of female hormones is then absent.[7]


      Calcified Stylohyoid Ligament Top


    Another commonly calcified structure in the head-and-neck region is the stylohyoid ligament that usually occurs bilaterally and extends downward from the skull base.[4] One theory states that degeneration of the ligament with deposition of calcium salts in the fibrous tissue accounts for the calcification of stylohyoid ligament [Figure 5].[5] The other theory suggests that direct ossification of cartilaginous cells (of Reichert's cartilage) remaining in the ligament in patients of adult age contributes. They appear as single or multiple segments of calcifications distributed from the styloid process of the temporal bone inferiorly to the hyoid bone. They appear as heterogeneous, irregular, and well-demarcated radiopacities in soft tissues of the upper neck.[4] The size is variable. The best suitable radiographic tool is conventional (panoramic or any other extraoral) radiography being cheaper and sufficient in detecting the intended.
    Figure 5: Stylohyoid ligament calcification in cone-beam computed tomography image

    Click here to view



      Osteoma Cutis Top


    This rare soft-tissue calcification appears when there is normal bone formation in abnormal locations that develop secondary to chronic acne or dermatosis scar. Cheek, lips, and tongue are the common anatomic locations. They are single or multiple in number and diffuse in their distribution. They appear as tiny doughnut-shaped radiopacities with radiolucent centers that represent central marrow cavities [Figure 6].[4] Their size range is 0.1 mm–5 cm. CBCT is the best suitable radiographic tool for their diagnosis.
    Figure 6: Cone-beam computed tomography image showing osteoma cutis in the mandibular region

    Click here to view



      Sialoliths Top


    Sialoliths are calcareous deposits in the salivary glands formed by precipitation of calcium salts around a central nidus that may consist of desquamated epithelial cells, bacterial debris, foreign body, or mucus plug.[4] Salivary stones occur most commonly in the submandibular glands (80%–90%), followed by the parotid (5%–15%) and sublingual (2%–5%) glands, and only very rarely occur in the minor salivary glands.[8] Usually, single in number sialolith (this demarcates them from lymph node calcifications of the same anatomic area which are usually multiple) appears inside the gland or the duct of the involved salivary gland [Figure 7]. Sialoliths often are homogeneously radiopaque and show evidence of multiple layers of calcification (laminated appearance).[4] Sialoliths are usually up to 1 cm in size, while occasional giant ones of up to 3 cm[9] can be seen. Sialogram is the best radiographic tool for the detection of sialoliths.
    Figure 7: Cone-beam computed tomography image showing sialolith in the submandibular gland

    Click here to view



      Phleboliths Top


    Intravascular thrombi associated with hemangioma and venolymphatic malformations may get organized and mineralized forming phleboliths. The common anatomic locations are masseter and buccinator muscle regions.[10] They are usually several to dozens in number. Their distribution is diffuse [Figure 8]. They appear as round or ovoid calcified bodies with concentric calcific rings similar to section of an onion or may present bull's eye or target appearance. Their size varies with time. Both conventional radiography and CBCT are suitable radiographic tools for phleboliths.
    Figure 8: (a) Cone-beam computed tomography image showing phleboliths. (b) Cone-beam computed tomography (axial view) exhibiting target or bull's eye appearance of phleboliths

    Click here to view



      Antroliths Top


    Deposition of mineral salts around a central endogenous nidus leads to the formation of calcified mass in the maxillary sinus. The common anatomic location is maxillary sinus. Antroliths can be single or multiple in number. They are usually distributed just above the floor of the sinus. The appearance of antroliths may be round to ovoid and irregular, ragged, or smooth in outline. Their size range is not certain. Conventional radiographs (periapical, occlusal, and panoramic) are the best suited radiographic tools for antroliths.


      Rhinoliths Top


    Deposition of mineral salts around a central exogenous foreign body leads to the formation of calcified mass in the nasal fossa [Figure 9]. Their common anatomic location is nasal cavity, near maxillary sinus. Rhinolith is usually single in number. Rhinoliths appear as homogeneous or heterogeneous radiopacities with varied shapes and sizes and smooth or irregular borders. Their size is variable.
    Figure 9: Rhinolith in the right nasal cavity

    Click here to view



      Conclusion Top


    Soft-tissue calcifications are quite common in the head-and-neck region which are usually discovered incidentally but symptomatic in certain cases and may or may not require intervention. An apt radiographic imaging technique and thorough knowledge of the anatomy aids in reaching up to the precise diagnosis which may enhance their approach and management by clinicians. Furthermore, as health-care costs continue to rise, avoiding unnecessary and unjustified diagnostic tests and referrals is a welcome consequence of an increase in the understanding of the nature of soft-tissue calcifications in the head and neck.

    Financial support and sponsorship

    Nil.

    Conflicts of interest

    There are no conflicts of interest.



     
      References Top

    1.
    Oral Radiology, Principles and Interpretation, Second South Asia Edition, Soft tissue Calcification and Ossification. Reed elsevier India private ltd. 2014. p. 607.  Back to cited text no. 1
        
    2.
    Kirsch T. Determinants of pathological mineralization. Curr Opin Rheumatol 2006;18:174-80.  Back to cited text no. 2
        
    3.
    Shroff RC, Shanahan CM. The vascular biology of calcification. Semin Dial 2007;20:103-9.  Back to cited text no. 3
        
    4.
    Omami G. Soft tissue calcification in oral and maxillofacial imaging: A pictorial review. Int J Dent Oral Sci 2016;3:219-24.  Back to cited text no. 4
        
    5.
    Adam B. Wells. Incidence of soft tissue calcifications of the head and neck region on maxillofacial cone beam computed tomography, thesis, School of Dentistry University of Louisville, Kentucky. 2011.  Back to cited text no. 5
        
    6.
    Muto T, Michiya H, Kanazawa M, Sato K. Pathological calcification of the cervico-facial region. Br J Oral Maxillofac Surg 1991;29:120-2.  Back to cited text no. 6
        
    7.
    Patil SR, Alam MK, Moriyama K, Matsuda S, Shoumura M, Osuga N. 3D CBCT assessment of soft tissue calcification. J Hard Tissue Biol 2017;26:297-300.  Back to cited text no. 7
        
    8.
    Leah m bowers, philip c fox, micheal p brennan, salivary galand diseases, burkets oral medicine, 12th edition, 2015. peoples medical publishing house, usa p.233.  Back to cited text no. 8
        
    9.
    Kaur K, Konidena A, Puri G, Jatti D. Imaging features of giant sialolith of submandibular gland: A case report. J Indian Acad Oral Med Radiol 2016;28:180.  Back to cited text no. 9
      [Full text]  
    10.
    Kamatani T, Saito T, Hamada Y, Kondo S, Shirota T, Shintani S. Intramuscular hemangioma with phleboliths of the tongue. Indian J Dent 2014;5:100-1.  Back to cited text no. 10
      [Full text]  


        Figures

      [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



     

    Top
     
     
      Search
     
    Similar in PUBMED
       Search Pubmed for
       Search in Google Scholar for
     Related articles
    Access Statistics
    Email Alert *
    Add to My List *
    * Registration required (free)

     
      In this article
    Abstract
    Introduction
    Pathogenesis of ...
    Significance of ...
    Conventional Rad...
    Cone-Beam Comput...
    Interpretative C...
    Classification o...
    General Dystroph...
    Lymph Node Calci...
    Tonsiloliths
    Arterial Calcifi...
    Calcified Styloh...
    Osteoma Cutis
    Sialoliths
    Phleboliths
    Antroliths
    Rhinoliths
    Conclusion
    References
    Article Figures

     Article Access Statistics
        Viewed633    
        Printed14    
        Emailed0    
        PDF Downloaded83    
        Comments [Add]    

    Recommend this journal


    [TAG2]
    [TAG3]
    [TAG4]