Transcript for:
Understanding Soft Tissue Calcifications

good day class and welcome to the lecture on soft tissue calcifications this is a very important lecture and in some instances can become quite difficult i do encourage you to visit your study guide look at the study objectives that is prescribed for this lecture topic as well as supplement these lecture notes with the chapter in the prescribed textbook which is white and pharaoh this is a topic that is very close to my heart because soft tissue calcifications in most instances is a radiological diagnosis and therefore it is very important to understand this concept so before we start off with today's lecture topic i first want to just inform you that it is extremely important that you understand the radiographic anatomy of soft tissue as well as the general radiographic anatomy the reason being is that soft tissue calcifications are diagnosed using a combination of how the calcification presents meaning the pattern of calcification as well as the anatomical location so in order to make appropriate or proper diagnosis of soft tissue calcifications you have to have a good understanding of [Music] the radiographic anatomy so i'm just going to go through a few key points in this radiograph the first thing that we see is we see the cervical spine in the periphery of both radiographs anterior to the cervical spine we see the soft tissue outline of the neck this is a very important factor to note when we are going to diagnose carotid artery calcifications the next thing that is important to be able to notice is the soft tissue of the ear or the earlobe this is an important factor to take into account when we will diagnose calcifications of your stylo high weight ligament next if we look at this radiograph we can identify some normal anatomy which includes our orbits on both sides we have got our maxillary sinuses the posterior wall of the maxillary sinus is joined to the batterigo maxillary fissure which is the teardrop shape structure that i outlined for you superimposed over the maxillary sinus we have are zygomatic buttresses which is the insertion of your zygomatic arch into your maxilla so your zygomatic arch starts at your zygomatic batches and then it continues where it then ends into your articular imminence and eventually then your glenoid fossa on this side you can also see your zygomatic arch starting from your zygomatic buttress ending into the articular imminence the next important anatomical structure that i want to outline for you is our nasal septum our nasal septum terminates into our anterior nasal spine on both sides of the nasal septum we have our nasal cavities where we then can find our nasal concha another important factor to remember on anatomy of a radiograph is firstly the hard palate which will then terminate into the soft palate which we can see over here we also see then this airway space because the patient did not put his tongue against the palate so here's the palette here's the airway space and then this soft tissue shadow will then represent the tongue ending into the posterior dorsum of the tongue and the posterior dorsum of the tongue goes up into your epiglottis which is that structure then over there on this side we can then see your epiglottis as well as the posterior dorsum of the tongue we can clearly see our thyroid bone which forms double images on both sides of a panoramic radiograph and for the rest of the anatomy it's pretty much simple your external auditory meatus as well as then posterior to that you will find your mastoid a cells let's look at a little bit of soft tissue anatomy on a cb ct scan so this you can see is a coronal slice of a cvct scan we can identify some anatomy firstly we can see the frontal sinus we see our sala tershika directly underneath our salatoshika is our sweenoidal sinuses we can see our maxilla this canal represents our incisive canal anterior nasal spine is where the hard palate starts and it ends in our posterior nasal spine attached to a hard palate is our soft palate this will represent our c-spine this is the dense of the axis that is protruding into my c1 which is my atlas this represents the soft tissue of the neck here we can clearly see the tongue and the posterior dorsum of the tongue coming up and ending in my epiglottis just for intersex we can also see some genial tubercles nasal bone and that is about all the anatomy that i can identify from this cbct slice again it is important to understand the radiographic anatomy of all of the projections that we have covered up until this point this represents a lateral cephalogram i'm going to point out a few anatomical features just to recap as i already stated the reason for me doing this is anatomy is extremely important in the diagnosis of soft tissue calcifications so here we have our nasal bone our frontal sinus you see our anterior nasal spine which is the start of our heart palette and our posterior nasal spine here we can see the salatus directly beneath the salatoshika we have our sween weight signers and this area we have got a lot of overlap from our maxillary sinus our orbit and our ethmoid a cells which is the multiple bubbles that we can see superimposed the posterior margin of our maxillary sinus we find our target maxillary fissure again here it is extremely important to be able to see the soft palate which terminates roughly then we see the posterior dorsum of the tongue going up into hypic lotus in that region over there you can also see that these structures are superimposed over a hybrid bone another important feature that i will point out for you is look at this airspace that you can see which represents our nasopharynx coming from the nose into the nasopharynx the little bulge that you see there is our adenoids so it's one of our tonsils that we get in the aurora cavity so that is our adenoids and here we can also see protruding close to the posterior dorsum of the tongue we can see extremely swollen palatine tonsils also on this radiograph you can also see your external auditory measures as well as your mastoid a cells so calcifications is exist due to the deposition of calcium salts in soft tissues we get different types of calcifications the first being idiopathic calcification idiopathic calcifications means that the etiology or pathogenesis cannot be described to a specific cause it just occurs due to an unknown reason we are not quite sure why it happens the other two types of calcifications is firstly dystrophic calcifications dystrophic calcification is where there is the deposition of calcium salts in dead or dying tissues so the de-endostrophic points to the tissue being dead or dying so dystrophic calcifications we normally see this in tissues that are either undergoing inflammation or necrosis metastatic calcification on the other hand is where there is the deposition of calcium salts in normal tissue but the reason for this calcifications is because there's an increase in serum levels of calcium especially in conditions such as hyperparathyroidism which you will cover in your pathology lectures we also see it in cases of multiple myeloma again this will be covered in your pathology lectures and also in cases where there is a lot of metastatic disease so the m in metastatic calcification points to a metabolic problem okay so calcifications in most instances are detected as incidental findings on a radiograph from your lecture on legal aspects of dental radiography you will learn that it is important to write a radiological report on all radiographs that are being taken in your practice so if you have taken a radiograph on a patient and that patient presents with a calcification it is your duty as a healthcare worker to note and report on those calcifications and if need be refer the patient for additional treatment or management this is the basic flow diagram that we are going to follow in this lecture we are going to do two types of soft tissue calcifications the one being heterotrophic calcification which is a disorganized deposition of calcium salt in soft tissues and heterotrophic ossification is where the calcifications within soft tissues organized to form sort of bony like structures so under heterotrophic calcification we will then do dystrophic idiopathic and metastatic calcifications under dystrophic calcifications it is important to note that any inflamed tissue for example an inflamed cyst a periapical granuloma or any form of inflammation that you know of and will be taught in your mfp lectures can have dystrophic calcifications due to the deposition of the calcium salts in inflamed tissue other forms of dystrophic calcification that we will cover in this lecture is the calcification of lymph nodes tonsils and even arterial calcifications the idiopathic calcifications that we will cover in this lecture includes calcification of your thyroid cartilage calcifications that are found within the library glands calcifications that are finding veins and also in the sinuses so i always want to refer back to this slide the reason being that as already mentioned calcifications are diagnosed based on a combination of how they present meaning the pattern of calcification and where they present so i made this little diagram to show you for example if you look at the styloid ligament which is highlighted in pink this is the typical region as well as presentation of the style of highway ligament so please after this lecture refer back to this slide so let's talk about dystrophic calcification dystrophic calcification as i already mentioned can occur in any cyst or lesion that is affected by inflammation let's look example at an example of this case you will see that there is a lesion that is associated with an impacted canine on the left hand side the lesion you can see has got a nice corticated rim it's nice and well demarcated but there also is areas that are filled with soft tissue within the flow of the soft tissue you see numerous types of calcifications this can be a good example of an aot which is an adenomatoid or antigenic tumor it is a benign orontogenic neoplasm of epithelium that typically presents with dystrophic snowflake-like calcifications dystrophic calcifications can also occur in calcified or in lymph nodes calcified lymph nodes as you know the lymph nodes are do drain areas that are affected by inflammation and infection for example if you have a tooth with a periapical lesion and that lesion is chronic in nature you will sometimes find that the patient can also present with swollen lymph nodes due to the lymph node being enlarged caused by the draining of that inflammation in the lymphatic system so calcified lymph nodes normally point to a sort of an inflammatory process that occurred in the past so but we do see numerous calcified lymph nodes in the setting of tb okay so the typical appearance of a calcified lymph node is this irregular cauliflower like appearance and it occurs in the regions where you will find lymph nodes in the head and neck area so again you have to go study your anatomy and study your typical locations of your lymph nodes just a quick recap of the anatomy of your lymph nodes we've got lymph nodes in our pre and posterior auricular area we've got lymph nodes in our parotid gland tonsillar lymph nodes submental submandibular and then we get superficial as well as deep cervical lymph nodes and supra clavicular lymph nodes the majority of the radiographs that we take in our clinic downstairs only goes up until the highway bone so we very rarely will see supraclavicular lymph nodes so again it is important to correlate the anatomy of your lymph nodes for where they can present on the radiographs that you have been exposed to let's look at this radiograph as an example so if you can remember from how we analyze a radiograph the first thing we look at is the periphery in the periphery on the left hand side and please note on how we or rather the terminology that we use to describe these presentations and calcifications when i go through each of the radiographs in the upcoming lecture so in the left periphery we see multiple cauliflower-like calcifications that are overlying the thyroid bone and approximate the left mandibular angle these calcifications are typically representative of calcified lymph nodes this is another panoramic radiograph and here we can see a more irregular type of calcification that we can see in the right periphery that is approximate the right mandibular angle area from this radiograph it's also nice to note that there is left and right maxillary sinus pneumatization as well as we have an irregular shape left condyle that has an osteophyte formation these are a lateral cephalogram as well as an anterior posterior radiograph that present with multiple cauliflower-like calcifications that are fine found bilateral in the cervical area of this patient so with these widespread calcification of the lymph nodes we can even see some in the submandibular area is should be a strong indication that the patient has active tuberculosis or even previous history of tuberculosis infection remember that seeing calcified lymph nodes does not necessarily point to an active tb infection but it does warrant further investigation so the next form of dystrophic calcifications that we are going to discuss is the dystrophic calcification that occurs in tonsils that we refer to as tonsillitis now tonsils are aggregates of lymphoid tissue and that can frequently be affected by inflammation that is why a large amount of people have their tonsils removed as a child due to chronic inflammation so calcifications in the tonsils usually occur due to repeated episodes of information and there are various tonsils that you need to be aware of mainly when you focus on the wall dyes ring so wall dyer's ring you have your adenoid which is situated roughly below the swenoid sinus as already indicated in the natural cephalogram in one of the first slices of this lecture the tubule tonsils is roughly located in the area where the extasion tubes open up into the nasal pharynx palatine tonsils those are the tonsils that we normally can see in an intra-oral examination which sits bilaterally of the posterior area of the tongue in the tonsillar pillars and then the lingual tonsil is a little bit further down and this we can find at the base of the tongue so dystrophic calcifications in the tonsils can occur in any of these tonsils we most often see them in the palatine tonsils but we have seen rare cases of calcifications in other areas as well so now that you know the location of where these tonsils can occur remember to orientate yourself on a panoramic radiograph your palatine tonsils will normally be situated overlying the ramus area and your lingual tonsil will be situated near the base of the tongue your adenoids we can mainly see that on lateral cephalograms and your tubal tonsils can sometimes present in this rough area so this is the location now for the pattern of calcification so remember lymph node has a cauliflower pattern this trophic calcification in the tonsils occurs as multiple spec like calcifications as you can see in this image multiple spec like calcifications and the location where it's overlying the ramus points to the area of the palatine tonsils it's important also to note here you can see ghost image formation so you will then be able to incorporate your previously gained knowledge into this into the analysis of this radiograph you know that the tonsils will be situated on the lingual side of the ramus and because therefore it is between the center of rotation and the source it will form ghost images very important concept to understand this is another example of a beautiful case of calcifications in the tonsils that we can particularly see in the right hand side so how we will describe it is there's multiple spec-like calcifications over line the right ramus area resembling calcifications in the right palatine tonsils or tonsil lifts this next few circles was just to indicate to you where we will find lingual tonsil calcifications and cubal tonsil calcifications calcifications in these tonsils are not visible in this image this is a beautiful radiograph and probably one of my favorite to illustrate soft tissue calcifications the reason being is that we can see calcifications of our thyroid cartilage triticus cartilage which i will cover in a little bit more detail later on but also we can see extensive calcification in the lingual tonsils ghost image formation on the left-hand side and also on the palatine tonsils ghost image formation on the right hand side there's another palatine tonsil with its ghost image formation beautiful radiograph and you can even see some mucosal thickening or pacification of your left maxillary sinus this is another radiograph we we noted a small calcification roughly found in this region it is an abnormal pattern of calcification but the location can only point to one of two things it can either point to a calcification in your tubal tonsil or a calcification in the lymph nodes this was a very interesting case that i saw in the clinic when i was on duty it was a patient and that came in for impaction of the 47 and what i noted was that if you look at the soft tissue anatomy of this patient we see a soft palate that is attached to our hard palate and then we see the posterior dorsum of the tongue and knowing your normal anatomy you know the posterior dorsum of the tongue has a rough appearance like that ending into our epiglottis right but here we can see epiglottis actually presents there sorry for that but here we can see an additional soft tissue projection that almost looks like it is superimposed over over the posterior dorsum of the tongue so initially i thought this was a case of a swollen lingual tonsil or even some sort of lingual thyroid it was a little bit concerning for me and what i did was i called the patient into the room to do an intraoral examination and what i found was that it the patient actually had palatine tonsils and her palatine tonsils were swollen to such an extent that they had this appearance on this radiograph it is our duty as healthcare workers to note these types of things in a radiograph that we take because this patient needs to be referred to an ent to have a look at her tonsils for possible removal this is a natural cephalogram and on this natural cephalogram i want to point out how you can then see the swollen tonsil much clearer on this radiograph also on this radiograph now that we are on it i want to point out the location of the adenoids so where you can see this airway space right the adenoid is situated in that area the next radiograph it will show you how if your adenoids are swollen you will see a decrease in this airspace here you can see a patient with an extensively swollen adenoid again it is of importance for us to recognize these entities and then make appropriate referrals for further investigations so dystrophic calcifications within the arteries are extremely important to diagnose on radiographs the reason being that these types of calcifications points to the patient having cardiovascular morbidities and this in some instances can be fatal so dystrophic calcification in the arteries we normally find them within atherosclerotic plaque okay so calcified atherosclerosclerotic blocks are extremely important to identify on radiographs so artherosclerosis as you know from your previous lectures in anatomical pathology is a process of chronic inflammation arthrosclerosis that occurs in the external carotid artery can calcify but they can also be a contributing source for either emboli that can lead to a myocardial infarction or heart attack or even a stroke so when we see dystrophic calcifications that resembles calcified atherosclerotic plaques it is of importance that the patient be referred to for cardiovascular workup as it may point to the patient having problems with blood pressure cholesterol and so on that needs to be treated and managed appropriately calcifications in these arteries can narrow the lumen of the artery and also then result in a decreased blood flow to the cranium and its surrounding structures carotid artery calcification the location of where we find these calcifications more more common or most commonly is at the bifurcation where the common carotid artery splits into the external and internal carotid artery this occurs due to there being an area of increased endothelial damage due to increased stresses that is experienced at this bifurcation so the carotid artery bifurcation normally occurs at the level of c3 and c4 if your positioning on a panoramic radiograph is correct this closely corresponds to the area of the highway bone as well so we normally find these calcifications in next to the cervical spine in the soft tissue of the neck at the level of c3 and c4 it has a typical linear-like calcification where you can see the artherosclerotic blocks that are deposited on the wall calcify and as i already mentioned it is extremely important to identify these calcifications and refer the patients for appropriate management as the patients are at risk for cerebrovascular events such as a stroke or heart attack so this is just a example of how to um locate the area commonly affected by carotid artery calcifications so here we have our dens of our c2 that is situated within the um the atlas of c1 this will represent c3 and c4 so typically in this rough area and then also it is important that the calcification is in the soft tissue of the neck so typically there you can see a calcification so the problem with calcifications in the karate artery is you will not be able to see them unless you go look for them very often when you do a radiological interpretation with me you will see that the first thing i do is i lighten the periphery i do that in order to look for any calcifications when the periphery is dark like in this radiograph it is impossible to detect calcifications you need to go highlight or lighten that area here you can see that the soft tissue of the neck is roughly in this region and then you can see this typical linear-like calcifications that are deposited on the walls this side looks a little bit more irregular but this on the left-hand side we have a classical appearance of carotid artery calcifications just want to remove this to show you again the very linear-like form of calcifications as if the calcifications are deposited on the walls of the artery this is a coronal cb ct scan and here you can also then identify calcifications within the arteries you can see this in many many different regions this representing the external carotid artery and the internal carotid artery this is just an interesting case not something that i will test you on in a test situation but this patient we noted on the cbct scan a track like calcification from the three dimensional reconstructions we could see that it was located on a lateral aspect of the jaw and even on the coronal sides you can see it here so this is a case where a patient had calcifications within their facial artery so the next form of calcification that we will talk about is idiopathic calcification and this is calcification that cannot be attributed to a known cause so before we go on to that i think it's very important that we just recap some of your anatomy first of all we will look mainly from the side because this is how it will present on a panoramic radiograph if you remember the posterior dorsum of the tongue will go up and terminate into our epiglottis okay now sometimes we can see where the thyroid cartilage calcifies and what we will typically see is we will only see roughly up until that point this small cartilage that you see there is called the triticus cartilage true so this tradicuous cartilage is very often seen on panoramic radiographs and it's very important that these types of calcification is not mistaken for calcifications of the carotid artery as they occur in the same region but they do not have the same presentation calcification of your thyroid cartilage and your tradicuous cartilage have a typical eye shaped presentation all right so this is a radiograph that we will discuss you will see bilateral maxillary sinus pneumatization with a dome-shaped soft tissue swelling in the left and axillary sinus that resembles an annual pseudocyst here we can see our high weight bone and below the hyoid bone we have a very round like structure with a linear structure directly underneath it i'm going to erase it so that you can see more clearly so even though it might seem like it is in the soft tissue of the neck it is close to the c3c4 area it has a different pattern of calcification a round with linear type of calcific pattern of calcification so this is indicative of carotid excuse me of thyroid cartilage calcification as well as straticus cartilage calcification here's another example where you can see a little bit more of the thyroid was calcified where we have the typical a i shaped as long as well as more of the base of the thyroid cartilage that also calcified you will see that in a majority of the cases the thyroid and cheticuous cartilage will be far below the thyroid bone whereas our carotid artery calcifications are normally quite close to the highway bone if your position was correct this is another case where you can see typical linear and circular type of calcification that resembles your thyroid and your traticuous cartilage calcification you can see this occurring bilaterally in the periphery another example where we have this typical linear like calcification with more of the base of the thyroid cartilage that is also visible we find these calcifications quite far below the highway bone whereas carotid artery calcifications is quite close to the hyoid bone if your positioning was correct another form of idiopathic calcification is a cyalolith which is a stone within the salivary gland so your textbook in radiology often classifies this as idiopathic calcification but i am of a different opinion i believe that it can in some instances represent a form of dystrophic calcification where you have calcification around essential nidas or bacteria that can be found especially when there's decreased in salivary flow um such as in cases where this obstruction or even if there is bacterial infection so cyalolyths is normally found in the ducts of salivary gland and we most often see calcifications occurring within the submandibular salivary gland due to a very specific reason the submandibular gland has got thick mucous secretions and also a long tortuous upward path of the waters duct the combination of the thick secretions as well as the long duct of drainage puts this gland in the ideal situation for the formation of calcifications patients often can either be asymptomatic or they can present with intermittent pain and swallowing especially at meal times again it is important to familiarize yourself on the location of your major salivary glands the parotid roughly overlying the posterior area of uramus sublingual is a little bit higher up and we often see it uh bilaterally close to the mandibular anterior teeth and our submandibular is situated a little bit lower down close to the molar regions but then it's also important to remember where your duct drains in each instance because a calcification can occur anywhere along the drainage duct of a salivary gland so cyanolymphs typically have a homogeneous form of calcification most often they can present as round calcifications so if you look at the panoramic radiograph your sublinguals library glands will be roughly in this area submandibular glands can be found in your submandibular gland fossa area and then your parotids roughly in this area so this calcification is a sciatica of the right submandibular salivary gland we can see sciatica lifts beautifully on occlusal projections it is another view that you can then acquire to determine whether that calcification that we just saw was located baccaline which and then in that instance it can represent the lymph node or lingually which means it represents a salivary gland stone just to point out how you can beautifully see the genial tubercles on this mandeville occlusal projection this was a case that we saw in the clinic downstairs and the patient presented with a painful swelling and on the radiograph we noted in the fourth quadrant that there was a well-defined radiopaque lesion that was roughly in the 4-3-2-4-7 area so the first thing that we needed to do is we needed to determine is this lesion situated within bone meaning it's a bony lesion or was it situated within the soft tissue so we did an occlusal projection from the occlusal projection that we performed with our digital sensors we could clearly see that the structure was located on the lingual surface of the jaws which meant that it was a calcification in the submandibularis library gland the salivary gland stone was then subsequently removed this is another example of a radiograph and although this calcification is quite small and difficult to detect i put in this radiograph to point out that you need to go look for calcifications in order to find them they won't always jump out to you so here we can see on the right hand side close to where the hyoid bone is situated we see a small calcified structure overlying the right mandibular corpus it is situated within the submandibular gland fossa and therefore is most likely to be a calcification in your right submandibular gland this is another example of a calcification it was located a little bit more posteriorly we could not perform an occlusal projection due to the posterior nature of this structure so we took a cbct scan on the cbct scan from our coronal axial and three-dimensional images we could see that the calcification was located on the lingual side of the jaw and therefore represented a calcification in your left submandibular library gland again another radiograph to show you that calcifications will not always jump out you need to train your eye to look for them very very carefully here we can see two small calcifications that overlies the right mandibular inferior border in the region of the four seven which most of um in most instances will represent calcification either in the lymph node or in the submandibular library gland so in this instance because it's not characteristic we can only provide a differential diagnosis this is another beautiful case that we saw in our clinic so the patient was sent to radiology not for any major problems or pathology on the radiograph we noted that there was a radio page structure that overlies the three three three four area so at this point there was a differential diagnosis of this either being an impacted supernumerary teeth or a calcification within the salivary gland so the first thing we did is we took an occlusal radiograph with our digital sensors from the occlusal radiograph it was easy to see that this structure is definitely located outside of the bone and it's not situated in bone therefore this radial opaque structure was then diagnosed as a cyalolith found in the duct of the submandibular gland this is just another interesting case that i want to show you so firstly there's another form of calcifications that i want to make you aware of this forms part of dystrophic calcifications as you can see if you look closely at the cbct images and the superficial layer of this patient's skin you see these small calcifications small irregular calcifications these are calcifications that we normally find in chronic acne scars a patient that had acne which is a form of inflammation and then they typically undergo dystrophic calcifications the radiology textbooks refer to this as osteoma cutis but the term is not really um very descriptive so therefore we just refer to it as calcifications found in old acne scars interestingly on this coronal cb ct we can also see conchol belosa which is where the nasal conquer exhibits this airfield or sinus formation bilaterally this patient then also presented with numerous calcifications that were found in the parotid region on both sides so you can also note on the three-dimensional reconstruction that the patient was also swollen and this most likely represented some sort of salivary gland disease such as shrogens or even something that can represent hiv-associated library plant disease this is just for interest sake and this is not on the level of an undergraduate student another form of idiopathic calcification that you need to be aware of is calcifications that occur in within um veins which we refer to as flavor lifts so flavourless represents intravascular thrombine and this occurs normally due to venous stagnation meaning a decrease in the flow of blood it often signals the presence of a hemangioma when sometimes we can also see it in vascular malformations typically it has got a bull eye or target-like appearance and they appear to be more numerous in comparison to other calcifications this is an example where you see these multiple round bull eye type of calcifications so you need to go investigate whether this patient has got a hemangioma another form of idiopathic calcification is the calcifications that we can either find within our antrums or meaning on auxiliary sinuses or even our nasal cavity referred to as rhinolists so this is due to the deposition of calcium salts around essential nitrous which can be a foreign body root fragment blood clots inflammation and also remember you get a fungal ball which can then also calcify and become [Music] then referred to as an anchor antroloth and we frequently see this in the fungal bone formed by aspergillosis or an aspergilloma this you will learn more about in your pathology lectures so here on this radiograph we can see a small calcification within the right maxillary sinus your textbook still refers to it as idiopathic calcification but just remember when there is the deposition of calcium around essential nitrous me associated with inflammation it actually represents a form of dystrophic calcification this is another example of a panoramic radiograph where we then can see an anterolith in the right maxillary sinus again this is a coronal cb ct scan where we can see that the left maxillary sinus um is filled with mucus it exhibits mucosal thickening and then you find a central area of calcification again in this instance i would classify this as a form of dystrophic rather than idiopathic calcification another example of a large calcification found in the right maxillary sinus you should for these types of patients investigate whether this doesn't represent a aspergilloma that eventually calcified and and that you will be able to do with exploring the maxillary sinus surgically let's now talk about metastatic calcification metastatic calcification is where there is a metabolic problem meaning there's a high level of calcium or phosphate levels in the blood this could be caused by various conditions such as hyperparathyroidism you know from pathology you will be learn about the primary and secondary hyperparathyroidism it could be due to hypercalcemia due to a malignancy resulting in a lot of bone destruction such as the cases of multiple myeloma so hyperparathyroidism i'm not going to go into a lot of detail regarding this because this will be covered in your pathology lectures and we won't test you on it in radiology but it will be important if you see a patient with numerous calcifications to always be aware that metastatic calcifications could be a possible cause and that will then warrant any further investigations again hyperparathyroidism just an easy way to remember it it is a disease of stone bones and groans stones mean there's a lot of metastatic calcification the deposition in soft tissues bones there's subperiosteal resorption of your phalanges and middle finger and also you get brown tumors from hyperparathyroidism and then groans it is associated with a lot of duodenal ulcers now we talk about heterotropic ossification and this is ossification meaning that the deposition of the calcium and minerals is an organized fashion that the structure will then resemble a bone so we're going to talk about ossification of your stylo highway ligament it is important that you know that we very frequently see calcification of your stylohyoid ligament but it does not mean that all of this patient has got eagle syndrome it is only called eagle syndrome if the patient is symptomatic and the symptoms that we see associated with this form of calcification is cranial nerve impingement which means pain upon swallowing and carotid artery impingement meaning if the patient abruptly turns their head it might impinge on the carotid artery and cut off blood supply to the head and then the patient will faint so again it is important to understand your anatomy and i hope that i only have to say this once and you guys will listen and learn the styloid bone is a normal bone that each of us have in our body it is normal up to about three centimeters if it is larger than three centimeters then you refer to it as where the ligament starts to calcify so there's two ligaments that attach to your styloid process one going to the mandible meaning your stylum and dibaly ligament and one going to the higher weight bone meaning your style highway ligament just important here you can see on this um illustration the anatomy of the hyoid bone as well as then your thyroid cartilage which always shows that the thyroid cartilage will always be below the heroic bone this is just a slice from a ct to show you the calcification of your style or highway ligament so a normal styloid process will be roughly about this length but this is where the ligaments started to calcify all the way up to the hyoid bone we get three different types of calcification of this ligament the first type is where there is continuous calcification of the ligament to the thyroid bone type 2 where this calcification where it almost looks like these bony projections form joint like structures and also we get interrupted calcification where the calcification of the ligament is not continuous but it is interrupted very often we will see the normal styloid process and just a small part of the ligament at the inferior portion calcifying it is still a form of interrupted calcification of your stylo highway ligament this is a radiograph to show you where this calcification of your stylohyoid ligament mainly a type one on your right hand side where it's continuous and then on the left hand side here we see the styloid process right and then approximate the angle and the thyroid bone we see another piece so this will be classified as type 1 or continuous calcification of your styloid ligament and this will be classified as type 3 interrupted calcification of your stylo highway ligament this is another beautiful example on this radiograph we can see a lot of calcifications firstly we see multiple spec-like calcifications overlying the right and left ramus area this is indicative of calcification of your palatine tonsils we also see some calcifications a little bit lower down approximate the angle of the mandible also multiple specular calcifications and this resembles calcifications in your lingual tonsil we also see an irregular calcification situated on the left-hand side next to the c-spine within the soft tissue of the neck and this could be indicative of carotid artery calcifications and then finally we see this linear calcification in the right periphery and we also see a little bit here in the left-hand side and this represents interrupted calcification of the left and the right style of high weight ligament just another beautiful radiograph here we see an elongated styloid process and then continuous calcification of your right style of highway ligament this is an image from your textbook just to show you what the typical pattern as well as location of calcifications will look like to answer this overlying the ramus being multiple specular calcifications calcification of your triticus and thyroid cartilage having a typical eye-like appearance below the hyoid bone ossification of your styloid ligament linear pattern going from the styloid process to your high weight bone calcifications in the carotid artery being linear plaque-like calcifications in the soft tissue of the neck next to the c-spine an antrolith will present within either the maxillary sinuses and then finally flebolifts which are example of bull target-like appearances normally found in areas where that is affected by hemangioma okay lastly or second lastly lymph nodes has a typical cauliflower-like appearance appearing at the area where we expect to see lymph nodes sub-mental submandibular deep cervical superficial cervical parotid pre-auricular posterior auricular and then cyalolives in the submandibular salire gland most often either within the gland itself or in the drainage duct so that is the end for this lecture on soft tissue calcifications because every patient's anatomy is unique and every form of calcification is unique in its pattern and location the only way to properly nail this topic is to look at as much radiographs as you can and try to identify as many calcifications when you interpret in the radiology ward as always if you have got any questions you are welcome to send me an email good luck with all of the studying