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