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Radiology Quiz Case 2: Diagnosis

Radiology Quiz Case 2: Diagnosis Diagnosis: Acute calcific tendinitis of the longus colli (also known as calcific retropharyngeal/prevertebral tendinitis) Originally described by Hartley1 in 1964, acute calcific tendinitis of the longus colli is a benign, uncommon, and often underrecognized cause of acute neck pain due to calcium hydroxyapatite deposition in the tendon of the longus colli, with reactive inflammation of the longus colli muscle.1,2 The peak incidence occurs in patients aged between 30 and 60 years but has been reported within an age range of 21 to 81 years.3 It more commonly occurs in other areas of the body, such as the hips or shoulders (eg, calcific tendenitis of the supraspinatus tendon).4 The etiology of calcium hydroxyapatite deposition remains unclear, but it has been suggested that injury or ischemia may be involved. The foreign body–like inflammatory reaction, potentially caused by rupture of calcific crystals, may result in edema or fluid collection within the retropharyngeal or prevertebral space surrounding the muscle.2,4 Acute calcific tendinitis of the longus colli is largely underdiagnosed and often confused with infectious, neoplastic, or traumatic conditions.2 The most common erroneous diagnosis is retropharyngeal abscess or phlegmon, which presents with a similar clinical picture. Presenting symptoms may include any or all of the following: acute or subacute onset of neck pain, neck stiffness, dysphagia, odynophagia, sore throat, and low-grade fever.2,5 Worsening of pain on head turning, neck flexion, and especially extension is typical. Furthermore, the condition may be precipitated by a recent upper respiratory tract infection or trauma to the head and neck region. Physical examination typically demonstrates pharyngeal soft-tissue edema with mild erythema and cervical paraspinal muscle spasms on slight neck flexion and a limited range of motion because of pain. Laboratory evaluation may reveal mild leukocytosis, elevated C-reactive protein levels, and a mildly increased erythrocyte sedimentation rate.2,6 Though difficult to distinguish from retropharyngeal infection or abscess based on history, examination, and laboratory findings, the diagnosis of acute calcific tendinitis is best discerned radiographically. The classic finding is the presence of amorphous globular or linear calcified densities at or near the attachment of the longus colli muscle to the cervical vertebrae, most commonly at the C1-C2 level.6 Although the present case may represent a subtle example of such calcification, the location of the calcified density correlated exactly to the muscle attachment, as shown in Figures 1 and 2. Nonspecific diffuse soft-tissue edema in the prevertebral or retropharyngeal soft tissues typically occurs from C1 to C4 but potentially extends as inferiorly as C6.7 Computed tomography is the most sensitive and specific imaging modality in establishing the diagnosis, with the advantages of contrast resolution, multiplanar imaging, and the ability to detect subtle calcification. The diagnosis may not be fully recognized on plain film if the calcification is not sufficiently dense. The severity of the symptoms does not necessarily correlate with the degree of calcium deposition.8 Fluid collection, if present, as shown in Figure 3, is typically linear or lenticular and will lack a rim of enhancement, which helps to distinguish the reactive effusion from an abscess.5 Other corroborating imaging findings include the absence of suppurative inflammatory retropharyngeal lymph nodes and the absence of destructive changes in the cervical vertebrae.8 Magnetic resonance imaging adequately reveals inflammation involving and surrounding the longus colli muscle, but it less sensitive than CT in the detection of calcification. This type of imaging, however, would be prudent to use in the event of negative CT findings to look for other disorders with similar symptoms, such as those affecting the vertebral discs, spinal cord, ligaments, or other soft tissues.9 Acute calcific tendinitis of the longus colli is a self-limiting condition that typically resolves within a few weeks after the onset of symptoms. Treatment focuses on conservative management with the use of nonsteroidal anti-inflammatory agents for both their analgesic and their anti-inflammatory properties, with the occasional use of systemic corticosteroids in severe cases.2 Physical rest, with the avoidance of neck movements that may exacerbate the pain, is recommended to hasten recovery. The treatment described herein led to the resolution of our patient's symptoms in 3 weeks, with no further sequelae and no need for corticosteroid therapy. Heightened awareness of this condition, with the appropriate radiographic diagnosis, may prevent unnecessary treatment such as prolonged antibiotic therapy, hospitalization, and surgical drainage. Return to Quiz Case. References 1. Hartley J. Acute cervical pain associated with retropharyngeal calcium deposit: a case report. J Bone Joint Surg Am. 1964;46:1753-175414239862PubMedGoogle Scholar 2. Ring D, Vaccaro AR, Scuderi G, Pathria MN, Garfin SR. Acute calcific retropharyngeal tendinitis: clinical presentation and pathological characterization. J Bone Joint Surg Am. 1994;76(11):1636-16427962023PubMedGoogle Scholar 3. Kaplan MJ, Eavey RD. Calcific tendinitis of the longus colli muscle. Ann Otol Rhinol Laryngol. 1984;93(3, pt 1):215-2196732105PubMedGoogle Scholar 4. Hayes CW, Conway WF. Calcium hydroxyapatite deposition disease. Radiographics. 1990;10(6):1031-10482175444PubMedGoogle Scholar 5. Eastwood JD, Hudgins PA, Malone D. Retropharyngeal effusion in acute calcific prevertebral tendinitis: diagnosis with CT and MR imaging. AJNR Am J Neuroradiol. 1998;19(9):1789-17929802506PubMedGoogle Scholar 6. De Maeseneer M, Vreugde S, Laureys S, Sartoris DJ, De Ridder F, Osteaux M. Calcific tendinitis of the longus colli muscle. Head Neck. 1997;19(6):545-5489278764PubMedGoogle ScholarCrossref 7. Fahlgren H. Retropharyngeal tendinitis: three probable cases with an unusually low epicentre. Cephalalgia. 1988;8(2):105-1103401912PubMedGoogle ScholarCrossref 8. Offiah CE, Hall E. Acute calcific tendinitis of the longus colli muscle: spectrum of CT appearances and anatomical correlation. Br J Radiol. 2009;82(978):e117-e12119451311PubMedGoogle ScholarCrossref 9. Schoenfeld AJ, Bono CM, McGuire KJ, Warholic N, Harris MB. Computed tomography alone versus computed tomography and magnetic resonance imaging in the identification of occult injuries to the cervical spine: a meta-analysis. J Trauma. 2010;68(1):109-11420065765PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Otolaryngology - Head & Neck Surgery American Medical Association

Radiology Quiz Case 2: Diagnosis

Archives of Otolaryngology - Head & Neck Surgery , Volume 138 (6) – Jun 1, 2012

Radiology Quiz Case 2: Diagnosis

Abstract

Diagnosis: Acute calcific tendinitis of the longus colli (also known as calcific retropharyngeal/prevertebral tendinitis) Originally described by Hartley1 in 1964, acute calcific tendinitis of the longus colli is a benign, uncommon, and often underrecognized cause of acute neck pain due to calcium hydroxyapatite deposition in the tendon of the longus colli, with reactive inflammation of the longus colli muscle.1,2 The peak incidence occurs in patients aged between 30 and 60 years but has been...
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Publisher
American Medical Association
Copyright
Copyright © 2012 American Medical Association. All Rights Reserved.
ISSN
0886-4470
eISSN
1538-361X
DOI
10.1001/archoto.2012.519b
Publisher site
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Abstract

Diagnosis: Acute calcific tendinitis of the longus colli (also known as calcific retropharyngeal/prevertebral tendinitis) Originally described by Hartley1 in 1964, acute calcific tendinitis of the longus colli is a benign, uncommon, and often underrecognized cause of acute neck pain due to calcium hydroxyapatite deposition in the tendon of the longus colli, with reactive inflammation of the longus colli muscle.1,2 The peak incidence occurs in patients aged between 30 and 60 years but has been reported within an age range of 21 to 81 years.3 It more commonly occurs in other areas of the body, such as the hips or shoulders (eg, calcific tendenitis of the supraspinatus tendon).4 The etiology of calcium hydroxyapatite deposition remains unclear, but it has been suggested that injury or ischemia may be involved. The foreign body–like inflammatory reaction, potentially caused by rupture of calcific crystals, may result in edema or fluid collection within the retropharyngeal or prevertebral space surrounding the muscle.2,4 Acute calcific tendinitis of the longus colli is largely underdiagnosed and often confused with infectious, neoplastic, or traumatic conditions.2 The most common erroneous diagnosis is retropharyngeal abscess or phlegmon, which presents with a similar clinical picture. Presenting symptoms may include any or all of the following: acute or subacute onset of neck pain, neck stiffness, dysphagia, odynophagia, sore throat, and low-grade fever.2,5 Worsening of pain on head turning, neck flexion, and especially extension is typical. Furthermore, the condition may be precipitated by a recent upper respiratory tract infection or trauma to the head and neck region. Physical examination typically demonstrates pharyngeal soft-tissue edema with mild erythema and cervical paraspinal muscle spasms on slight neck flexion and a limited range of motion because of pain. Laboratory evaluation may reveal mild leukocytosis, elevated C-reactive protein levels, and a mildly increased erythrocyte sedimentation rate.2,6 Though difficult to distinguish from retropharyngeal infection or abscess based on history, examination, and laboratory findings, the diagnosis of acute calcific tendinitis is best discerned radiographically. The classic finding is the presence of amorphous globular or linear calcified densities at or near the attachment of the longus colli muscle to the cervical vertebrae, most commonly at the C1-C2 level.6 Although the present case may represent a subtle example of such calcification, the location of the calcified density correlated exactly to the muscle attachment, as shown in Figures 1 and 2. Nonspecific diffuse soft-tissue edema in the prevertebral or retropharyngeal soft tissues typically occurs from C1 to C4 but potentially extends as inferiorly as C6.7 Computed tomography is the most sensitive and specific imaging modality in establishing the diagnosis, with the advantages of contrast resolution, multiplanar imaging, and the ability to detect subtle calcification. The diagnosis may not be fully recognized on plain film if the calcification is not sufficiently dense. The severity of the symptoms does not necessarily correlate with the degree of calcium deposition.8 Fluid collection, if present, as shown in Figure 3, is typically linear or lenticular and will lack a rim of enhancement, which helps to distinguish the reactive effusion from an abscess.5 Other corroborating imaging findings include the absence of suppurative inflammatory retropharyngeal lymph nodes and the absence of destructive changes in the cervical vertebrae.8 Magnetic resonance imaging adequately reveals inflammation involving and surrounding the longus colli muscle, but it less sensitive than CT in the detection of calcification. This type of imaging, however, would be prudent to use in the event of negative CT findings to look for other disorders with similar symptoms, such as those affecting the vertebral discs, spinal cord, ligaments, or other soft tissues.9 Acute calcific tendinitis of the longus colli is a self-limiting condition that typically resolves within a few weeks after the onset of symptoms. Treatment focuses on conservative management with the use of nonsteroidal anti-inflammatory agents for both their analgesic and their anti-inflammatory properties, with the occasional use of systemic corticosteroids in severe cases.2 Physical rest, with the avoidance of neck movements that may exacerbate the pain, is recommended to hasten recovery. The treatment described herein led to the resolution of our patient's symptoms in 3 weeks, with no further sequelae and no need for corticosteroid therapy. Heightened awareness of this condition, with the appropriate radiographic diagnosis, may prevent unnecessary treatment such as prolonged antibiotic therapy, hospitalization, and surgical drainage. Return to Quiz Case. References 1. Hartley J. Acute cervical pain associated with retropharyngeal calcium deposit: a case report. J Bone Joint Surg Am. 1964;46:1753-175414239862PubMedGoogle Scholar 2. Ring D, Vaccaro AR, Scuderi G, Pathria MN, Garfin SR. Acute calcific retropharyngeal tendinitis: clinical presentation and pathological characterization. J Bone Joint Surg Am. 1994;76(11):1636-16427962023PubMedGoogle Scholar 3. Kaplan MJ, Eavey RD. Calcific tendinitis of the longus colli muscle. Ann Otol Rhinol Laryngol. 1984;93(3, pt 1):215-2196732105PubMedGoogle Scholar 4. Hayes CW, Conway WF. Calcium hydroxyapatite deposition disease. Radiographics. 1990;10(6):1031-10482175444PubMedGoogle Scholar 5. Eastwood JD, Hudgins PA, Malone D. Retropharyngeal effusion in acute calcific prevertebral tendinitis: diagnosis with CT and MR imaging. AJNR Am J Neuroradiol. 1998;19(9):1789-17929802506PubMedGoogle Scholar 6. De Maeseneer M, Vreugde S, Laureys S, Sartoris DJ, De Ridder F, Osteaux M. Calcific tendinitis of the longus colli muscle. Head Neck. 1997;19(6):545-5489278764PubMedGoogle ScholarCrossref 7. Fahlgren H. Retropharyngeal tendinitis: three probable cases with an unusually low epicentre. Cephalalgia. 1988;8(2):105-1103401912PubMedGoogle ScholarCrossref 8. Offiah CE, Hall E. Acute calcific tendinitis of the longus colli muscle: spectrum of CT appearances and anatomical correlation. Br J Radiol. 2009;82(978):e117-e12119451311PubMedGoogle ScholarCrossref 9. Schoenfeld AJ, Bono CM, McGuire KJ, Warholic N, Harris MB. Computed tomography alone versus computed tomography and magnetic resonance imaging in the identification of occult injuries to the cervical spine: a meta-analysis. J Trauma. 2010;68(1):109-11420065765PubMedGoogle ScholarCrossref

Journal

Archives of Otolaryngology - Head & Neck SurgeryAmerican Medical Association

Published: Jun 1, 2012

Keywords: radiology specialty,longus colli muscle,calcific tendinitis

References