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Dentomaxillofacial Radiology (2008) 37, 121–124 ’ 2008 The British Institute of Radiology http://dmfr.birjournals.org CASE REPORT Acute calcific tendinitis of the longus colli: an imaging diagnosis SK Ellika1, SC Payne2, SC Patel1 and R Jain*,1 1 Division of Neuroradiology, Department of Radiology, Henry Ford Hospital, Detroit, MI, USA; 2Department of Otolaryngology, Henry Ford Hospital, Detroit, MI, USA Acute calcific retropharyngeal tendinitis or longus colli tendinitis is an uncommon benign condition presenting as acute neck pain. Clinically, it can be misdiagnosed as retropharyngeal abscess, traumatic injury, or infectious spondylitis. The diagnosis is made radiographically by calcification anterior to C1–C2 and prevertebral soft-tissue swelling. We present two cases of this uncommon condition to illustrate the classic findings on CT and MRI. In addition to the typical calcifications anterior to C1–C2, we detected a retropharyngeal effusion in both patients and effusions involving both lateral atlantoaxial joints in one patient, which to our knowledge has not been published in the literature. In both patients, the correct diagnosis was established by prospective review of the radiographic studies. Recognition of the pathognomonic imaging appearance allows for easy diagnosis preventing unnecessary tests and treatment. Dentomaxillofacial Radiology (2008) 37, 121–124. doi: 10.1259/dmfr/23211511 Keywords: calcific tendinitis; longus colli; retropharyngeal effusion; computed tomography; magnetic resonance imaging Introduction Case reports Acute calcific tendinitis of the longus colli muscle is an inflammatory condition caused by deposition of calcium hydroxyapatite crystals in the superior oblique tendon of the longus colli muscle. It is an uncommon cause of pain and stiffness in the neck associated with odynophagia and retropharyngeal soft tissue swelling. Imaging findings and clinical presentation should both be used in differentiating acute calcific longus colli tendinitis (LCT) from retropharyngeal abscess, infectious or inflammatory spondylitis, traumatic injury, or foreign body aspiration. Plain radiographs, CT and MRI can help make the correct diagnosis and help prevent extensive work-up and surgical exploration. We present here two cases in which an imaging diagnosis of LCT was made. One of the patients also had reactive effusion of the lateral atlantoaxial joints, which has not been previously described in the literature. Case 1 A 35-year-old man presented to an affiliated emergency department with a 3 day history of neck pain that was described as dull in nature and exacerbated by neck movements. Recent onset of sore throat and odynophagia was also reported. No history of recent trauma, diabetes or other medical history was elicited except that he was a fork-lift operator and his work involved repeated flexion and extension of the neck. Cervical spine radiographs were obtained, revealing increased thickness of the prevertebral soft tissues. The patient was transferred to our institution with the possible diagnosis of retropharyngeal abscess to be evaluated by crosssectional imaging. His temperature was 37.2˚C and other vital signs were normal. On examination, he had limited neck motion with tenderness but no lymphadenopathy. Palatine tonsillar hypertrophy and mild pharyngeal crowding with no overt oedema or erythema was noted on oral examination. The white blood cell count (WBC) was mildly elevated to 12 000 mm23 with no increase in neutrophil or band counts. A contrast-enhanced CT scan of the neck was obtained, which demonstrated prevertebral space oedema and effusion without obvious abscess formation or rim enhancement. Amorphous *Correspondence to: Rajan Jain, Senior Staff, Department of Radiology, Division of Neuroradiology, Henry Ford Health Systems, 2799 West Grand Blvd, Detroit 48202, MI, USA; Email: [email protected] Received 23 February 2007; revised 11 April 2007; accepted 11 April 2007 Acute calcific tendinitis of the longus colli SK Ellika et al 122 calcification was noted at the insertion of the superior oblique tendon of the longus colli muscles anterior to the anterior arch of C1. There were no imaging findings to suggest infectious spondylitis or discitis osteomyelitis. A diagnosis of acute calcific LCT was made and the patient was discharged on non-steroidal anti-inflammatory medication. His symptoms resolved completely in 3 days. Case 2 A 41-year-old woman with a 2 day history of neck stiffness, headache and dysphagia presented to the emergency department. A past history of trauma, diabetes or recent upper respiratory tract infection was negative. On arrival her temperature was 37.4 ˚C and she had a mildly elevated WBC of 11 600 mm23 with a differential count showing a very minimal increase in neutrophil count. Endoscopic examination was negative for erythema or exudate, but mild symmetric oedema of the posterior pharyngeal wall was noted. Lateral neck radiograph revealed prevertebral soft tissue swelling and a contrast-enhanced the CT scan of the neck was performed. A fluid collection smoothly expanding the retropharyngeal space without rim enhancement extending from the C1 to C5 levels was noted. Calcification was seen within the superior oblique tendon of longus colli anterior to the C1 arch (Figure 1). She had had another CT of the cervical spine performed 2 years prior to the present event for an unrelated motor vehicle accident and review of the previous CT did not show any calcification at the insertion of the superior oblique tendon of longus colli, suggesting interval deposition of calcium hydroxyapatite crystals. Sagittal T2 weighted fast-spin echo MR images (repetition time 3500/echo time 124) showed an area of high signal intensity extending from the skull base to the inferior border of C5 suggestive of prevertebral oedema/effusion (Figure 2). T2 weighted images also demonstrated joint effusion involving the Figure 1 Axial CT scan showing dense calcification (long arrow) within the superior oblique tendon of the left longus colli muscle at the C1–C2 level; calcific deposits are also noted around the left side of the odontoid process (short arrow) Dentomaxillofacial Radiology Figure 2 Sagittal T2 weighted MR image showing retropharyngeal fluid (long arrows) with acute inferior margin (curved arrow) extending from the skull base to the inferior border of C5 and hypointense calcifications in the longus colli tendon (short arrow) lateral atlantoaxial joints bilaterally in addition to oedema of the longus colli muscle (Figure 3). The calcification exhibited hypointense signal intensity on the T2 weighted sequences (Figure 4). No enhancement of prevertebral soft tissues or disc space was noted on the post-contrast scans to suggest an infectious spondylitis. She showed significant clinical improvement after 1 week of therapy with oral administration of non-steroidal anti-inflammatory agents. Discussion The prevertebral space is limited anteriorly by the deep layer of deep cervical fascia, which separates it from the retropharyngeal space containing fat and lymph nodes. Figure 3 T2 weighted axial MR image at the level of the atlantoaxial joints shows bilateral joint effusions (long arrows) with the enlarged and oedematous tendon of the left longus colli muscle noted anterior to the body of the C2 vertebra (short arrow) Acute calcific tendinitis of the longus colli SK Ellika et al Figure 4 T2 weighted axial MR image showing swelling and oedema of the left longus colli muscle (long arrow) with hypointense calcifications (short arrow) The longus colli muscle is a paired neck muscle that originates from the bodies of the C3–C7 and T1–T3 vertebrae, and inserts along bodies of the C2–C4 and anterior tubercles of C1–C6 vertebrae. The muscle is formed by vertical, inferior oblique and superior oblique portions. The superior oblique portion, which arises from the anterior tubercles of the transverse processes of C3–C5 and inserts into the anterior tubercle of the atlas, is the one that becomes involved in acute LCT.1,2 LCT is a clinical syndrome that was originally described by Hartley in 19643 and usually affects patients who are mostly between 30 years and 60 years of age with no gender predilection.4 Ring et al in 19945 showed this condition to be due to calcium hydroxyapatite deposition in the longus colli tendon and a foreign-body inflammatory response to the crystals was demonstrated in the tissue specimen taken from the prevertebral space.5 The most frequent presentation is neck pain, neck rigidity, dysphagia, odynophagia and headache. In some cases, there may be a low-grade fever perhaps secondary to an inflammatory response. Laboratory data are usually normal, but inflammatory changes may be observed with elevated erythrocyte sedimentation rates and mildly elevated white blood cell counts.6 Clinical presentation can be confused with retropharyngeal abscess, infectious spondylitis, trauma, or foreign body aspiration; however, awareness of acute LCT, particularly in the emergency rooms, can be helpful. Cross-sectional imaging with CT or MRI can be diagnostic in the appropriate clinical setting. The pathognomonic radiographic findings consist of prevertebral soft tissue swelling typically extending from C1 to C4 and amorphous calcification anterior to C1–C2 at the insertion of the superior oblique tendon of the longus colli muscle.2,3,5,6–10 The appearance of the calcification varies from punctate to densely amorphous. The greater contrast resolution of CT makes it a more sensitive technique than plain 123 radiography for the detection and localization of calcification to the superior oblique fibres of the longus colli muscle, thus differentiating it from other causes of prevertebral densities such as fracture or extruded calcified disc.2,11 MRI, which is a superior imaging technique for the demonstration of soft tissue changes, may show oedema of the longus colli tendon and muscle along with retropharyngeal effusion and these are probably secondary to local inflammatory mediators.12 T2 weighted MR images may demonstrate a prevertebral high signal intensity which tends to extend beyond the region of calcification, suggestive of oedema and inflammatory changes of the muscle.13 On cursory inspection, an effusion if present may be confused with retropharyngeal abscess. Imaging features to distinguish this effusion from retropharyngeal abscess include uniform expansion of the retropharyngeal space by effusion, no peripheral enhancement around the effusion and absence of suppurative retropharyngeal lymphadenopathy associated with the effusion.12 CT and MRI can also help to rule out infectious spondylitis as the cause for prevertebral space swelling. Bone marrow signal abnormality in the adjacent C2 vertebra during an episode of longus colli tendinitis has, however, been recently reported,14 but was found to resolve completely on follow-up imaging suggesting an inflammatory aetiology. These marrow signal changes were thought to be due to direct continuity of the periodontoidal venous plexus and the suboccipital epidural sinuses with the pharyngovertebral veins which may facilitate haematogenous spread of retropharyngeal inflammation to the upper cervical vertebrae.14 Radiographic differential diagnostic considerations include vertebral fracture, anteriorly bowed transverse process, and calcified and protruded cervical disc. If there is a coincidental history of recent trauma, CT can rule out the possibility of an avulsed fracture since a bone fragment can be easily distinguished from the amorphous calcification associated with LCT. An anteriorly bowed transverse process can project anterior to the vertebral body on a lateral view of the cervical spine; however, careful evaluation of the lateral and oblique views on the cervical spine should lead to the correct diagnosis. CT is helpful in confirmation of the location of the calcifications and to differentiate them from other causes of prevertebral densities.11 One of the cases in the present study also showed effusion in the adjacent lateral atlantoaxial joints without any articular surface irregularity or joint destruction, which to our knowledge has not been described in the literature before with this entity. We think this is probably due to contiguous spread of prevertebral and retropharyngeal space inflammation to the upper cervical joints causing reactive sympathetic effusion, or could be due to intra-articular deposition of hydroxyapatite crystals. This patient had also had a CT scan for an unrelated reason 2 years prior to the present event that did not show any calcification at the superior Dentomaxillofacial Radiology Acute calcific tendinitis of the longus colli SK Ellika et al 124 oblique tendon insertion, suggesting interval deposition of the crystals. Calcium hydroxyapatite deposition disease (CHADD) typically involves the large joints, such as the hip or shoulder; however, it can also be located around the odontoid. The precise cause of CHADD is unknown. It has been speculated that crystal deposition in and around joints may be due to local or systemic metabolic disturbances such as those following injury, tissue necrosis, ischaemia, or repetitive trauma. A genetic predisposition and metabolic factors have also been suggested to play a role.11 These disturbances may raise solute concentration, cause the loss of local inhibitors of crystal growth and cause the presence of abnormal surfaces, all of which may promote crystal nucleation.15 Symptoms of LCT usually improve spontaneously over the course of 1–2 weeks. Conservative treatment with a short course of non-steroidal anti-inflammatory medications and avoidance of aggravating neck movements help to alleviate symptoms. Follow-up imaging is usually not necessary due to the self-limiting nature of this condition; however, if performed, this can be easily achieved with plain films which might show resolution of the characteristic findings of the amorphous calcification and prevertebral soft tissue swelling. Conclusion The diagnosis of acute LCT can be made based on characteristic imaging features in the appropriate clinical setting of neck pain, rigidity, restricted movements and headache associated with odynophagia without a history of trauma, particularly in an afebrile patient. Lateral radiograph and CT scan of the soft tissues of the neck may demonstrate characteristic prevertebral calcification at the C1–C2 level. MRI can better delineate prevertebral effusion and may also show oedema in the muscle with calcification at the tendinous insertion. Early diagnosis of this benign condition is important to avoid inappropriate surgical exploration to drain the fluid collection. References 1. 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