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Age / Sex : /
Age/Sex: 44/M
C.C.: Acute neck pain and difficulty in opening the mouth
onset) 3 days ago
1) What is your impression? Two weeks later, you can see the final diagnosis with a brief discussion of this case.
* Send Application Answers to Ja-Young Choi, MD (drchoi01@radiol.snu.ac.kr).
Courtesy : Moon Sung Gyu, MD. Department of Radiology, Konkuk University Hospital.
Diagnosis: retrophalangeal calcific tendinitis
Discussion
Findings:
Lateral plain radiograph of cervical spines reveals characteristic amorphous calcification anterior to C1-C2 and prevertebral soft tissue thickening. Sagittal T2 and T1 WI demonstrates a prevertebral effusion spainning C1-C5 and a signal void representing an amorphous calcification anteroinferior to the anterior arch of C1. Axial T2 WI shows splaying of the longus colli muscle as a result of the effusion. Follow-up sagittal images after 15 days reveals a normal examination with complete resolution of the calcification and prevertebral soft tissue edema.
Differential Diagnosis:
Retropharyngeal abscess
Traumatic injury
Infectious spondylitis
Discussion:
Retropharyngeal calcific tendinitis is an uncommon benign condition caused by calcium hydroxyapatite deposition in the superior oblique tendon fibers of the longus colli tendon and inflammation of the longus colli muscle. The longus colli muscle is one of the four muscles comprising the anterior vertebral muscles. The entire muscle lies anterior to the cervical and upper thoracic vertebrae spanning C1–T3. The anterior vertebral muscles lie within the prevertebral space, and are separated from the anteriorly situated potential retropharyngeal space by a fascial plane, known as the prevertebral layer of the deep cervical fascia. The term ‘‘retropharyngeal calcific tendinitis’’ may be somewhat misleading as the disease actually begins within the prevertebral space, sometimes but not always extending into the retropharyngeal space. Hence, this condition is sometimes referred to as acute calcific prevertebral tendinitis or longus colli tendinitis.
The clinical presentation is often non-specific characterized by spontaneous acute or subacute neck pain, dysphagia or odynophagia, and low-grade fever.
Laboratory tests may demonstrate a mild leukocytosis and slightly elevated ESR.
The principal radiographic findings of retropharyngeal calcific tendinitis include prevertebral soft tissue swelling, and amorphous calcification anterior to C1–C2. The diffuse prevertebral soft tissue thickening typically extends from C1 to C4, although it can extend as inferiorly to C6. The soft tissue thickening represents either a discrete effusion or diffuse edema, which can be differentiated on CT or MRI. An effusion can splay these muscles and localize the fluid within the prevertebral space. This should not be confused with a collection in the retropharyngeal space. The lack of enhancement surrounding the effusion is helpful in differentiating a reactive effusion from an abscess. CT with its superior spatial resolution helps to identify the amorphous calcification, which can often appear quite faint on plain film. If there is a coincidental history of recent trauma, CT can also rule out the possibility of an avulsed fracture, which may mimic a similar appearance. MRI is not typically necessary for this diagnosis, but can sometimes demonstrate marrow edema in the adjacent vertebrae
Retropharyngeal calcific tendinitis is a self-limiting condition and spontaneously resolves after 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.
References:
1. Chung T, Rebello R, Gooden EA. Retropharyngeal calcific tendinitis: case report and review of literature. Emerg Radiol. 2005 Nov;11(6):375-80. Epub 2005 Jul 15. Review
2. Eastwood JD, Hudgins PA, Malone D. Retropharyngeal effusion in acute calcific prevertebral tendinitis: diagnosis with CT and MR imaging. AJNR Am J Neuroradiol. 1998 Oct;19(9):1789-92.
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