Age / Sex : 19 / M

Chief complaint: Swallowing difficulty

What is your impression?

Two weeks later, you can see the final diagnosis with a brief discussion of this case.

(답안은 한 개만 보내주시기 바랍니다)

Courtesy: 강병성 (Byeong Seong Kang), 울산대학교병원 (Ulsan University Hospital)

Retropharyngeal calcific tendinitis

Discussion

Findings:

1) Plain radiography

- A lateral view radiograph shows calcification anterior to C1-C2 and prevertebral soft tissue thickening.

2) CT

- Axial unenhanced CT of the cervical spine demonstrates calcification with right para-midline location anterior to C1-C2.

3) MR

- Sagittal T2- and T1-weighted MR images show a signal void representing an amorphous calcification anteroinferior to the anterior arch of C1 and a prevertebral edema spanning C1-C5. Sagittal contrast-enhanced fat-suppressed sagittal T1-weighted MR image shows non-enhancing low signal intensity calcification anterior to C1-C2 and heterogeneously enhancement anterior to C1-C5.

Differential Diagnosis:

Retropharyngeal calcific tendinitis / Retropharyngeal abscess / Infectious spondylitis

Diagnosis: Retropharyngeal calcific tendinitis

Discussion:

Acute calcific tendinitis of the longus colli muscle is an aseptic inflammatory process located in the cervical prevertebral space. The proposed pathogenesis of this entity is the deposition of calcium hydroxyapatite crystals at the C1–C3 vertebral level.

Usual imaging control consists of CT scan, MRI and plain radiography. CT scan is the gold standard for diagnosing this condition as it can detect both the prevertebral edema and calcium hydroxyapatite crystals deposition at the longus colli tendon. Furthermore, CT is considered the most sensitive imaging technique for distinguishing retropharyngeal tendinitis from retropharyngeal abscess. MRI can show the prevertebral edema and corresponding fluid effusion, whereas it is difficult to recognize the calcific deposits with this imaging method. Plain radiography may miss the calcareous deposition and the prevertebral soft-tissue swelling, since the edema rapidly disappears, or may not show any pathological signs.

Differential diagnosis between retropharyngeal tendinitis and other diseases showing similar clinical features, such as meningitis, retropharyngeal abscess, neoplasm, cervical disc herniation and fracture dislocation, is considered critical to avoid unnecessary interventions. The most important mimicker of longus colli tendinitis is retropharyngeal abscess. Despite showing the same clinical presentation, these two entities can be differentiated with a CT scan, the most appropriate method to reveal the characteristic calcareous deposition at the C1–C3 vertebral level.

References:

1. Zibis AH, Giannis D, Malizos KN, Kitsioulis P, Arvanitis DL. Acute calcific tendinitis of the longus colli muscle: case report and review of the literature. Eur Spine J 2013;22 Suppl 3:S434-8

2. Chung T, Rebello R, Gooden EA. Retropharyngeal calcific tendinitis: case report and review of literature. Emerg Radiol 2005;11:375-80

3. Park SY, Jin W, Lee SH, Park JS, Yang DM, Ryu KN. Acute retropharyngeal calcific tendinitis: a case report with unusual location of calcification. Skeletal Radiol 2010;39:817-20