Calcific Retropharyngeal Tendinitis of the Longus Colli Muscle. Answer To

Diagnostic and Interventional Imaging (2013) 94, 470—473

E-QUID : ANSWER / ENT

Calciﬁc retropharyngeal tendinitis of the longus colli

muscle. Answer to the e-quid ‘‘Acute cervical pain

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and dysphagia in a 43 year-old man’’

a,∗ b a

F. Desmots ,R.Derkenne ,N. Couppey ,

a a a

B. Martin , C. Gabaudan , Y. Geffroy

Service d’imagerie médicale, hôpital d’instruction des armées A.-Laveran, BP 60149, 13384

Marseille cedex 13, France

Service d’oto-rhino-laryngologie, hôpital d’instruction des armées A.-Laveran, BP 60149,

133384 Marseille cedex 13, France

Case report

A 43-year-old patient without noteworthy antecedents consulted his attending physician

for dysphagia and diffuse cervical pain that has been evolving for three days. The patient

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was sub-febrile (38 C). The clinical examination detected stiffness of the neck without

neurological disorder. The ORL examination did not detect any signiﬁcant anomaly, in

particular in the tonsil region. The lab tests revealed mild hyperleukocytosis (12,000 GB/L)

with neutrophils (11,000 G/L) and an ascension or C-reactive protein (60 mg/L). A cervical

scan with the injection of iodine-based contrast products was carried out (Figs. 1 and 2).

DOI of original article:http://dx.doi.org/10.1016/j.diii.2012.09.005.

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Here is the answer to the case ‘‘Acute cervical pain and dysphagia in a 43 year-old man’’ previously published in the n 3/2013. As a

reminder we publish again the entire case with the response following. ∗

Corresponding author.

E-mail address: ﬂ[email protected] (F. Desmots).

Calciﬁc retropharyngeal tendinitis of the longus colli muscle 471

Figure 1. Axial CT section after injection of iodinated contract Figure 3. Axial CT section after injection of iodine conﬁrming

product. the presence of a retropharyngel oedema without organised col-

lection (no wall) (white arrow). Absence of suspect contrast of the

oropharyngeal mucosa. Absence of cervical adenomegaly or par-

What is your diagnosis?

avertebral collection.

After reading the case report, what diagnosis would you

Comments

choose from the following proposals: •

retropharyngeal abscess;

• Figs. 3 and 4a reveal a hypodense and extensive oedematous

cervical spondyldiskitis;

• inﬁltration of the retropharyngeal space without enhanced

calciﬁc retropharyngeal tendinitis;

• wall. The fatty pharyngeal spaces are respected. Cervical

retropharyngeal cellulitis;

• adenomegaly is not noted. Fig. 4b detects the presence of

acute inﬂammatory rheumatoid arthritis.

calciﬁcation located under the anterior arch of atlas, in front

of C2 vertebral body in the left paramedian region within

Diagnosis the prevertebral space. It is located at the spinal insertion

of the upper ﬁbres of the tendon of the longus colli mus-

Calciﬁc retropharyngeal tendinitis of the longus colli cle that appears to be thickened. The diagnosis is that of

muscle. an inﬂammatory episode of calciﬁc tendinitis of the longus

Figure 2. Sagittal CT sections of the cervical vertebra in soft part window (a) and in bone window (b).

472 F. Desmots et al.

Figure 4. Sagittal CT sections in soft part window (a) and bone window (b) conﬁrming the presence of a left paramedian calciﬁcation in

the cervical prevertebral space (white arrow) at the upper insertion of the tendon of the longus colli muscle which is thickened (in front

of C2). Pathognomonic image of calciﬁc tendinitis of the longus colli muscle. The absence of a scanographic argument in favour of cervical

spondylodiskitis should be noted.

colli muscle, accompanied by a reaction oedema of the fatty The CT scan is the reference examination for the diag-

retropharyngeal space. Medical treatment with analgesics nostic conﬁrmation, due to the possibility of multiplane

and non-steroid anti-inﬂammatories over a short period of reconstructions, its sensitivity for the detection of calci-

time quickly provided the patient with relief. ﬁcations and its ability to eliminate a great number of

differential diagnoses (retropharyngeal abscess, oropharyn-

geal neoplasia, cervical spondylodiskitis, spinal neoplasia).

Discussion The calciﬁcation of the upper ﬁbres of the longus colli mus-

cle is pathognomonic of the diagnosis. The soft prevertebral

The musculature of the prevertebral cervical space consists parts may be thickened. A reaction oedema of the fatty

of the longus colli muscle and two long muscles from the retropharyngeal space is often found [5,6]. The MRI lacks

head that are involved in the ﬂexion of the nape of the neck. sensitivity for the detection of calciﬁcations. However, its

They are separated from the retropharyngeal space at the excellent resolution in contract may reveal an inﬂammation

front by the deep cervical fascia. The longus colli muscle of the muscle and the oedematous suffusion of the retropha-

consists of a superior section, from the anterior tubercle of ryngeal space. The degree of calciﬁcation varies greatly,

the atlas to the transverse process of C3 to C5, an inferior without any correlation with the clinical impairment. The

section from T1 to T3 to the transverse process of C1 to lack of peripheral enhancement of the retropharyngeal

C6 and a middle section from C2 to C4 to the other cervi- oedema, cervical adenopathy, enhancement anomaly of the

cal vertebrae as well as the ﬁrst three thoracic vertebrae mucosa of the upper aerodigestive tract or the salivary

[1]. Calciﬁc tendinitis of the longus colli muscle is rare, fre- glands, osteolytic imaging of the cervical vertebral body are

quently under diagnosed, affecting the uppermost ﬁbres of negative arguments that reinforce the diagnostic hypothesis

the tendon. Hartley ﬁrst described it in 1964 [2]. In 1994, [6]. The treatment of this disorder is medical and consists

Ring et al. [3] described ﬁve non-diagnosed cases that led to of the use of analgesics and non-steroid anti-inﬂammatories

inappropriate medical treatment and even an open biopsy. and rest (cervical collar). Corticoids may also be

However, the latter lay the histopathological foundations of used.

the disease by conﬁrmation, with an electron microscope,

of the presence of deposits of non-birefrigent crystals on

the tendon responsible for the inﬂammation. Therefore, a Conclusion

microcrystalline arthropathy is an integral part of the cal-

cium phosphate deposition disease, which mainly affects the Calciﬁc tendinitis of the longus colli muscle is a rare disor-

hips, shoulders, elbows, wrists and ankles. der. Knowledge of its deceptive clinical manifestations and

It classically attacks a man or woman between the age its anatomo-radiological characteristics helps avoid diag-

of 30 and 60, complaining of quickly evolving acute cer- nostic errors and the prescription of treatments that, at

vical pain, whether or not contemporary with a cervical best are useless (antibiotics) or even dangerous (biopsy) [7].

traumatism or a respiratory infection. It is often associated The presence of calciﬁcations at the vertebral insertion (C1

with dysphagia or odynophagia. Low-grade fever may be and C2) of the upper ﬁbres of the longus colli muscle is

reported. An increase in the blood sedimentation rate and pathognomonic. A retropharyngeal oedema reaction is often

the CRP as well as hyperleukocytosis may be detected [4]. associated.

Calciﬁc retropharyngeal tendinitis of the longus colli muscle 473

[2] Hartley J. Acute cervical pain associated with retropharyngeal

Disclosure of interest

calcium deposit: a case report. J Bone Joint Surg 1964;46-

A:1753—4.

The authors declare that they have no conﬂicts of interest

[3] Ring D, Vaccaro AR, Scuderi G, Pathria MN, Garﬁn SR. Acute

concerning this article.

calciﬁc retropharyngeal tendonitis. J Bone Joint Surg 1994;76-

A:1636—42.

Acknowledgements [4] Mihmanli I, Karaaslan E, Kanberoglu K. Inﬂammation of vertebral

bone associated with acute calciﬁc tendonitis of the longus colli

muscle. Neuroradiology 2001;43:1098—101.

Dr Jean-Jacques Pinot.

[5] Ofﬁah CE. Acute calciﬁc tendinitis of the longus colli muscle:

spectrum of CT appearances and anatomical correlation. Br J

Radiol 2009;82:e117—21.

References [6] Eastwood JD, Hudgins PA, Malone D. Retropharyngeal effusion

in acute calciﬁc prevertebral tendinitis: diagnosis with CT and

[1] Stranding S, Healy J, Johnson D, Williams A. Neck and upper MR imaging. Am J Neuroradiol 1998;19:1789—92.

aerodigestive track. In: Ellis H, editor. Gray’s anatomy: the [7] Szelei N, Tassart M, Le Breton C, Perié S, Boumenir ZE, Bazot

anatomical bases of clinical practice. Edinburgh, UK: Elsevier M, et al. Tendinite calciﬁante rétropharyngée : une lésion rare

Churchill Livingstone; 2004. p. 535—40. à évoquer. J Radiol 2001;82:1001—4.