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Calcific Retropharyngeal Tendinitis of the Longus Colli Muscle. Answer To

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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 ଝ 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 a Service d’imagerie médicale, hôpital d’instruction des armées A.-Laveran, BP 60149, 13384 Marseille cedex 13, France b 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 ◦ 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. ଝ o 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). 2211-5684/$ — see front matter © 2012 Éditions françaises de radiologie. Published by Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.diii.2012.09.006 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..
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