Phleboliths

Soft tissue calcifications -- Phleboliths -- Rhinoliths and Antroliths -- Metastatic Calcification Supervisor : Dr. Mustafa Al-KhadrPhleboliths . Disease Mechanism . Clinical Features . Imaging Features . Differential Diagnosis - Intravascular thrombi arise from venous Stagnation- Calcified thrombi in veins, venulae, or sinusoidal vessels of hemangiomas (CAVERNOUS type). - sometimes become organized, mineralized Mineralization begins in the core of thrombus - consist of: crystals of calcium carbonate-fluorohydroxyapatite Disease Mechanism - In the head and neck, phleboliths nearly always signal the presence of a hemangioma.- In an adults, it may be the sole residual of a childhood hemangioma. - involved soft tissue may be: swollen throbbing discolored (by presence of veins or soft tissue hemangioma)

Clinical Features

-Hemangiomas often fluctuate in size- associated with changes in body position or during a Valsalva Maneuver - involved tissue may be blanch or change in color if lesion is vascular by applying pressure.- Auscultation may reveal a bruit in cases of cavernous type

Hemangioma Location - Most commonly are found in Hemangiomas Periphery and Shape - shape is round or oval, up to 6 mm in diameter - with smooth periphery - phlebolith may resemble a straight or slightly curved sausage

Internal structure - homogeneously radiopaque - commonly it has appearance of laminations (bulls-eye or targetoid appearance). - radiolucent flow voids: represent the remaining patent portions of the vessel

bull s -eye or target

Phleboliths are soft tissue dystrophic calcifications found in veins. They are usually associated with hemangiomas.

- Submandibular sialoliths usually occur singly- If more than one is present theyre oriented in a single line.

Phleboliths usually are multiple, have more random, clustered distribution -Identification of a possible vascular lesion , such as a hemangioma.- Critical if surgical procedures are contemplated Sialoliths

.Disease mechanism . Clinical Features . Imaging Features . Differential Diagnosis . Management Rhinoliths and Antroliths

Rhinoliths Calcareous concretions occur in the noseAntroliths Calcareous concretions occur in the antrum of the maxillary sinus - Arise from the deposition of nasal, lacrimal, and inflammatory mineral salts (Calcium phosphate, calcium carbonate, and magnesium, by accretion around a nidus)- Rarely formed in frontal or ethmoid sinus Periphery and shape: stones with various shapes and sizes, depending on nidus natureInternal structure: homogeneous or heterogeneous radiopacities and sometimes may have laminations *The density exceeds the surrounding bone.

Lateral occlusal film shows a rhinolith above the floor of nose

Posteroanterior skull film shows a rhinolith within the nasal fossa

Axial and coronal CBCT image reveals the presence of antrolith

- The nidus is usually endogenous (e.g. Root tip, bone fragment, blood clot, ectopic tooth)- dystrophic calcification within chronically inflamed sinus in long standing sinusitis - small scattered and faint calcifications in thickened mucosal lining- noninvasive aspergillosis mycetoma may develop in antrum- Mycetoma manifest as a muddy, necrotic fungus ball or transform into a hard mycolith - The nidus is usually an exogenous foreign body (e.g. Coins, beads, seeds and fruit pits) - Adult drug smugglers- route of entry is usually anterior - some may enter the choana posteriorly during sneezing, coughing, or emesis. Rhinolith Antrolith - Patient may be asymptomatic for extended periods - expanding mass may impinge on the mucosa, producing pain, congestion, and ulceration - nasal obstruction, unilateral purulent or blood-stained rhinorrhea, sinusitis, headache, epistaxis, anosmia, fetor and fever

1- Osteoma2- odontoma3- calcified polyp4- surgical ciliated cyst Differential Diagnosis

-Patient should be referred to an (otorhinolaryngologist) for endonasal or sinus endoscopic surgical removal of the mass.

- Lithotripsy to debulk large rhinoliths

Metastatic Calcifications -- Caused by conditions involving elevated serum calcium and phosphate levels : e.g. * Hyperparathyroidism * Hypercalcemia of malignancy-Extremely rare - Symmetrical and bilateral

Done by: Dana QataminWith all due respect