Phleboliths. A report of three unusual cases

Ultrasonographic Evaluation of Soft Tissue Calcifications in the Head and Neck Region Detected on Panoramic Radiographs

OBJECTIVE

The aim of this study is to present a comparison between panoramic radiographs and USG imaging with a focus on revealing the advantages of USG over radiographs, and to show the distribution of calcifications detected in USG by considering the age and gender.

METHODS

A total of 148 patients with soft tissue calcifications as seen on panoramic radiographs were examined with USG imaging. Sialoliths, carotid artery calcifications, tonsilloliths, phleboliths and lymph node calcifications were examined in terms of anatomical localization, distribution and shape.

RESULTS

In the USG evaluation of these 148 patients, soft tissue calcifications were observed in 113 (76.4%) patients. The mean age of the patients with calcification was 55.6 ± 13.1 (min: 22-max: 77). Bilateral calcifications were detected in 25 (22.1%) patients, whereas unilateral calcifications were found in 88 (77.9%) patients. While the rates of tonsilloliths, sialoliths, phleboliths, and lymph node calcifications were statistically similar in male and female patients, the rate of carotid artery calcifications was found to be higher in men than in women (P = 0.017). No statistical significance was found between age groups in terms of the formation of soft tissue calcifications (P = 0.117).

CONCLUSIONS

Panoramic radiographs may mislead clinicians in the diagnosis and differential diagnosis of soft tissue calcifications in the head and neck region due to the presence of distortion, superpositions, metal artefacts, and ghost images. USG is an important diagnostic tool in determining the localization of soft tissue calcifications that can be confused on two-dimensional radiographs, their relationship with neighboring structures, and defining calcification. It can be used safely in the detection of soft tissue calcifications as it provides dynamic imaging without the use of radiation or contrast material compared to other advanced imaging methods.

Phleboliths of the Head and Neck Region - A Case Report

Rationale

Phleboliths are idiopathic calcifications resulting from mineralised structures inside veins, venules or blood vessels.

Patient Concerns

A 48-year-old woman presented with multiple hard bodies on palpation.

Diagnosis

Imaging studies revealed multiple, round, well-defined radiopaque lesions, extending from the coronoid process region down to the base of the mandible. The diagnosis was vascular malformation with multiple phleboliths.

Treatment and Outcome

No treatment was proposed and the patient is under follow-up.

Take-Away Lessons

Asymptomatic phleboliths of the head and neck region in an adult woman have been under surveillance.

Unusual Case of Masseter Muscle Hypertrophy in Adolescence—Case Report and Literature Overview

Unilateral hypertrophy of the masseter muscle is a very rare pathological entity in children. Its etiology is uncertain and it requires a high degree of suspicion, as it must be differentiated from other conditions of the masseter area. As there are few pathological studies to elucidate this condition, we report a rare case of unilateral masseter muscle hypertrophy in a 16-year-old female patient with gradual onset of a painless swelling in the posterior left cheek which caused facial asymmetry with repercussions on the patient’s self-image. The diagnosis of unilateral masseter muscle hypertrophy was suggested by clinical examination, ultrasound scanning, and nuclear magnetic resonance, and was confirmed by histologic examination two years later when the patient returned for the surgical correction. The pathological findings report showed fragments of skeletal muscle with hypertrophic fibers associated with normal-sized muscle fibers in both longitudinal and transverse sections. The postoperative evaluation was favorable as both the adolescent and her family were satisfied with her look on the 14th day, 1st year, and 3rd year follow-ups. In conclusion, unilateral masseter muscle hypertrophy in adolescence is a sensitive problem due to the psychological implications of facial appearance. Definite diagnosis and treatment of the hypertrophied muscle is the ideal solution.

Buccal vascular malformation with multiple giant phleboliths: a rare case presentation and review of the literature

PURPOSE

The purpose of this study was to describe a case and to review the diameters, symptoms, locations, and treatment methods for vascular malformations (VMs) with phleboliths. Our case report is probably the first to mention this observation because of sizes and large number of phleboliths in buccal region.

CASE PRESENTATION

A 26-year-old male patient was referred to Ordu University, Faculty of Dentistry, Department of Oral and Maxillofacial Surgery for the evaluation and management of a painless tender swelling in the left buccal region. Clinically, a bluish mucosal lesion of the posterior region of the left buccal mucosa and lip is apparent. Panoramic radiography and CT were obtained for radiographical examinations. Multiple giant phleboliths with the largest dimension of 32 mm were seen in this region. Left maxillary first molar teeth extraction was indicated. An aspiration was performed and revealed that there is a risk of severe hemorrhage. The patient did not want to take MRI and stated that he only wanted to have dental treatment. Therefore, it was decided that the maxillary first molar should be retained in the region and endodontic treatment should be done, if necessary.

CONCLUSIONS

The clinic of phlebolith patients is painless swelling and can reach up to 6 cm. The localization is not specific but is found in the masseter and parotid regions generally. Treatment may be invasive or non-invasive depending on, location, accessibility, depth of invasion, age, cosmetic issues, and risk of severe hemorrhage, as with the current case.

A Pearl-Like 30-Year-Old Moving Phlebolith in the Left Cephalic Vein

BACKGROUND

Phleboliths are a common finding, especially in the pelvic veins. There are generally multiple thrombi associated with vascular malformations, trauma, or iatrogenic or noniatrogenic intravenous foreign bodies.

METHODS

Herein, we report a unique case of a single moving phlebolith in the cephalic vein of a 65-year-old man, not associated with any vascular lesion, trauma, or foreign body.

RESULTS

Too many cases of phleboliths have been reported in the literature since 1948, referred to vascular disorders, injuries, or foreign bodies. Only this work we are presenting refers to a phlebolith not associated with other vascular, pathological, or traumatic lesion.

CONCLUSION

Phleboliths not associated with other vascular lesions are not common and less rare when not associated with injuries or iatrogenic interventions. Clinicians should be aware of the existence of this pathology and include it as the differential diagnosis of various pathological conditions.

A case of dystrophic calcification in the masseter muscle

Background

Dystrophic calcification can occur in any soft tissue with the absence of a systemic mineral imbalance and is often associated with trauma, infection, or inflammation. It is easily found in the site of the heart and skeletal muscles and rarely appears in the head and neck area.

Case report

We present a rare case of multiple calcified masses in the left masseter muscle of a 26-year-old female with a history of trauma in the area. In computed tomography, multiple radiopaque masses were observed inside the left masseter muscle and blood test results were normal. The calcified masses were diagnosed as dystrophic calcification and removed by surgery without any complications.

Conclusion

Different types of calcifications may occur in the cheek area, and they need to be distinguished from dystrophic calcification. Thorough clinical examination and history taking is required together with blood testing and radiographic examinations.

A Solitary Phlebolith in the Buccal Mucosa: Report of a Rare Entity and Clinicopathologic Correlation

Pathological conditions can give rise to calcifications within oral mucosa representing either a local or systemic disturbance. Inflammation, trauma, debris acting as nidus and vascular lesions have been attributed as principal causes for occurrence of calcifications within the oral mucosa. Occurrence of multiple calcified thrombi (phleboliths) is considered pathognomonic for hemangiomas and vascular malformations in the oral and maxillofacial region. Isolated occurrence of phlebolith in oral mucosa though very rare, especially without any underlying vascular lesions, can be diagnostically challenging. Either a traumatic association at that site or a hemangioma of childhood that has regressed once the individual became an adult are the possible explanations suggested for the occurrence of these unique solitary phleboliths. Histologically, an "onion-ring"-like concentric lamellar fibrosis around a central core with varying amounts of calcifications and presence of minute vascular channels within or around calcified lamellae is characteristic for phlebolith. There is a high propensity for misdiagnosing solitary phlebolith located in sites like the buccal mucosa where various other pathologic soft-tissue calcifications, such as sialoliths, calcified lymph nodes, traumatic myositis ossificans, etc. can occur and they too appear radiopaque in radiographs. Besides, the absence of any associated underlying vascular lesion adds to the mispercep-tion. In such cases, histopathological examination with routine hematoxylin and eosin staining alone may not be sufficient to determine the accurate diagnosis. Allied clinical history and immunohistochemistry can aid to arrive at the final diagnosis. We report such a case of nonvascular lesion-associated solitary phlebolith in the right buccal mucosa of a healthy 49-year-old male patient and discuss its differential diagnosis with emphasis on histological presentation.

An Isolated Phlebolith on the Lip: An Unusual Case and Review of the Literature

Background. Calcified thrombi are a common finding, especially in the pelvic veins. There are generally multiple thrombi, and they are generally associated with vascular malformations. Design. Herein we report a rare case of a single labial phlebolith, not associated with any other vascular lesion. We aim to alert clinicians to the possibility of the occurrence of vascular thrombi in the mouth and to describe the clinical and histological characteristics of such lesions in order to simplify the diagnosis and treatment. Furthermore, we have reviewed the English-language literature published since 1970 reporting oral (including masticatory muscles) phleboliths. Results. Twenty-nine cases of phleboliths have been reported in the literature since 1970. Only three of the reported phleboliths were solitary and not associated with other vascular lesions, as in the case presented here. Conclusion. Although phleboliths not associated with other vascular lesions are not common, clinicians should be aware of the existence of this pathology and include it as differential diagnosis of oral lesions.

Carotid artery calcification detected on panoramic radiographs in a group of Thai population

OBJECTIVE

To determine the prevalence of carotid artery calcification (CAC) detected on panoramic radiographs in a Thai population.

STUDY DESIGN

The panoramic radiographs of the patients 50 and older (N = 1,370) visiting Mahidol University from January 1998 through September 2004 were retrospectively reviewed for CAC. The medical records of the positive subjects were then reviewed.

RESULTS

Thirty-four (2.5%) of the 1,370 patients, 16 men and 18 women, with a mean age of 69 and a range of 50 to 87 years, had 1 or more CACs. These calcifications were unilateral in 25 (73.5%) and bilateral in 9 (26.5%) subjects. Of those positive subjects, 18 reported hypertension, 10 reported diabetes mellitus, and 5 reported hyperlipidemia.

CONCLUSIONS

Although it is uncommon to find CAC in the Thai population, dentists should be aware of this calcification on the routine panoramic radiographs and promptly refer for cerebrovascular and cardiovascular evaluation.

Die Chemodenervation mit Botulinumtoxin bei Masseterhypertrophie

BACKGROUND

Masseteric hypertrophy is a unilateral or bilateral enlargement of the masseteric muscle of various aetiologies. The therapeutic options range from solely conservative measures, especially in functionally induced abnormalities, up to surgical ablation of the muscle. The presented study evaluates the application of botulinum toxin serotype A for the treatment of masseteric hypertrophy.

PATIENTS AND METHODS

Between June 2000 and August 2004 seven patients with a unilateral and one patient with a bilateral manifestation of the condition were treated by an injection of botulinum toxin.

RESULTS

A significant improvement of facial asymmetry caused by chemodenervation and following reduction of the hypertrophic muscle mass could be achieved in all cases. Complications during the injection, side effects, signs of intoxication, and therapy failure were not observed.

CONCLUSION

The results of this treatment series show in agreement with the reports in the literature that the application of botulinum toxin can be currently considered as the therapy of choice in masseteric hypertrophy.

Angiolithiasis and sialolithiasis in the head and neck

Of the two principal forms of macrolithiasis and microlithiasis in the head and neck, that occurring in salivary glands (sialoliths) is much more prevalent than intravascular lithiasis (angioliths). Sialoliths are also more often symptomatic, particularly when formed in the preponderant gland of involvement, the submandibular gland. Angiolithiasis is always coincidental with vascular stasis: in hemangiomas or varices. Both forms of lithiasis share several radiographic features and have a similar basis of formation. For sialoliths, secretory stasis forms a nidus for mineralization. Thrombus formation in vessels is the formative “nucleus” for an angiolith.