1. Case of the Month - October 2013 50 year old male with 2 week history of dysphagia and odynophagia. No trauma. Investigations reveal: – Temperature 37.5 – WBC normal – C-spine X-rays reveal prevertebral soft tissue swelling. Case submitted by Yoan Kagoma, PGY2

2. Contrast Enhanced CT of the Neck What are the imaging findings? What is the differential diagnosis? Diagnosis?

3. Sagittal Soft Tissue and Bone Windows

4. Axial Soft Tissue Window

5. Coronal Soft Tissue Window

6. Axial Bone Window

7. Findings Smooth soft tissue edema and swelling within the prevertebral soft tissues from C1-C4 No evidence of peripheral enhancement. Amorphous soft tissue calcifications surrounding the atlanto-axial joint.

8. Differential Diagnosis Retropharyngeal abscess? Retropharyngeal effusion? Perivertebral space infection? Other?

9. Diagnosis Findings are most in keeping with calcific tendonitis of the longus colli muscle. Infection or retropharyngeal abcess are less likely given that the patient is not febrile, has a normal white count, and the collection does not exhibit peripheral enhancement.

10. Discussion A rare diagnosis; first described by Hartley in 1964. Clinical presentation: dysphagia, odynophagia, subacute neck pain, and low grade pyrexia. There may be preceding URTI or minor neck trauma. Demographics: Most common amongst 30-60 year olds. No male/female predominance.

11. Pathophysiology: granulomatous and/or inflammatory reaction due to deposition of calcium hydroxyapatite crystals within the fibers of the longus colli that insert into C1/C2. Treatment: anti-inflammatory and analgesic medications. Incision and drainage is NOT required. Discussion

12. The 3 imaging findings most suggestive of the diagnosis: Amorphous calcifications in the prevertebral muscles, particularly C1-C2 Inflammation with swelling of prevertebral muscles Smoothly expanding retropharyngeal space edema Image from Offiah C & Hall E. British Journal of Radiology. 2009 (82): e117-3121.

13. References Acute calcific tendinitis of the longus colli muscle: spectrum of CT appearances and anatomical correlation. Offiah C & Hall E. British Journal of Radiology. 2009 (82): e117-3121. Retropharyngeal Effusion in Acute Calcific Prevertebral Tendinitis: Diagnosis with CT and MR Imaging. Eastwood J et al. American Journal of Neuroradiology. October 1998 (19): 1789-1792. Acute cervical pain associated with retropharyngeal calcium deposit: a case report. Harley J. Journal of Bone and Joint Surgery. 1964 (46-A):1753–1754. StatDx – Acute Calcific tendonitis of the longus colli