Acute longus colli calcific tendonitis causing neck pain and dysphagia

Abstract

Calcific tendonitis of the longus colli muscle is a condition not well recognized in the otolaryngology literature despite its presentation with common ENT symptoms of dysphagia and neck pain. We present a case, its relevant radiology, and provide a discussion on the presentation, diagnosis, and management of the condition. A 56-year-old man with a 2-month history of a painful stiff neck after minor trauma presented to the emergency department with progressive symptoms and dysphagia lasting 2 days. He was systemically well with no fever or malaise and had no significant medical history. ENT and neck examination were normal apart from painful restricted neck lateral flexion and extension, plus edematous nasopharyngeal mucosa on flexible nasoendoscopy (FNE). Laboratory studies were normal including his white blood cell count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), anti-neotrophil cytoplasmic antibodies (ANCA) rheumatoid factor, and antinuclear antibodies. A lateral cervical spine radiograph showed thickening of the upper cervical prevertebral tissue, with an oval opacification anterior of the vertebral body of C2 (Fig 1). Computer tomography (CT) demonstrated a 13-mm area of calcification anterior to C2 with a 6-mm low attenuation collection in the prevertebral tissue adjacent to C2-4 (Fig 2). A magnetic resonance imaging (MRI) scan performed 5 days after presentation showed thin fluid in the prevertebral space with no significant surrounding reactive changes and confirmed the diagnosis of reactive effusion. He was admitted and managed with simple analgesia. His symptoms significantly improved such that he had no dysphagia and minimal residual neck discomfort and was discharged home 2 days later. At review 1 month later, his symptoms had completely resolved and FNE confirmed resolution of prevertebral edema. Acute calcific tendonitis is well recognized in orthopedics to most commonly affect the rotator cuff of the shoulder as well as other tendons that cross mobile joints. The occurrence in the prevertebral musculature, specifically the longus collis tendon, is uncommon with only a small number of cases presented in the otolaryngology literature.1, 2 The true incidence of longus collis calcific tendonitis is unknown as the condition may be underdiagnosed. Because of the nonspecific symptoms, investigations must rule out serious pathoses that include retropharyngeal infection, cervical disk herniation/infection, cervical vertebral body subluxation/fracture, meningitis, and extradural hemorrhage. In the present case, the lack of significant trauma, systemic malaise, and neurologic symptoms made these diagnoses unlikely. The longus collis muscle originates from the C1 to T3 vertebrae and consists of vertical, inferior oblique, and superior oblique fibers. The superior oblique fibers originate from the transverse processes of C3 to C5 and fuse into a tendon that inserts onto the anterior tubercle of the atlas and is most vulnerable to calcific deposits. The cause of this condition is unclear with no evidence to suggest abnormal systemic calcium metabolism.3 Histologically, a deposition of calcium hydroxyapatite crystals is found within the musculotendonous tissue.4 It is thought that rupture of the capsule releases crystals into the tissue and results in acute inflammatory response that causes pain, muscle spasm, and local inflammation. As calcium is absorbed from the tissue, inflammation and symptoms resolve. Plain film lateral neck shows an amorphous calcific deposit opposite vertebral body of C2. The condition most commonly occurs in the middle-aged patient with no sex predilection.5 The clinical presentation is consistent in published reports, including neck pain and stiffness with associated dysphagia either with or without odynophagia and possibly a prior history of minor neck trauma. Examination may reveal a low-grade or no fever and find restricted neck movements and retropharyngeal tenderness. Edema of the posterior pharyngeal wall may be seen. Laboratory tests sometimes show a mild leukocytosis and raised inflammatory markers. Axial CT of the cervical spine shows a low density prevertebral collection. The diagnosis of this condition is made radiologically. A plain lateral neck film will show an amorphous calcific deposit below the arch of C1 and anterior to the body of C2 with associated swelling of the prevertebral soft tissue from C1 to C4. This can be distinguished from an accessory ossicle that will appear osseous with a demarcated cortex, without soft tissue swelling. It should also be distinguished from the styloid process, calcification of the stylohyoid ligament, and from the transverse process of C2 in a rotated film. With reabsorption of the calcium deposit from the tissue after rupture, the margins of the deposit become less well-defined and radiologic changes usually resolve in 2 weeks. Further imaging is not usually necessary but CT can demonstrate the retropharyngeal anatomy and depict subtle calcium deposits. An MRI is excellent to identify soft tissue edema or fluid collection. In our case, both CT and MRI were used to demonstrate the extent and nature of the prevertebral fluid. The natural history of this condition is spontaneous resolution. Symptomatic support with analgesia and anti-inflammatories is useful; symptoms improve over a 1 to 2 week period.6 Treatment for calcific tendonitis in other parts of the body has included extracorporeal shock wave therapy, aspiration and lavage, corticosteroid and local anesthetic injection, and surgical curetting.7 Given the anatomic relationships of the longus collis muscle and the benign natural history of the condition, we would advocate only conservative management. Local recurrence has not been reported, but some patients have had chronic calcification at other sites.7 Calcific tendonitis of the longus colli muscle is a rare condition that is not well recognized in the otolaryngology literature. A presentation of acute neck pain with dysphagia in the systemically well patient should alert the otolaryngologist to the potential diagnosis, which can be confirmed on a plain lateral neck film. The treatment is supportive with analgesia and anti-inflammatories with resolution expected within several weeks. Katherine Southwell, Jeremy Hornibrook, and David O'Neill-Kerr, writers. None.