LONGUS COLLI TENDONITIS: CLINICAL – RADIOLOGICAL CORRELATION IN RESORPTIVE PHASE ASNR Annual Meeting 2015, Poster #: EE-10 Authors: S Mathur1, P Howard1, K Higgins2, P Jabehdar Maralani1 Institutional Affiliation : 1Division of Neuroradiology, Department of Medical Imaging, 2Department of Otolaryngology Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON

DISCLOSURE INFORMATION Authors have no financial relationships to disclose. Authors will not discuss off label use and / or investigational use in this presentation.

PURPOSE Awareness of typical clinical and imaging features of longus colli tendonitis can lead to timely and accurate diagnosis and appropriate management. Our case demonstrates the imaging findings in the symptomatic resorptive phase of this condition with clinical correlation.

MATERIAL & METHODS (Case History) 44-year-old male Presented with 1 day history of progressive neck pain, painful neck & jaw movements, odynophagia, hot potato voice No history of trauma Recent history of substance abuse Past Medical History: Left submandibular space infection requiring incision & drainage 20 years ago

Examination Findings : Painful neck and jaw movements Several white small pustules on the soft palate, uvula and base of tongue which were concerning for infection No fever / palpable neck mass / cervical adenopathy Lab Investigations: White blood cell (WBC) count : borderline high (11.2 x109/L) Erythrocyte Sedimentation Rate (ESR) : High (38 mm/hr) C-reactive protein (CRP) : High (208 mg/L)

Imaging findings: Lateral neck radiograph demonstrated prevertebral soft tissue widening and calcific density anterior to C1-2 vertebrae. Subsequent CT study confirmed the prevertebral effusion and calcific focus anterior to C1-2 with no abnormal enhancement.

drugs (NSAIDs) were started. The symptoms resolved over 5 days. ON PRESENTATION Based on the clinical, imaging and lab findings, a diagnosis of longus colli tendonitis was made and nonsteroidal anti-inflammatory drugs (NSAIDs) were started. The symptoms resolved over 5 days. C5 C1-2 THREE DAYS LATER CT study after 3 days of presentation demonstrated marked resolution of prevertebral effusion and significant resorption of tendinous calcification. C5 C1-2

DISCUSSION LONGUS COLLI TENDONITIS (calcific prevertebral tendonitis / calcific retropharyngeal tendonitis / longus colli myositis) Calcium hydroxyapatite deposition occurs at the superomedial insertion of the superior oblique portion of the longus colli muscle at the anterior tubercle of the atlas. Etiology is not clear; repetitive trauma, tissue necrosis, inflammation, or ischemia may play a role. Genetic and metabolic factors have also been postulated. Longus colli tendonitis is similar in histopathologic, clinical and radiological presentation to calcific tendonitis in other locations. Four stages of calcific tendonitis have been described and the third resorptive stage is usually symptomatic.

PRECALCIFIC / FORMATIVE STAGE NORMAL TENDON PRECALCIFIC / FORMATIVE STAGE CALCIFIC STAGE RESORPTIVE STAGE POST CALCIFIC / REPARATIVE STAGE (Fibroblasts restore the normal tendon collagen pattern) STAGES OF CALCIFIC TENDONITIS (SYMPTOMATIC PHASE: Increased vascularity at periphery, phagocytic activity of macrophages and multinuclear giant cells, resorption of the calcium, associated inflammatory response) (Fibrocartilaginous metaplasia, calcium hydroxyapatite crystal deposition, enlargement of calcification) (Calcific deposit enters a resting period)

Clinical features of longus colli tendonitis : No gender predilection. Wide age range (20-80 yrs). Acute to subacute onset (usually 2-7 days history), possibly triggered by preceeding minor head and neck trauma Neck pain and rigiditiy (due to involvement of longus colli muscle) Odynophagia (effect on pharyngeal constrictors) Less commonly , Torticollis (spasm of longus colli) Choking sensation (prevertebral collection causing airway compromise) Occipital headache (irritation of greater occipital nerve) Mild fever, leukocytosis, elevation of the ESR & CRP (inflammatory response) Usually treated with NSAIDs; occasionally immbolization with neck collar, steroids. Typically, resolution within 1-2 weeks of symptom onset. Recurrence possible (9months to 20 years). Retropharyngeal abscess is a strong clinical mimic where antibiotics and incision & drainage is the standard care. CT/MRI is crucial to differentiate these two entities.

Imaging features of longus colli tendonitis : Key features: Tendinous calcifications within the longus colli, typically at C1-2, fluffy and amorphous. Retropharyngeal fluid with no peripheral enhancement Absence of retropharyngeal lymphadenopathy Absence of bony destructive change to adjacent vertebra Different patterns may arise from different resorption rates : Simultaneous resolution of the calcification and prevertebral effusion. Resorption of the calcification with persistence of effusion. Persistence of the calcification but resorption of effusion. CT is the imaging modality of choice and MRI is usually not necessary for the diagnosis.

RESULTS Our case demonstrates typical imaging features of longus colli tendonitis on patient presentation with rapid change (within three days) in the tendinous calcification and prevertebral effusion. There was significant resorption of tendinous calcification on sequential CT images over a span of just three days in our case. This provided a good imaging correlate to the rapid resolution of symptoms of the patient. It also supports the hypothesis that clinical syndrome in calcific tendinitis is associated with resorptive phase.

CONCLUSION The clinical symptoms of longus colli tendonitis including acute neck pain and range-of-motion limitation and imaging findings including prevertebral effusion and calcification anterior to C1-2 are usually seen in the resorptive phase of this disease as seen in our case. Knowledge of these clinical and imaging features is essential to prevent delay in diagnosis and misdirected therapy.

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