A case of dystrophic calcification in the masseter muscle
© The Author(s). 2017
Received: 28 July 2017
Accepted: 18 September 2017
Published: 5 November 2017
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.
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.
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.
Pathologic soft tissue calcification of the cheek is an uncommon condition. There are many different types of calcifications, which includes dystrophic calcification, metastatic calcification, phleboliths, myositis ossificans, calcifications within lymph nodes, and calcified cutaneous aces, making differential diagnosis difficult . In order to manage these lesions, they need to be distinguished from others that occur at the same area. Precise examination and selection of appropriate imaging, such as plain radiographs, ultrasonography, computed tomography (CT) with contrast, and magnetic resonance imaging (MRI), are important to aid in differentiation. Histological evaluation is also essential to arrive at a final diagnosis .
Among many different types of calcification, a dystrophic calcification is deposition of calcium salt in the soft tissue which associated with trauma, infection, or inflammation without elevated serum calcium level . The precise mechanism of the disease is unknown, but it seems to be related to necrosis and apoptosis of the tissue [3, 4]. Dystrophic calcification is most often seen in the heart muscles and valves and rarely appears in the head and neck area . Currently, there is no established protocol for its treatment. Some clinicians have recommended observation, but others have suggested the surgical treatment case by case . This article presents a rare case of the multiple dystrophic calcifications in the masseter muscle.
Cases of dystrophic calcification in masseteric area have been reported
Right masseter muscle (2 calcified masses)
Left masseter muscle (multiple calcified masses)
Right masseter muscle (multiple calcified masses)
Right masseter muscle (1 calcified mass)
The pathogenesis of dystrophic calcification is known to involve intracellular or extracellular initiation and propagation. Intracellular calcification is initiated with dead or dying cells that are not able to regulate intracellular calcium. After initiation, propagation of calcium phosphate crystalline formation occurs, which is affected by the concentration of Ca2+and PO4− in the extracellular space . Dystrophic calcification occurs when calcium is accumulated in the area of trauma or necrosis which may be caused by blunt trauma, inflammation, injections, and the presence of parasites .
In many cases, it appears early in childhood but it often tends to be diagnosed late since it shows no signs or symptoms. Therefore, it is found after lesion is enlarged enough to be palpated. In our case, we suppose that dystrophic calcification was caused by a trauma experienced at a young age. Because there had been no symptoms such as swelling or pain, it was discovered after a long period of time.
Different types of calcifications, including phleboliths, sialoliths, myositis ossificans, metastatic calcification, calcifications within lymph nodes, and calcified cutaneous aces, may occur in the cheek area, and they need to be distinguished from dystrophic calcification. Phleboliths are pathological, calcified thrombi that are associated with hemangiomas and developmental vascular malformations of the head and neck region . Radiographically, they appear as round or oval radiopaque nodules, which may show a radiopaque center with surrounding onion ring-like concentric calcific rings . In this case, there was no evidence of hemangioma or vascular malformation clinically and radiographically. Also, the calcified mass had no radiopaque center and concentric rings.
On the other hand, sialoliths are one of the most common diseases that appear in the salivary glands. Sialoliths of the parotid gland or duct need to be distinguished from calcification of the cheek, because the parotid gland is located behind the masseter muscle, with the Stensen’s duct, passing through it before opening into the oral cavity. Sialoliths may be composed of one or more stones and may cause pain or swelling when the salivary gland is stimulated by eating . In our case, we ruled out a diagnosis of such because the calcified masses were located inside the masseter muscle, away from the Stensen’s duct or parotid gland based on the CT images. In addition, salivary flow of the duct was found to be normal.
Another differential diagnosis is myositis ossificans which results from trauma or heavy muscular strain associated with the bone or cartilage, producing reactive lesions. Clinically, it can be palpated beneath the skin or mucosa, as a minimally movable firm mass . When the lesion is located within a muscle of mastication, it usually causes trismus because of limitation of the muscle . On a radiograph, the linear streaks running in the same direction as the normal muscle fibers are regarded as a typical character for myositis ossificans . In our case, the patient had no trismus and the radiographic finding was different from myositis ossificans .
In addition, calcifications within lymph nodes commonly involve cervical lymph nodes with metastatic deposits from malignancies such as squamous cell carcinoma and Hodgkin’s lymphoma. On a radiograph, they most often are irregular with a cauliflower appearance . Metastatic calcifications occur due to increased calcium levels in the blood. Chronic renal failure, milk-alkali syndrome, extensive bone malignancy, and hypervitaminosis D are some of the conditions known to cause metastatic calcifications . In our case, there was no evidence of malignancy causing metastasis or systemic mineral imbalance.
Due to this wide variety of diagnostic possibilities including phleboliths, sialoliths, myositis ossificans, calcification within lymph nodes, and the potential for malignancy, it is important to establish a proper diagnosis . In fact, physiologic and pathologic soft tissue calcification of the head and neck is rare, and plain radiography is rarely helpful in diagnosing . Therefore, thorough clinical examination and history taking is required together with blood testing and radiographic examinations such as CT, MRI, and ultrasound. In addition, fine needle aspiration for checking the contents of the lesions if deemed indicated can also help in confirming the diagnosis. The final diagnosis should be obtained after acquiring relevant information, and only then, the appropriate treatment can take place . There is no established protocol for its treatment. Some clinicians have recommended observation. However, various factors such as the size and location of the lesion, and patient discomfort should be put into consideration. In such cases and if deemed necessary, meticulous surgical excision and periodic follow up are recommended [18, 19].
Dystrophic calcification is deposition of calcium salt in degenerated tissues with the absence of a systemic mineral imbalance. It is often associated with trauma, infection, or inflammation and rarely appears in the head and neck area. Different types of calcifications, including phleboliths, sialoliths, myositis ossificans, metastatic calcification, calcifications within lymph nodes, and calcified cutaneous aces, 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 such as CT, MRI and ultrasound.
This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
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HYK, JBL, and SJK are responsible for the data collection, drafting the article, and the critical revision of the article. JHP is responsible for the critical revision of the article and the approval of the article. All authors read and approved the final manuscript.
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