Discrimination between calcified triticeous cartilage and calcified

carotid atheroma on panoramic radiography

Laurie C. Carter, DDS, MA, PhD,a Buffalo, NY
STATE UNIVERSITY OF NEW YORK

The differential diagnosis of calcified atherosclerotic plaque in the extracranial carotid vasculature includes a
number of anatomic and pathologic radiopacities. Most of these are readily distinguishable on the basis of location and
morphologic features. The calcified triticeous cartilage, however, can be a confounding alternative that is frequently misdiag-
nosed as a calcified atheroma. This paper describes the radiographic differences between these 2 entities, enabling clinicians
to improve their diagnostic acumen when evaluating cervical soft tissue calcifications. (Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 2000;90:108-10)

The review of existing panoramic radiographs for the

presence of calcified atherosclerotic plaque in the
extracranial carotid vasculature has enjoyed considerable
interest in recent years.1-9 During this review process, the
clinician must distinguish calcified carotid artery
atheromas from anatomic and pathologic radiopacities
that lie in close proximity to the vessel. Neighboring
anatomic radiopacities include the hyoid bone, epiglottis,
and mineralized stylomandibular and stylohyoid liga-
ments. Pathologic radiopacities that may present in the
region of the vessel include calcified thyroid or
submandibular gland, sialoliths, phleboliths, calcified
lymph nodes, and tonsilloliths. Based on the location and
typical morphology of the above-mentioned entities,
there is rarely a problem in distinguishing them from
calcified atheromas. However, many practitioners are
unaware that a calcified triticeous cartilage, or less
frequently the superior horn of a calcified thyroid carti-
lage, may be mistaken for calcified arterial plaque. The Fig 1. Sketch illustrates morphology and location of calcified
purpose of this manuscript is to provide assistance in triticeous cartilage (T), superior cornu of calcified thyroid
identifying these variants of normal and to raise clini- cartilage (S) and calcified carotid atheroma (C) as they appear
cians’ awareness of the existence of these structures to on panoramic radiograph. Also labeled are the following
normal anatomic landmarks: epiglottis (E), greater cornu of
reduce the likelihood that they will be misdiagnosed as
hyoid bone (H), soft tissue of base of tongue (B), prevertebral
calcified carotid atheromas. soft tissue (P) and parapharyngeal air space (A).
In addition to the thyroid, arytenoid, and cricoid carti-
lages, 3 smaller pairs of cartilages form part of the upper
laryngeal skeleton (Fig 1).10 The corniculate cartilages
are small paired structures situated immediately superior thyrohyoid ligaments form the posterior borders of the
to the arytenoids. Just lateral and superior to the cornicu- thyrohyoid membrane, connecting the posterior aspect of
late cartilages, buried in the aryepiglottic folds, are the the greater cornua of the hyoid bone with the superior
thin cuneiform cartilages. The round, cord-like lateral cornua of the thyroid cartilage on each side.11 The small
aAssociate Professor and Director Oral and Maxillofacial Diagnostic paired triticeous cartilages are found centrally within the
Imaging Clinic, Director of Patient Admissions, Department of Oral posterior free edge of the lateral thyrohyoid ligaments.
Diagnostic Sciences, School of Dental Medicine, University at These ovoid radiopacities, approximately 2 to 4 mm
Buffalo, State University of New York. wide by 7 to 9 mm in length, are usually imaged within
Received for publication Oct 18, 1999; accepted for publication Jan the pharyngeal air space adjacent to the superior portion
19, 2000.
Copyright © 2000 by Mosby, Inc.
of C4 (Fig 2).12,13 The word triticeous comes from the
1079-2104/2000/$12.00 + 0 7/16/106297 Latin triticeus, meaning resembling a grain of wheat.14
doi:10.1067/moe.2000.106297 The function of the triticeous cartilage is unknown,

108
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
Volume 90, Number 1
A A
B Fig 3. Cropped panoramic radiographs demonstrate superior
Fig 2. Cropped panoramic radiographs demonstrate features of
calcified triticeous cartilage. Also indicated are hyoid bone (H)
and epiglottis (E). A, 54-year-old woman. B, 60-year-old man.
although it is postulated that it may serve to strengthen
the lateral thyrohyoid ligament.13
Calcification of tracheobronchial, laryngeal, and costo-
chondral cartilages are unusual radiologic findings in
infants and children under 13 years of age.15 According
to Haddad et al,16 in children, calcification in these carti-
lages only occurs under pathologic conditions (eg, severe
respiratory stridor, Keutel syndrome, chondrodysplasia
punctata, hypercalcemia, or hypervitaminosis D) or in
acquired states, such as warfarin embryopathy.16
Although the cartilages of the laryngeal skeleton are
initially hyaline in nature, the corniculate and cuneiform
cartilages, the epiglottis, and the apices of the arytenoids
Carter 109
B
cornu of calcified thyroid cartilage. Also indicated are hyoid
bone (H) and epiglottis (E). A, Film cassette positioned too
inferiorly; entire length of calcified cornu visible (arrow-
heads). B, With proper positioning, only very tip of calcified
cornu is visible (arrowhead).
are transformed into elastic cartilage with aging.13
However, the thyroid, cricoid, triticeum, and greater wing
of the arytenoid cartilages remain hyaline.17 This
anatomic variation is of considerable radiologic signifi-
cance because elastic cartilage shows little tendency to
calcify whereas hyaline cartilages show a propensity to
calcify and even ossify with advancing age. The superior
cornu of a calcified thyroid cartilage is imaged on the
panoramic radiograph as a vertical soft tissue calcifica-
tion approximately 4 mm wide and 15 mm in length,
medial to the image of C4 superimposed over the prever-
110 Carter
Fig 4. Cropped panoramic radiograph illustrating calcified
carotid atheroma in region of bifurcation adjacent to ghost
image of C3-C4, epiglottis, and greater cornu of hyoid bone,
superimposed on prevertebral soft tissue.
tebral soft tissue (Fig 3). Generally, only the top 2 to 3
mm of this calcified cartilage will be visible at the lower
edge of the panoramic radiograph. Only if the cassette is
positioned too far inferiorly will a greater length of this
cartilage be visualized.
Hately et al12 examined a series of 516 unselected
neck radiographs to evaluate normal patterns and vari-
ations in calcification in the laryngeal cartilages. In the
age group 21 to 80, 29% of men and 22% of women
demonstrated calcification of the triticeous cartilages,
the earliest cases being 2 women, both aged 23 years.12
On average, the laryngeal cartilages of men contain a
greater area of calcification than those of women, but
great variations occur in both sexes.18 No single pattern
of calcium deposition in the laryngeal skeleton has
been described. Although, as a general trend, calcifica-
tion increases with advancing age, the absolute preva-
lence and degree of calcification and chronologic age
have not been well correlated.19
On the other hand, calcified carotid atheromas occur-
ring at the bifurcation of the artery are visualized as irreg-
ular, heterogeneous, verticolinear radiopacities inferior to
the angle of the mandible and adjacent to the images of
C3, C4, or both, superimposed over the prevertebral soft
tissue (Fig 4). Calcified carotid atheromas appear more
laterally on the panoramic radiograph than a calcified
triticeous cartilage would.7 Careful attention to these
differences in morphology and location should enable the
clinician to distinguish between calcified triticeous carti-
lage and calcified carotid atheroma. No treatment is
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
July 2000
needed for calcified triticeous cartilage, but patients with
calcified carotid atheromata should be referred to their
physicians for further evaluation to determine the risk of
cerebrovascular accident.
Thanks to Mr John Nyquist and Mr James Ulrich, Art and
Photographic Services, University at Buffalo, for their assis-
tance in biomedical illustration and in the translation of fine
radiographic details onto photographic paper.
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Reprint requests:
Laurie Carter, DDS, PhD
Department of Oral Diagnostic Sciences
355 Squire Hall, School of Dental Medicine
State University of New York
University at Buffalo
Buffalo, NY 14214-3008
lccarter@acsu.buffalo.edu