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Acute calcific prevertebral tendonitis of the longus colli muscle.


An otherwise healthy 39-year-old man presented the emergency room with a 3-day history of throat pain and stiff neck. Direct visualization of the pharynx revealed prominent retropharyngeal soft tissues with a normal mucosal surface. The patient's temperature was 99.9[degrees], white count was 12,000/mL, and the sedimentation rate was 9. Radiographs of the soft tissues of the neck were performed, followed by contrast-enhanced computed tomography (CT), and magnetic resonance imaging (MRI) of the neck for further characterization.


A lateral radiograph of the soft tissues of the neck reveals smooth, mild thickening of the prevertebral soft tissues (5 mm), with a 1.3 cm focus of amorphous calcification anterior to the C2 vertebrae (Figure 1). A contrast-enhanced CT exam (with sagittal reconstructed images) showed a smooth, lenticular-shaped fluid collection within the prevertebral soft tissues. In addition, amorphous calcification was seen embedded within the superior oblique tendon (proximal tendon of the longus colli muscle; Figure 2). An MRI examination also depicted a lenticular shaped prevertebral fluid collection with amorphous calcification in the proximal fibers of longus colli tendon, at its origin from the anterior arch of the C1 vertebrae (Figure 3).



Acute calcific tendonitis of the longus colli muscle


Given the clinical symptoms, physical examination and specific imaging findings, the diagnosis of acute calcific tendonitis of the longus colli was established. At this point, empiric antibiotic therapy was discontinued, and the patient was treated with nonsteroidal antiinflammatory medication. The patient responded well to conservative treatment and subsequently made a full recovery.




Acute retropharyngeal tendonitis (calcific tendonitis of the longus colli), initially described by Hartley in 1964, is an acute inflammation condition of the longus colli tendon, which is related to calcium hydroxyapatite deposition in the superior oblique fibers of the longus colli muscles. (1-3) The longus colli muscle extends from the anterior arch C1 to the T3 vertebrae. (4) Patients most often present during the third through sixth decades of life (5) with acute neck pain, stiffness, odynophagia, low-grade fever and mild leukocytosis. (2-8) The clinical presentation can be difficult to differentiate from a retrophayngeal abscess. Radiology can play a key role in the diagnosis: specifically, by identifying characteristic, amorphous calcification in the proximal fibers of the longus colli (just inferior to the anterior arch of the atlas); and, by identifying a prevertebral fluid collection/effusion, which is considered nearly pathognomonic of this entity. The prevertebral fluid collections in this entity tend to be smooth, linear/lenticular and do not contain an enhancing wall (as one may expect with an abscess). (3)


Acute retropharyngeal tendonitis is a cause of acute neck pain that can mimic infection (retropharyngeal abscess, pharyngitis or peritonsilar abscess). Recognition of this entity is critical in order to avoid misdiagnosis and inappropriate treatment with antibiotics and possible "abscess" drainage. In the proper clinical setting, the presence of amorphous calcification anterior to C1/ C2, along with prevertebral edema/fluid, is nearly pathognominic of this entity.


(1.) Hartley J. Acute cervical pain associated with retropharyngeal calcium deposit: A case report. J Bone Joint Surg Am. 1964;46:1753-1754.

(2.) Ring D, Vaccaro AR, Scuderi G, et al. Acute calcific retropharyngeal tendonitis: Clinical presentation and pathological characterization. J Bone Joint Surg Am. 1994;76(11):1636-1642.

(3.) Eastwood JD, Hudgins PA, Malone D. Retropharyngeal effusion in acute calcific prevertebral tendonitis: Diagnosis with CT and MR imaging. AJNR Am J Neuroradiol. 1998;19:1789-1792.

(4.) Benanti JC, Grambling O, Bulat PI et al. Retropharyngeal calcific tendinitis: Report of five cases and review of the literature. J Emerg Med. 1986;4(1):15-24.

(5.) Kaplan MJ, Eavey RD. Calcific tendinitis of the longus colli muscle. Ann Otol Rhinol Laryngol. 1984;93(3 pt 1):215-219.

(6.) Newmark H 3d, Forrester DM, Brown JC, et al. Calcific tendinitis of the neck. Radiology. 1978; 128:355-358.

(7.) Haun CL. Retropharyngeal tendinitis. Am J Roentgenol. 1978;130:1137-1140.

(8.) Artinian DJ, Lippman JK, Scidmore GK, Brandt-Zawadzki M. Acute neck pain due to tendonitis of the longus colli: CT and MRI findings. Neuroradiology. 1989;31(2):166-169.

Evan Wasserman, MD, Alan Richman, MD, Namik Erdag, MD, and Rob Weiss, MD

Prepared by Evan Wasserman, MD, Alan Richman, MD, Namik Erdag, MD, and Rob Weiss, MD, Norwalk Hospital, Norwalk, CT.
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Author:Wasserman, Evan; Richman, Alan; Erdag, Namik; Weiss, Rob
Publication:Applied Radiology
Article Type:Case study
Geographic Code:1USA
Date:May 1, 2009
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