Panoramic Radiographic Appearance of Giant Bilateral Tonsilloliths.

Abstract

A 52-year-old male patient reported with a chief complaint of pus discharge from left mandibular posterior region, with an associated history of extraction of tooth 36 one year ago. Past medical history of patient was not significant in relation to patient’s current complaint. Draining sinus was observed near the left body region of the mandible extraorally [Table/Fig-1]. Intraorally associated region disclosed a mobile root remnant [Table/Fig-2]. A provisional diagnosis of chronic suppurative osteomyelitis was made because of mobile root remnant of mandibular left first molar. A periapical radiograph showed extensive radiolucent bony changes surrounding the root remnant and hence a panoramic radiograph was advised. Interestingly, the panoramic radiograph showed the presence of two ovoid shaped radiopaque areas superimposed one on either side of the ramus of mandible measuring of size approximately 2.5cm x 2.8cm and 1.3cm x 1.6cm respectively on right and left side [Table/Fig-3] and large radiolucent lesion associated with periapical to root piece of lower left first molar. A lateral oblique view of left ramus showed the large ovoid shaped radiopacity above the sigmoid notch excluding intraosseous radiopaque lesion [Table/Fig-4], right lateral oblique view of ramus showed small calcified radiopaque area superimposed on sigmoid notch [Table/Fig-5]. On comparison with panoramic image radiopacity on right side ramus area appears larger in size giving an impression of “Ghost Image” formation. To rule out the size and determine the exact anatomical location patient was advised Computed Tomography (CT) Scan. Radiographic diagnosis of osteomyelitis of left body mandible and soft tissue calcification was given with a differential diagnosis of calcification of phleboliths, calcified lymph node, foreign bodies, an elongated styloid apparatus, large maxillary tuberosity, displaced mandibular third molar and calcified tuberculous lymphadenitis was made. His blood and serological investigations was normal.