Pseudo bilateral tonsilloliths: A case report and review of the literature Saravanan Ram, BDS, a Chong Huat Siar, BDS, MSc, FDSRCPS, FRCPath, b Siti Mazlipah Ismail, BDS, FDSRCS, c and Narayanan Prepageran, MBBS, MS, FRCS, d Kuala Lumpur, Malaysia UNIVERSITY OF MALAYA Tonsilloliths are very rare concretions found in the tonsillar crypt. They are usually single and unilateral, but occasionally may be multiple or bilateral. Small concretions in the tonsils are common, but well formed giant unilateral or bilateral tonsilloliths are extremely uncommon. Only two cases of bilateral tonsilloliths have so far been reported in the literature. A case of unilateral tonsillolith, mimicking bilateral tonsilloliths taken with the orthopantogram (OPT) in a 57-year-old Malaysian Indian female with squamous cell carcinoma of the oral cavity is described. Although the OPT is a reliable and standard panoramic X-ray unit used in dentistry, superimposition of a lesion involving one side of the jaw creates a pseudo or ghost image on the contralateral side leading to a misdiagnosis of bilateral lesions. This report highlights that tonsilloliths, though rare, should be considered in the differential diagnosis of radiopaque masses involving the mandibular ramus, and that investigations such as CT scan or MRI may be required to differentiate pseudo or ghost images from true bilateral pathologies. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;98:110-4) INTRODUCTION Tonsilloliths are calcified structures that develop in enlarged tonsillar crypts that are packed with bacteria and organic debris. 1 Tonsilloliths are relatively uncommon findings. The literature states that the Otolaryngologist may come across such a case only once in their career if at all. 2 Small areas of calcification are frequently encountered on routine sectioning of gross specimens of tonsillec- tomy. 3 Larger concretions occur with a much lower incidence. 4 They can be single, multiple, unilateral or bilateral. 5 Only two cases of bilateral tonsilloliths are reported in the literature. 4 A case of unilateral tonsillolith appearing as bilateral tonsilloliths using the OPT is described here. The aim of this report is to highlight for the reader that pathology of the tonsils, namely a tonsillolith, may be difficult to distinguish from other radiopaque lesions of the jaws. This is especially true in asymptomatic patients, and investigations such as CT scan or MRI may be necessary to differentiate pseudo or ghost images from actual bilateral pathologies. Moreover, ghost images should be ruled out while evaluating lesions using a panoramic radiograph. CASE REPORT A general dental practitioner referred a 57-year-old Malaysian Indian female to the Oral Medicine Clinic, Faculty of Dentistry, University of Malaya for an opinion and management of pain on the right buccal mucosa of four weeks duration. The patient had noted a growth on the right cheek where she had previously placed a tablet. She habitually chewed betel leaf with areca nut, slaked lime and tobacco for the past 40 years. Her medical history was eventful for hypertensive cerebrovascular accident with a left-sided hemiplegia about a year ago. Clinical examination revealed an intra oral ulcerative growth arising from the right retromolar region and extending mesially on to the buccal mucosa. At initial presentation, it measured 4 3 3 cm, had rolled margins and an indurated base with friable tissue in the center. A single right submandibular lymph node measuring approximately 1.5 - 2.0 cm in size, not fixed and of hard consistency was evident on palpation. A panoramic film was taken but there was no evidence of bony involvement of the mandible on the affected side. However it revealed the presence of two large, radiopaque lesions, one on either side of the ramus of the mandible (Fig. 1). This led us to assume that the panoramic radiograph may have been taken with betel quid remnants in both buccal mucosae. The panoramic film was repeated without the quid, and we were perplexed to find that the radiopaque lesions still persisted. Further discussion at the clinicopathologic session led to a radiologic diagnosis of bilateral tonsilloliths. At the same time, an incisional biopsy of the right retromolar region was performed under local anesthesia and subsequent histopathological evaluation of the submitted specimen confirmed a diagnosis of a Graduate student, University of Malaya, Kuala Lumpur, Malaysia. b Professor, Department of Oral Pathology, Oral Medicine & Periodon- tology, Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia. c Lecturer, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia. d Lecturer, Department of Otorhinolaryngology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia. Received for publication Jul 25, 2003; returned for revision Aug 12, 2003; accepted for publication Nov 21, 2003. 1079-2104/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.tripleo.2003.11.015 110