# A patient presents with recurrent symptoms suggestive of chronic tonsillitis and a foreign body sensation. On panoramic radiography (OPG), a small, dense radiopacity is noted in the region of the mandibular angle, superior to the hyoid bone. What is the most important differential diagnosis to rule out before confirming a tonsillolith?
a) Elongated styloid process (Eagle Syndrome)
b) Calcified carotid artery plaque
c) Sialolith in the submandibular duct
d) Calcified lymph node (scrofula/granulomatous disease)
On panoramic radiography (OPG), tonsilloliths present as small, dense, ovoid or irregular radiopacities superimposed on the mandibular ramus or angle, often superior to the hyoid bone, reflecting their location in the palatine tonsils. However, this appearance closely mimics other soft tissue calcifications in the same region. Among the differentials, calcified carotid artery plaque (atheroma at the bifurcation) is the most critical to exclude due to its high prevalence (∼29% of such findings in radiographic studies) and serious implications for cardiovascular risk, including potential stroke. It appears as a small, irregular, low-density opacity near the mandibular angle, often unilateral and in older patients (>40 years).
In contrast:
Elongated styloid process (a) typically shows as a linear, vertical radiopacity extending from the skull base, not a small discrete mass.
Submandibular sialoliths (c) are less common mimics (∼11%) and usually project more anteriorly along Wharton's duct, with associated salivary gland symptoms absent here.
Calcified lymph nodes (d) are rarer (∼4%) and often multiple or associated with granulomatous disease signs like fever or lymphadenopathy, not isolated chronic tonsillitis.
Confirmation requires clinical correlation, possibly with CT angiography or ultrasound for vascular assessment, as per otolaryngology and radiology guidelines (e.g., studies in Int J Clin Exp Med and J Indian Acad Oral Med Radiol).
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