Abstract
To determine the prevalence of tonsilloliths in CT PNS (Computed Tomography ParaNasal Sinuses) of patients with and without features of chronic rhinosinusitis. 97 CT PNS of the patients with features of chronic rhinosinusitis were included in the study group, and 124 CT PNS of cases without features of chronic rhinosinusitis were taken as the control group. All 221 CT PNS were then evaluated for the presence of tonsillar calcifications indicative of tonsilloliths and the prevalence of the same in the study and control groups. 97 of the 221 CT PNS evaluated showed features of chronic rhinosinusitis. 60 of these 97 CT PNS showed features of tonsillolith in one or both tonsils. Of these 60 cases, 58 had maxillary sinusitis, and 17 had pansinusitis. Most of the cases had small tonsilloliths (1–3 mm), and only one case had a large tonsillolith (> 6 mm). At the same time, 27 out of the remaining 124 CT PNS without chronic rhinosinusitis showed the presence of tonsilloliths in one or both tonsils. The prevalence of tonsilloliths is significantly higher in patients with chronic rhinosinusitis than in the control group. The presence of tonsilloliths in patients with chronic rhinosinusitis indicates repeated inflammation of the tonsils due to sinusitis. Such chronic inflammation of the mucosa of the pharynx should prompt more aggressive treatment of chronic rhinosinusitis.
Keywords: Chronic sinusitis, Computed tomography, Tonsillitis, Pathologic calcification
Introduction
Chronic rhinosinusitis is an inflammation of the mucosa of the nasal passages and the paranasal sinuses lasting more than 12 weeks. Patients with chronic rhinosinusitis present with complaints of nasal obstruction, headache or facial pain, and anterior or posterior nasal discharge. They can also present with rare symptoms like chronic cough, anosmia or hyposmia, and halitosis. Although the diagnosis of chronic sinusitis is based on clinical symptoms and signs, Computed Tomography (CT) of the Paranasal sinuses (PNS) showing mucosal abnormalities of varying degrees in the paranasal sinuses helps to confirm the diagnosis.
One of the incidental findings on CT PNS is the presence of calcification in the tonsils. The association between chronic pharyngitis and tonsillitis in patients with chronic sinusitis is well established. In this study, we have evaluated 221 CT PNS to look for the presence of concomitant calcifications in the tonsils and features suggestive of chronic rhinosinusitis on CT scan.
Materials and Methods
221 CT PNS were evaluated to look for features of chronic rhinosinusitis. 97 of the CT PNS with features of chronic rhinosinusitis were included in the case group, and the remaining 124 cases (without features of chronic rhinosinusitis) were included in the control group. All the CT PNS of the case and control groups were analysed to look for the presence of calcifications within the tonsillar tissue suggestive of tonsilloliths.
An axial plain helical CT scan of the PNS was performed on a 64-slice Seimans Somatom machine. 1 mm retrospective reconstruction was done, and the images were studied in the axial, coronal, and sagittal planes (Figs. 1, 2). All scans were evaluated by a single radiologist.
Fig. 1.
AXIAL plain CT scan of the PNS through pharynx reveals dense calcifications in bilateral palatine tonsils (yellow arrows)
Fig. 2.
Sagittal reconstructed image reveals dense calcification of the right palatine tonsil (yellow arrow)
The degree of calcification was graded based on the size of the largest individual calcification seen in the tonsillar tissue of each tonsil (right and left tonsils separately) (Table 1).
Table 1.
Grading of tonsillolith on CT PNS
| Size of the tonsillolith | Grading of tonsillolith |
|---|---|
| 1–3 mm | Small |
| 4–6 mm | Medium |
| > 6 mm | Large |
Results
97 CT PNS, which had features suggestive of chronic rhinosinusitis were evaluated retrospectively by a single radiologist to look for calcifications within the tonsillar tissue suggestive of tonsilloliths. Of these 97 cases of chronic rhinosinusitis, 60 cases (62%) had varying degrees of calcification within the tonsils, indicating tonsilloliths (Table 2).
Table 2.
Prevalance of tonsilloliths in the cases and control group
| CT showing tonsillar calicification | CT without any tonsillar calicification | |
|---|---|---|
| CT PNS with features of Chronic Rhinosinusitis (Cases-97) | 60 | 37 |
| CT PNS without evidence of chronic rhinosinusitis (Control-124) | 27 | 97 |
124 CT PNS without features of chronic rhinosinusitis were included in the control group, and evaluation for the presence of tonsilloliths showed 27 CT PNS (21.7%) with varying degrees of calcification within the tonsils.
Analysis of the data using the Chi-square test showed a p value of < 0.0001, indicating a high significance of the prevalence of tonsilloliths in the case group compared to the controls.
There was a slightly higher preponderance of male patients having tonsilloliths compared to females: 38 males and 22 females in the case group and 15 males and 12 females in the control group. The oldest patient was 75 years old, and the youngest patient was 15 years old, with average age of 41.48 years.
The degree of calcification was graded based on the size of the individual calcifications seen in the tonsillar tissue of each tonsil (right and left tonsils separately). 59 cases had small tonsilloliths about 1–3 mm, 11 had medium-sized tonsilloliths (4–6 mm), and a single case had a large tonsillolith > 6 mm.
Maxillary sinusitis was a common sinus involved in the case group; 58 of the 60 cases with tonsilloliths had maxillary sinus involvement. 25 cases had ethmoid sinus involvement, 21 had frontal sinus involvement and 19 had sphenoid sinus involvement. 17 cases had pansinusitis.
Discussion
Tonsillolith is a rare dystrophic calcification as a result of chronic inflammation of the tonsils. This type of calcification occurs in degenerative and dead tissue despite normal serum calcium and phosphate levels [1]. Tonsilloliths are seen in patients with chronic tonsillitis and are formed when exfoliated epithelium cells, keratin debris, and food particles get entrapped within the blind-ending crypts on the tonsillar surface [2].
Tonsilloliths can be completely asymptomatic or can cause symptoms like irritation in the throat, recurrent tonsillitis, dysphagia, foreign body sensation in the throat, and halitosis [3].
Takahashi A et al. reviewed CT scans of the head and neck of 2,873 patients and found tonsillar calcification in 1,145 (39.9%) of these cases. The CT scans in this study were done for various indications like tumours of the head and neck, inflammatory lesions, head and neck injuries, congenital diseases, and other miscellaneous conditions. They also found a higher prevalence of tonsillolith among men than women. This was attributed to the higher rates of smoking and poor oral hygiene among men [4].
In our study, too, we found a slightly higher male preponderance. The incidence of tonsillolith is higher in the older age group, possibly due to repeated pharyngitis. This was also noted in our study, where the average age of the patients was 42 years.
Chronic rhinosinusitis is a common disease worldwide and is usually diagnosed based on clinical symptoms and signs as formulated by the Rhinosinusitis Task Force of the American Academy of Otolaryngology and Head and Neck Surgery. The symptoms and signs are classified as major and minor criteria, and the presence of two major criteria or one major and two minor criteria can be used to establish the clinical diagnosis of rhinosinusitis [5].
A CT scan of the paranasal sinuses (PNS) is the best radiologic tool for the diagnosis of sinusitis. Although it lacks specificity, CT PNS continues to be the gold standard for decision-making regarding medical therapy or surgery for all otolaryngologists [6]. A CT finding of mucosal thickening and opacification is indicative of chronic sinusitis and can be further graded based on the Lund-Mackay grading system to determine disease severity [5].
Chronic sinusitis is accompanied by thick mucoid or mucopurulent post-nasal drip. This constant dripping into the pharynx is responsible for chronic cough, recurrent pharyngitis, Gastro Esophageal Reflux Disease (GERD), and chronic inflammation of the entire pharynx. It has also been attributed to head and neck cancers like nasopharyngeal carcinoma, nasal cancer, and paranasal sinus cancer [7].
Chronic sinusitis is associated with thick mucoid post-nasal drip, and the repeated episodes of inflammation caused by this may produce fibrosis at the opening of the tonsillar crypts. Bacterial and epithelial debris gets entrapped within the tonsillar crypts, leading to retention cysts that get calcified over time [1]. This is a possible etiopathogenesis for tonsilloliths in cases of chronic rhinosinusitis.
The high incidence of tonsillolith in patients with chronic sinusitis indicates chronic, indolent inflammation of the upper respiratory tract in these patients. Given the risk of malignancy in such cases, this finding of tonsilloliths should prompt the surgeon to seek more aggressive therapy for the resolution of the chronic rhinosinusitis.
Conclusion
More than half (62%) of the cases of chronic rhinosinusitis showed features of calcification of the tonsils indicative of tonsilloliths, compared to 21.7% of the controls. Although an incidental finding, the presence of tonsilloliths indicates chronic inflammation of the pharynx and could be of significance in treatment planning for such patients.
Funding
The Authors did not receive any funding for the submitted work during conduct of the study or manuscript preparation.
Declarations
Conflict of Interest
The Authors declare that this study was performed in line with the principles of the Declaration of Helsinki. The Authors have no relevant financial or non-financial interests to disclose.
Ethical Approval
Approval was granted by the Institutional Ethics Committee for the study.
Informed Consent
Informed consent was obtained from all individual participants for participation in the study and publishing of the data collected as part of the study.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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