Tonsillolith

A Tonsillolith (also called tonsil stone or calculi of the tonsil) is a piece (or more commonly, a cluster) of calcium which forms in the rear of the mouth, in the crevasses (called "crypts") of the palatine tonsils (which are what most people commonly refer to as simply tonsils).

Tonsil stones, it is theorized, are the result of a combination of any of the following:

food particles
dead white blood cells (a.k.a. "leukocytes")
oral bacteria, possibly from mouth breathing
overactive salivary glands

They are described as having a pungent odor, often compared to rotten eggs. Visually, they may resemble sesame seeds in color and texture; they are of similar constitution and are equally friable, especially when clustered.

Protruding tonsilloliths have the feel of a foreign object, lodged between the outside of wisdom teeth and the temporomandibular joint region of the fleshed jaw. They may be an especially uncomfortable nuisance, but are not often harmful.

Appearance Characteristics & Symptoms

Tonsilloliths or tonsil stones are calcifications that form in the crypts of the palatal tonsils. These calculi are composed of calcium salts either alone or in combination with other mineral salts, and are usually of small size - though there have been occasional reports of large tonsilloliths or calculi inperitonsillar locations.

Tonsilloliths are difficult to diagnose in the absence of clear manifestations, and often constitute casual findings of routine radiological studies

These calculi are composed of calcium salts such as hydroxyapatite or calcium carbonate apatite, oxalates and other magnesium salts or containing ammonium radicals, and macroscopically appear white or yellowish in color. The mechanism by which these calculi form is subject to debate, though they appear to result from the accumulation of material retained within the crypts, along with the growth of bacteria and fungi such as Leptothrix buccalis – sometimes in association with persistent chronic purulent tonsillitis.

Alternative mechanisms have been proposed for calculi that are located in peritonsillar areas, such as the existence of ectopic tonsillar tissue, the formation of calculi secondary to salivary stasis within the minor salivary gland secretory ducts in these locations, or the calcification of abscessified accumulations

Symptoms

Tonsilloliths occur more frequently in adults than in children. Symptoms are usually non-specific such as sore throat, chronic cough or otalgia. A foreign body sensation may also exist in the back of throat with recurrent foul breath (halitosis). Treatment is usually removal of concretions by curettage; larger lesions may require local excision.

Tonsilloliths tend to present in young adolescents and can manifest with bad breath and swallowing pain accompanied by a foreign body sensation and – in some cases – reflex ear pain. The condition may also prove asymptomatic, with detection upon palpating a hard intratonsillar or submucosal mass.

Differential Diagnosis

Differential diagnosis of tonsilloliths includes foreign body, calcified granuloma, malignancy, an enlarged styloid process or rarely, isolated bone which is usually derived from embryonic rests originating from the brachial arches ^*.

Imaging diagnostic techniques can identify a radiopaque mass that may be mistaken for foreign bodies, displaced teeth or calcified blood vessels. Computed tomography (CT) may reveal nonspecific calcified images in the tonsillar zone. The differential diagnosis must be established with acute and chronic tonsillitis, tonsillar hypertrophy, peritonsillar abscesses, foreign bodies, phlebolites, ectopic bone or cartilage, lymph nodes, granulomatous lesions or calcification of the stylohyoid ligament in the context of Eagle’s syndrome (elongated styloid process) "Giant tonsillolith: Report of a case Tonsilolito gigante: A propósito de un caso" from Introduction.

Giant Tonsilloliths

Much rarer than typical tonsil stones, are giant tonsilloliths. Giant tonsilloliths may often be mistaken for other oral maladies, including peritonsillar abcess, and tumours of the tonsil.

Treatment & Prevention

Treatment could also go as far as surgical removal of the stone, via oral curette; Alternately, a tonsillectomy in the event the calculus is lodged within the tonsil tissue and is of large size

A cotton swab dipped in hydrogen peroxide applied directly on the tonsil stones will not necessarily dislodge them - it may help some sufferers of tonsilloliths while others may experience only an unpleasant gagging sensation. The use of a water pick (irrigator) to clear out the crypts of accumulated debris may also help (the lower pressure tongue-cleaner attachment is recommended). A more drastic method, a tonsillectomy, is not usually indicated or recommended, but will provide permanent relief.

It is important to remember that although tonsil stones can be uncomfortable, they are rarely ever dangerous and can be seen as more of an inconvenience than anything else.

Prevention

Prevention methods include gargling with salt water or a non-alcohol, non-sugar based mouth wash.

External links

http://www.drgreene.com/21_568.html

The Indian Journal of Radiology and Imaging SHETTY D, LAKHKAR B, SHETTY CM, 2001
Pittsburgh Tribune-Review "Eliminate Bad Breath with Good Hygiene" Maryann Gogniat Eidemiller November 25, 2002

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