What is Tonsilloliths?

Tonsilloliths or tonsil stones are a buildup of bacteria, mucus, debris and mineral salts (e.g. calcium salts, oxalates, magnesium salts) forming on the desquamated (shedding) cells of the tonsillar crypts (deep pockets or folds that occur naturally in the tonsils).

Tonsilloliths consistency range from soft and friable to hard as stone. They are white or yellowish in color. Sizes of tonsilloliths are varied, ranging from a few millimeters to several centimeters, but most tonsilloliths are about the size of a pencil eraser.

Tonsilloliths
Image: © Mayo Clinic

Tonsilloliths
Creator: Jeannot Olivet
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Tonsilloliths

Who gets Tonsilloliths?

Tonsilloliths are more likely to occur in older age groups and less like to occur in children. They appear most often in people between the ages of 20 and 60. Mean age of patients with tonsilloliths is 50 years old.

Some argue that, tonsilloliths occur most commonly in young adults with long histories of recurrent tonsillitis (inflammation of the tonsils).

The condition displays no sex preference (males: females ratio = 1:1).

 

What are the causes?

The exact mechanism of how tonsilloliths are formed is uncertain.

Most authors believe that tonsilloliths are caused by repeated episodes of tonsillar resulting in fibrosis and accumulation of debris within the tonsillar crypts; followed by the deposition of inorganic salts derived from saliva and bacterial overgrowth.

Unresolved tonsillitis associated with infectious agents (e.g. fungi and anaerobic bacteria) and puss is thought to be the ideal location for stone formation.

On the other hand, some have suggested that the tonsilloliths result from stasis of saliva in the efferent (exiting) ducts of the accessory salivary gland, secondary to mechanical obstruction arising from post-tonsillectomy scars or chronic inflammation.

 

Clinical Features

Many tonsilloliths, especially the small ones, are often asymptomatic. Patients may present due to concerns about the “white spots” on their tonsils when they look in the mirror. On the other hand, large tonsilloliths may produce several symptoms and mimic an abscess or cancer.

Below are symptoms that patients with tonsilloliths can present with:

  • Throat pain
  • Dysphagia (difficulty swallowing)
  • Odynophagia (pain on swallowing)
  • Otalgia (ear pain)
  • Foreign body-like sensation in the throat
  • Halitosis (foul-smelling breath)
  • A foul test
  • Irritable cough

 

How is it diagnosed?

Usually, the diagnosis of tonsillolith can be made clinically from the history and physical examination.

However, at times, imaging tests (e.g. X-ray, CT scan) of the oropharynx may be warranted if the tonsilloliths are too small or hidden so they cannot be seen with naked eyes. They are helpful for identifying the extent of the lesions, the exact locations, distribution, and the number and shape of the lesions.

Occasionally, large tonsilloliths are found incidentally during routine panoramic dental X-ray. The most common X-ray appearance of tonsilloliths is a cluster of multiple, small, ill-defined white-colored lesions of similar density to bone.

 

What are the potential complications?

There are very few complications associated to tonsilloliths. However, they may cause extreme concern for patients when they noticed the abnormality at the back of their throat.

Large tonsilloliths can damage and disrupt normal tonsil tissue leading to swelling, inflammation, and infection. Occasionally, tonsilloliths may cause formation of abscess within the tonsils which can result in trismus (spasm of the jaw muscles, causing the mouth to remain tightly closed).

In elderly patients, pulmonary complications (e.g. pneumonia, lung abscess) may occur secondary to aspiration of large tonsilloliths.

 

What are the treatment options?

No treatment is required for most asymptomatic tonsilloliths. Some may extrude spontaneously.

Patients may attempt to remove the tonsilloliths on their own. Recommended options are 1) gargling with salt water and 2) using pulsating water jets that is available commercially. These methods are safer and more effective than trying to dislodge the stones by other means. Using objects (e.g. cotton swabs, dental tools, straws) to pick the tonsilloliths out of the tonsillar crypts can lead to irritation and injury to the sensitive tonsillar tissues.

In more severe cases, tonsilloliths may be removed under topical or local infiltration anesthesia. Your doctor my express the tonsilloliths using gentle squeezing pressure or remove the tonsilloliths by curettage. Larger tonsilloliths may require local excision.

Tonsillectomy (removal of tonsils) is generally reserved as a final resort of treatment for patients with tonsilloliths that are chronically inflamed. Tonsillectomy is often done as an outpatient procedure. However, some patients may need to stay overnight in the hospital to be observed.

In some cases, a procedure to flatten the tonsils and reduce the number of tonsillar crypts to reduce chance of tonsillolith formation may be used. This is called ‘cryptolysis’ which can be done by laser or coblation (controlled ablation).

 

Prevention

Tonsilloliths may be preventable by good dental hygiene such as flossing and brushing the teeth and tongue after every meal. Tongue scraper may be used to help keeping tongue clean and clear of debris or bacteria that can contribute to stone formation.

For people who have previously had tonsilloliths in the past, gargling with an oral rinse or salt water daily may reduce the chance of developing new tonsilloliths.

Tonsillectomy may be considered as a prevention strategy in patients with recurrent tonsilloliths.

 

What is the prognosis?

Tonsilloliths, as mentioned prior, can be effectively removed either by the patient or doctors. However, it is possible for the tonsilloliths to form again especially if oral hygiene is not adequately maintained.

Only definitive treatment of tonsilloliths that can permanently prevent its formation is tonsillectomy.

 

Impact on DALY?

Symptomatic tonsilloliths often interfere with the patients’ daily activity. Not only that it can cause discomfort and difficulty eating and drinking, tonsilloliths can emit an offensive smell causing foul-smelling breath.

Patients may feel embarrass and uncomfortable in social situations due to this.

 

Further reading:

Tonsil Stones (Tonsilloliths)https://www.webmd.com/oral-health/guide/tonsil-stones-tonsilloliths-treatment-and-prevention#4-7
Tonsil Stones: What They Are and How to Get Rid of Them https://www.healthline.com/health/dental-and-oral-health/tonsil-stones
Tonsilloliths https://patient.info/ears-nose-throat-mouth/sore-throat-2/tonsillolith-tonsil-stones

 

References:

Mody RN, Srivastava S. Bilateral multiple tonsilloliths. Oral Radiology. 2009;25(1):67-70.

Bamgbose BO, Ruprecht A, Hellstein J, Timmons S, Qian F. The Prevalence of Tonsilloliths and Other Soft Tissue Calcifications in Patients Attending Oral and Maxillofacial Radiology Clinic of the University of Iowa. ISRN Dentistry. 2014;2014:839635.

Mesolella M, Cimmino M, Di Martino M, Criscuoli G, Albanese L, Galli V. Tonsillolith. Case report and review of the literature. Acta Otorhinolaryngol Ital. 2004;24(5):302-7.

Alfayez A, Albesher MB, Alqabasani MA. A giant tonsillolith. Saudi Medical Journal. 2018;39(4):412.

Moura MDGd, Madureira DF, Noman-Ferreira LC, Abdo EN, Aguiar EGd, Addah Regina da Silva F. Tonsillolith: a report of three clinical cases. Medicina Oral, Patología Oral y Cirugía Bucal (Internet). 2007;12(2):130-3.

Myers NE, Compliment JM, Post JC, Buchinsky FD. Tonsilloliths a common finding in pediatric patients. The Nurse Practitioner. 2006;31(7):53-4.

Cakur B, Yıldırım E, Demirtaş Ö. An investigation of relationship between tonsillolith and carotid artery calcification on panoramic radiography. Atatürk Üniversitesi Diş Hekimliği Fakültesi Dergisi. 2014;24(1).

Sharma KH, Phull TS. Unilateral tonsillolith: a serendipitous finding. Asian J Oral Health Allied Sci. 2011;1(3):213.

Reiner SA, Sawyer WP, Clark KF, Wood MW. Safety of outpatient tonsillectomy and adenoidectomy. Otolaryngology—Head and Neck Surgery. 1990;102(2):161-8.

Chang CY, Thrasher R. Coblation cryptolysis to treat tonsil stones: a retrospective case series. Ear, Nose & Throat Journal. 2012;91(6):238-54.

DeAssis-Soares MR, Maillet PJ. Halitosis from tonsilloliths: Literature review for oral healthcare providers. Canadian Journal of Dental Hygiene. 2011;45(4).

 

Author + Affiliation:
Thitapon Uiyapat

Date of Publication +/- Review:

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