Goodlettsville Dental Services

Tonsillolith

A tonsillolith, also known as a tonsil stone, is a piece (or more commonly, a cluster) of calcareous matter which forms in the rear of the mouth, in the crevasses (called tonsillar crypts) of the palatine tonsils (which are what most people commonly refer to as simply tonsils).

Protruding tonsilloliths may have the feel of a foreign object, lodged in the back of the tonsil crypt. They may be an especially uncomfortable nuisance, but are often not harmful. They are one possible cause of halitosis ("bad (via tonsils) breath").

Symptoms

Tonsilloliths occur more frequently in adults than in children. Many small tonsil stones do not cause any noticeable symptoms. Even when they are large, some tonsil stones are only discovered accidentally on X-rays or CT scans.

Other symptoms include a metallic taste, throat closing or tightening, coughing fits, and choking.

Larger tonsilloliths may have multiple symptoms, including recurrent halitosis, which frequently accompanies a tonsil infection, sore throat, white debris, a bad taste in the back of the throat, difficulty swallowing, otalgia, and tonsil swelling. A medical study conducted in 2007 found an association between tonsilloliths and bad breath. Among those with bad breath, 75% of the subjects had tonsilloliths while only 6% of subjects with normal halitometry values (normal breath) had tonsilloliths. A foreign body sensation may also exist in the back of throat. The condition may also be an asymptomatic condition, with detection upon palpating a hard intratonsillar or submucosal mass.

Treatment, if required, is usually removal of concretions by curettage; larger lesions may require local excision although these treatments may not help the bad breath issues that are often associated with this condition. Gargling with mouth wash and frequent teeth brushing will sometimes help stop the formation of tonsil stones. It is recommended to check your tonsils at least once a week in order to prevent giant tonsil stones from forming.

Classification

Tonsilloliths or tonsil stones are calcifications that form in the crypts of the palatal tonsils. They are also known to form in the throat and on the roof of the mouth. Tonsils are filled with crevices where bacteria and other materials, including dead cells and mucus, can become trapped. When this occurs, the debris can become concentrated in white formations that occur in the pockets. Tonsilloliths are formed when this trapped debris combines and hardens, or calcifies. This tends to occur most often in people who suffer from chronic inflammation in their tonsils or repeated bouts of tonsillitis. These calculi are composed of calcium salts such as hydroxyapatite or calcium carbonate apatite, oxalates and other magnesium salts or containing ammonium radicals, macroscopically appear white or yellowish in color, and are usually of small size – though there have been occasional reports of large tonsilloliths or calculi in peritonsillar locations. While many people have small tonsilloliths that develop in their tonsils, it is quite rare to have such a large and solidified tonsil stone.

Giant tonsilloliths

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

Causes

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

• dead white blood cells  
• oral bacteria  
• overactive salivary glands  
• mucus secretions  
• residual of enzyme action on retained food  
• smoking without a filter  

Tonsil stones are not a rare occurrence in people. It is not uncommon for both children and adults to have tonsil stones. Often, people may not know what tonsil stones are.

Pathophysiology

Low-power microscope magnification of a cross-section through one of the tonsillar crypts (running diagonally) as it opens onto the surface of the throat (at the top). Stratified epithelium (e) covers the throat’s surface and continues as a lining of the crypt. Beneath the surface are numerous nodules (f) of lymphoid tissue. Many lymph cells (dark-colored region) pass from the nodules toward the surface and will eventually mix with the saliva as salivary corpuscles (s).

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. In other words, "Because saliva contains digestive enzymes, trapped food begins to break down. Particularly, the starch or carbohydrate part of the food melts away, leaving firmer, harder remains of food in the tonsils." 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.

Diagnosis

Diagnosis is usually made upon inspection. 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 branchial arches.

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

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 syndrome (elongated styloid process).

Treatment

Self-treatment

The easiest way to remove them is with the tongue, which unlike other methods, does not provoke the gag reflex.

Various other methods also exist. While difficult to perform due to the gag reflex, a quick brushing with a toothbrush may remove surfaced tonsilloliths. Another effective way to remove tonsil stones is by pressing a finger or cotton swab against the bottom of the tonsil and pushing upward. The pressure acts to squeeze out stones. Using an oral analgesic like Chloraseptic can help suppress the gag reflex while cleaning the tonsils or crypts.

A remedy for removing them without stimulating the gag reflex is to simply flex the throat, raise the tongue to the roof of the mouth and swallow, which causes the tonsils to tense up and will sometimes result in the tonsil stone popping out.

Another remedy is to drink an abundance of water throughout the day. Carbonated drinks, preferably seltzer water, tonic water or club soda, which have been known to help dislodge tonsil stones. This is more of a gradual remedy which can either cause parts of a tonsil stone to break off, or loosen the tonsil stone completely.

One method is to use a stainless steel long handled spoon 7.5 inches. You would have to push the stone out from underneath. This method works easier when the stone is older and harder. You can also use tweezers to pluck the stone out. The use of pulsating irrigation to clear out the crypts of accumulated debris may also help (using an adjustable unit on a low pressure setting or a needleless Monoject syringe to avoid damaging tissue.) Alternately medicine droppers (especially one with a curved tip) are used to suck out the smaller stones. Using such a medicine dropper to first irrigate the area with saline which may help to bring the tonsil stone to the surface from which it can then be more easily sucked out with the dropper. To reduce gagging people sometimes think about using everyday objects, such as toothpicks, as small tools instead of using a much larger finger. This is not recommended because of the danger of the short lightweight toothpick/object being released and breathed into the throat. Use extreme caution when attempting any of the methods listed above. The tonsils and throat are very sensitive, and can be damaged or irritated quite easily.

Embedded tonsilloliths (which develop inside tonsils) are not easily removed, but will naturally erupt from the tonsils over time.

Surgical treatment

The most aggressive form of treatment involves surgical removal of the stone, via oral curette.

A longer term cure is possible by using laser resurfacing. The procedure is called laser cryptolysis. This technique can be performed under local anesthetic, using a scanned carbon dioxide laser, which vaporizes and removes the surface of the tonsils. In this way, the edges of the crypts and crevices that collect the debris are flattened out, so that they can no longer trap material. Therefore stones, which are almost like pearls (but not nearly as valuable) forming from a grain of sand, cannot form.

The most drastic method, a tonsillectomy, is permanently effective but should only be considered when less aggressive options fail or are not desired/tolerable.