Tonsilloliths

Tonsilloliths (tonsil stones) are small calcified concretions of food debris, desquamated epithelial cells, bacteria and mucus that form in the crypts of the palatine tonsils. They are common and usually harmless, found in up to 10 percent of adults on imaging, and are more frequent in people with chronic tonsillar inflammation or deep crypts.

• Composition: calcium salts (hydroxyapatite, calcium carbonate) with anaerobic bacteria such as Fusobacterium and Actinomyces and volatile sulfur compounds that cause the odour.
• Risk factors: large irregular tonsils with deep crypts, previous recurrent tonsillitis, poor oral hygiene, postnasal drip, chronic sinusitis, dry mouth, smoking.
• Size ranges from a grain of rice to over 1 cm; giant tonsilloliths are rare.
• Complications are uncommon: recurrent tonsillitis, peritonsillar abscess, tonsillar ulceration, dysphagia, ear pain (referred) and, rarely, aspiration or a tonsillolith mistaken for a tumour.

• Halitosis (the commonest complaint), a foreign body or lump sensation, sore throat, a metallic or unpleasant taste, ear pain on swallowing (referred via the glossopharyngeal nerve), cough, and white or yellow spots on the tonsils that the patient sometimes coughs up or dislodges.
• Examination: white or yellow nodules in the tonsillar crypts, tonsil surface irregular, mild erythema, no marked asymmetry.
• Red flags: unilateral tonsillar enlargement or firmness, ulceration that does not heal, bleeding, neck mass, weight loss, persistent unilateral sore throat or ear pain, dysphagia, trismus, drooling, fever with severe pain (peritonsillar abscess), night sweats, smoker over 40, history of oropharyngeal cancer risk (HPV).

• Clinical diagnosis on oral examination. Tonsilloliths are often detected incidentally on panoramic dental X-ray or CT.
• No investigations are needed for typical cases.
• For unilateral enlargement or suspicious lesion: ENT referral, biopsy, and contrast CT of the neck.
• Differentials: tonsillitis with exudate (fever, pain), tonsillar candidiasis, foreign body, tonsil cancer, lymphoma, calcified lymph node, tonsillar keratosis, peritonsillar abscess, vascular calcification (carotid, styloid process elongation causing Eagle syndrome).

• Reassure that tonsilloliths are benign and not contagious.
• Self-care: gargle with warm salt water (half a teaspoon of salt in a glass of water) several times daily; antiseptic mouthwash without alcohol; thorough tooth brushing, tongue scraping and flossing; stay hydrated; stop smoking; low pressure oral irrigator (water flosser) aimed gently at the crypt; gentle expression with a moistened cotton bud (do not use sharp objects, risk of bleeding and injury); coughing or gargling vigorously can dislodge stones.
• Treat contributors: postnasal drip (intranasal steroid and saline irrigation), reflux, dry mouth, chronic sinusitis.
• Antibiotics do not remove stones and are not indicated unless there is acute tonsillitis (phenoxymethylpenicillin 500 mg orally four times daily for 10 days in adults).
• Procedures for troublesome, recurrent stones (ENT): cryptolysis (laser or coblation) to open crypts; manual removal; tonsillectomy for severe symptoms, recurrent tonsillitis or stones that do not respond to conservative treatment (risks include post-tonsillectomy haemorrhage in about 3 to 5 percent, pain, and a recovery of 1 to 2 weeks).
• Review as needed; refer to ENT for red flags or persistent symptoms.