Tonsillolith

Tonsillolith

190px A tonsillolith lodged in the Tonsilar Crypt
ICD-10	J35.8

A tonsillolith, also known as a tonsil stone, is a piece or, more commonly, a cluster of calcareous matter that forms in the rear of the mouth, in the crevasses (called tonsillar crypts) of the palatine tonsils (commonly known as tonsils). They can range up to the size of a peppercorn and are white/cream color. The main substance is mostly collagen, but they have a strong unpleasant odor because of hydrogen sulfide, methyl mercaptan and other substances.

Protruding tonsilloliths may feel like foreign objects lodged in the tonsil crypt. They may be a nuisance, but are usually not harmful. They are a possible cause of halitosis (bad breath).

Symptoms

File:Tonsilstone.jpg

A tonsillolith protrudes from the tonsil

File:Tonsilloliths 20091119 prior to tonsillectomy.JPG

Large tonsillolith half exposed on tonsil

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 CAT 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, ear ache, 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.

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. They are often associated with post-nasal drip. 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. Many people have small tonsilloliths that develop in their tonsils, and it is quite rare to have 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.

• Tonsilolith-Measured.jpg

  A small tonsillolith

• Large Tonsillolith.jpg

  A large tonsillolith

Causes

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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
• allergy/intolerance to dairy products

Tonsil stones are not a rare occurrence in people. It is common for both children and adults to have tonsil stones.

Pathophysiology

File:Gray1027.png

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. Recently an association between biofilms and tonsilloliths was shown. The center of a biofilm concept assumes the bacteria to form a three dimensional structure with dormant bacteria in the center that serve as a constant nidus of infection. The impermeable to antibiotics structure renders the biofilm immune to antibiotic treatment. By use of confocal microscopy and microelectrodes biofilms similar to dental biofilms were shown to be present in the tonsillolith, with oxygen respiration at the outer layer of tonsillolith, denitrification toward the middle, and acidification toward the bottom.

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

A common method of removal is with use of the tongue. Unlike other methods, this 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 which hydrates the throat and prevents the formation of tonsil stones. Carbonated drinks, preferably seltzer water, tonic water or club soda, 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. Gargling with warm salty water seems to help heal the pockets themselves, as does a mixture of 1 or 2 drops of Grapefruit Seed Extract combined with a strong minty mouthwash to make it palatable. Expect the process to take about two weeks, gargling morning and night. Pressing the back of a sonic toothbrush against the bottom of the tonsil works well. This short term solution does not prevent recurrence.

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. 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. This technique flattens the edges of the crypts and crevices that collect the debris preventing trapped material from forming stones.

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

See also

• Oral candidiasis (thrush) - thick white or cream-color deposits in the mouth

External links

• Giant tonsillolith: Report of a case (In Spanish with English abstract)de:Tonsillenstein

sv:Tonsillolit