Tonsil stones

Tonsil stones, also known as tonsilloliths, are mineralizations of debris within the crevices of the tonsils.^[1][3] When not mineralized, the presence of debris is known as chronic caseous tonsillitis (CCT).^[1] Symptoms may include bad breath,^[1] foreign body sensation, sore throat, pain or discomfort with swallowing, and cough.^[4] Generally there is no pain, though there may be the feeling of something present.^[1] The presence of tonsil stones may be otherwise undetectable, however some people have reported seeing white material in the rear of their throat.

Risk factors may include recurrent

They are usually benign, so if tonsil stones do not bother the patient, no treatment is needed.[1] However in rare cases, tonsilloliths have presented patients with further complications necessitating surgical extraction. Tonsilloliths that exceed the average size are typically seen in older individuals as the likelihood of developing tonsil stones is linear. Otherwise, gargling salt water and manual removal may be tried.^[1] Chlorhexidine or cetylpyridinium chloride may also be tried.^[1] Surgical treatment may include partial or complete tonsil removal.^[1][10] Up to 10% of people have tonsil stones.^[1] Biological sex does not influence the chance of having tonsil stones,^[1] but older people are more commonly affected.^[2] Many people opt to extract their own tonsil stones manually or with developments in dental hygiene products. Water flossers have become a more common mechanism to extract tonsilloliths and alleviate the discomfort and complications they exacerbate. Tonsil stones can become dislodged on their own while eating, drinking, gargling, and coughing. Additionally, an exhalation technique that vigorously shakes the tonsils may be performed to dislodge them. This involves loudly producing a voiceless velar fricative sound, at various pitches to shake both the palatine and lingual tonsils.

Signs and symptoms

Tonsil stones may produce no symptoms or they may be associated with bad breath.^[1] In fact, many dental professionals argue that tonsil stones are the leading cause of bad breath in their patients. The smell may be that of rotting eggs.^[11] Tonsil stones tend to happen most often in people with longterm inflammation in their tonsils.^[12]

Occasionally there may be pain when swallowing.

Larger tonsil stones may cause recurrent bad breath, which frequently accompanies a tonsil infection,

• 
  A tonsillolith protrudes from the tonsil
• 
  Large tonsillolith half exposed on tonsil
• 
  Closeup of a tonsillolith

Pathophysiology

The mechanism by which these calculi form is subject to debate,[3] though they appear to result from the accumulation of material retained within the crypts, along with the growth of bacteria and fungi—sometimes in association with persistent chronic purulent tonsillitis.

In 2009, an association between

Diagnosis is usually made upon inspection. Tonsilloliths are difficult to

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.^[12] Researchers found aerobic bacteria present on the surface of tonsilloliths and anaerobic bacteria at the core of tonsilloliths. They have the potential to cause oral halitosis as they contain volatile sulfur compounds and sulfur derived gases, foul smelling compounds produced during bacterial metabolism.^[16] Tonsilloliths are formed when this trapped debris accumulates and are expressed from the tonsil. They are generally soft, sometimes rubbery. This tends to occur most often in people who suffer from chronic inflammation in their tonsils or repeated bouts of tonsillitis.^[12] They are often associated with post-nasal drip.

Enlarged Tonsil Stones

Much rarer than the typical tonsil stones are giant tonsilloliths. Giant tonsilloliths may often be mistaken for other oral maladies, including peritonsillar abscess, and tumors of the tonsil.^[17] On average, tonsil stones should appear within a similar range of the image on the right; however, individuals with extenuating cases have been reported. In these instances, extensive care such as extraction by a licensed medical professional may be needed.

Differential diagnosis

Imaging diagnostic techniques can identify a

Differential diagnosis of tonsilloliths includes foreign body, calcified granuloma, malignancy, an enlarged temporal styloid process or rarely, isolated bone which is usually derived from embryonic rests originating from the branchial arches.^[19]

Treatment

If tonsil stones do not bother a person, no treatment is needed.^[1] Otherwise gargling saltwater and manual removal may be tried.^[1] Chlorhexidine or cetylpyridinium chloride may also be tried.^[1] Surgical treatment may include partial or complete tonsil removal.^[1]

Some people are able to remove tonsil stones using a cotton swab. Oral irrigators are also effective. Most electric oral irrigators are unsuitable for tonsil stone removal because they are too powerful and are likely to cause discomfort and rupture the tonsils, which could result in further complications such as infection. Irrigators that connect directly to the sink tap via a threaded attachment or otherwise are suitable for tonsil stone removal and everyday washing of the tonsils because they can jet water at low-pressure levels that the user can adjust by simply manipulating the sink tap, allowing for a continuous range of pressures to suit each user's requirements.^[12]

There are also manually pressurized tonsil stone removers. A manual pump-type tonsil stone remover can adjust the water pressure depending on the number of pumps, effectively removing tonsil stones.

More simply still, gargling with warm, salty water may help alleviate the discomfort of tonsillitis, which often accompanies tonsil stones. Vigorous gargling each morning can also keep the tonsil crypts clear of all but the most persistent tonsilloliths.^[12]

Curettage

Larger tonsil stones may require removal by curettage (scooping) or otherwise, although thorough irrigation will still be required afterward to effectively wash out smaller pieces. Larger lesions may require local excision, although these treatments may not completely help the bad breath issues that are often associated with this condition.

Laser

Another option is to decrease the surface area (crypts, crevices, etc.) of the tonsils via laser resurfacing. The procedure is called a laser

Surgery

Tonsillectomy may be indicated if bad breath due to tonsillar stones persists despite other measures.^[20]

Epidemiology

Tonsilloliths or tonsillar concretions occur in up to 10% of the population, frequently due to episodes of tonsillitis.^[21] While small concretions in the tonsils are common, true stones are less so.^[3] They commonly occur in young adults and are rare in children.^[3]

References

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