Tonsillolith

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Tonsillolith

A tonsillolith lodged in the Tonsilar Crypt
ICD-10	J35.8
ICD-9

A tonsillolith (also called tonsil stone, tonsillar debris, or calculus of the tonsil) 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 have the feel of a foreign object, lodged in the back of your tonsil crypt. They may be an especially uncomfortable nuisance, but are not often harmful. They are one possible cause of halitosis ("bad breath").^[1]

[edit] Symptoms

A tonsillolith protrudes from the 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 incidentally on X-rays or CT scans.

Larger tonsilloliths may have multiple symptoms, including reoccurring 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.^[2] A foreign body sensation may also exist in the back of throat. The condition may also prove asymptomatic, with detection upon palpating a hard intratonsillar or submucosal mass.

Treatment 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.

[edit] 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 mucous, can become trapped. When this occurs, the debris can become concentrated in white formations that occur in the pockets.^[2] Tonsillothis 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.^[2] 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.

[edit] 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.^[3]

A small tonsillolith

A large tonsillolith

[edit] Causes

Tonsil stones, it is theorized, are the result of a combination of any of the following:^[4]

• dead white blood cells
• oral bacteria
• overactive salivary glands
• mucus secretions
• residual of enzyme action on retained food

[edit] 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."^[4] 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.

[edit] 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.^[5]

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’s syndrome (elongated styloid process).^[6]

[edit] Prevention

Prevention methods include gargling with salt water, cider vinegar, or a non-alcohol-, non-sugar-based mouth wash (eg sodium bicarbonate mouthwash).

[edit] Treatment

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[edit] Self treatment

Tonsilloliths can be removed by the patient. A medicine dropper (especially one with a curved tip) can help to suck out the stones if they are small enough. Embedded tonsilloliths (which develop inside tonsils) are not easily removed, but will naturally erupt from the tonsils with time.

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.) Use a solution of salt water to cleanse the tonsil crypts and help prevent future tonsilloliths. The use of a combination nasal/throat irrigation device is recommended. For direct cleansing of the tonsil stones use the throat irrigator tip, and for cleansing of the nasal passages use the nasal irrigation tip. This is especially beneficial for post-nasal drip which routinely contributes to the formation of tonsil stones.

While difficult to perform due to the gag reflex, a quick brushing with a toothbrush will generally remove surfaced tonsilloliths. Using an oral analgesic like Chloraseptic can help suppress the gag reflex while cleaning the tonsils or crypts. 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 squeezes out stones. Some people can even reach them with their tongue, which is the best method as the tongue doesn't stimulate the gag reflex.

Another remedy for removing them, without stimulating the gag reflex, (in most people) is to simply flex the throat, this causes the tonsils to tense up and will often result in the tonsil stone popping out.

[edit] Surgical treatment

The most aggressive form of treatment involves surgical removal of the stone, via oral curette or a tonsillectomy to remove the tonsils.

For large crevices, an effective tool for digging out a stone is an ear curette. The curette is used primarily for the removal of ear wax, but is effective for removal of tonsil stones as well. It comprises a long thin metal stick with a tiny metal loop at the end. Alternatives include the curved end of a crochet needle, a cotton swab, an unfolded paper clip (leaving the smallest bend intact), or a hair grip (bobby pin), although this is not recommended because it is known to cause infection due to the coating of the bobby pin that can flake into the cavity.

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 forming from a grain of sand, cannot form.

The most drastic method, a tonsillectomy, is not usually indicated or recommended, but will provide semi-permanent relief. There is still a possibility that the stones will return even with the tonsillectomy.^{[citation needed]}

[edit] See also

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

[edit] References

[edit] External links

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