Tonsillolith

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A tonsillolith (also called tonsil stone or calculi 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 "crypts") of the palatine tonsils (which are what most people commonly refer to as simply tonsils).

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

• food particles
• dead white blood cells (a.k.a. "leukocytes")
• oral bacteria, possibly from mouth breathing
• overactive salivary glands

They are described as having a pungent odor: Halitosis concentrated into a small solid object. Visually, they may resemble sesame seeds in color and texture.

Protruding tonsilloliths have the feel of a foreign object, lodged between the outside of wisdom teeth and the temporomandibular joint region of the fleshed jaw. They may be an especially uncomfortable nuisance, but are not often harmful.

Contents 1 Appearance and characteristics 2 Symptoms 3 Differential diagnosis 3.1 Giant tonsilloliths 4 Treatment and prevention 4.1 Prevention 5 Slang and foreign terms 6 See also 7 References 8 External links

Appearance and characteristics

Tonsilloliths or tonsil stones are calcifications that form in the crypts of the palatal tonsils. These calculi are composed of calcium salts either alone or in combination with other mineral salts, and are usually of small size - though there have been occasional reports of large tonsilloliths or calculi in peritonsillar locations.

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

These calculi are composed of calcium salts such as hydroxyapatite or calcium carbonate apatite, oxalates and other magnesium salts or containing ammonium radicals, and macroscopically appear white or yellowish in color. 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.

Symptoms

Tonsilloliths occur more frequently in adults than in children. Symptoms are usually non-specific such as sore throat, chronic cough or otalgia. A foreign body sensation may also exist in the back of throat with recurrent foul breath (halitosis). Treatment is usually removal of concretions by curettage; larger lesions may require local excision.

Tonsilloliths tend to be present in young adolescents and can manifest with bad breath and swallowing pain accompanied by a foreign body sensation and – in some cases – reflex ear pain. The condition may also prove asymptomatic, with detection upon palpating a hard intratonsillar or submucosal mass.

Differential diagnosis

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[1].

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) "Giant tonsillolith: Report of a case Tonsilolito gigante: A propósito de un caso" from Introduction.

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.

Treatment and prevention

Treatment could also go as far as surgical removal of the stone, via oral curette; alternately, a tonsillectomy in the event the calculus is lodged within the tonsil tissue and is of large size, or tonsillotomy when the surface of the tonsil is flattened.

A cotton swab dipped in hydrogen peroxide applied directly on the tonsil stones will not necessarily dislodge them - it may help some sufferers of tonsilloliths while others may experience only an unpleasant gagging sensation. The use of a water pick (irrigator) to clear out the crypts of accumulated debris may also help (the lower pressure tongue-cleaner attachment is recommended). While difficult to perform due to the gag reflex, a quick brushing with a toothbrush will generally remove any tonsilloliths. Another effective way to remove tonsil stones is by pressing your finger against the bottom of the tonsil and push upward. The pressure will squeeze any stones out from hiding. You can also try dislodging the tonsil rocks with a cotton bud or Q tip. This may be less irritating than a toothbrush. Some people can even reach around with their tongue, which is the best method as the tongue doesn't stimulate the gag reflex. If you have large crevises, 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 is comprised of a long thin metal stick with a tiny metal loop at the end. If you do not happen to have any of these around you, another useful trick is to use the curved end of a hair grip as it is smaller than a cotton bud and due to the hooped effect, grabs the debris quite successfully.

A longer term cure is possible by using laser resurfacing. The procedure is called laser tonsillotomy, or laser tonsillectomy. This technique can be performed under local anaesthetic, using the scanned carbon dioxide laser, which vapourises and removes the surface of the tonsils. In this way, the edges of the crypts and crevices which 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.

Nasal rinses with a neti-pot affords relief and improves the overall health of the sinuses. Neti-pots are available at health food stores (see Jala neti).

Complete healing has been experienced by some as a result of lap-swimming in a chlorinated pool. This may be attributed to several factors: 1. Sanitizing affects of chlorine on anaerobic bacteria 2. The oxygenating affects of aerobic exercise 3. Forced rhythmical "holding of your breath" cause a suction-plunger affect that dislodges the stones. 4. Overall improvement in health and circulation through exercise. Swimming may seem daunting to non-swimmers but beginner guides^[1] are readily available.

The most drastic method, a tonsillectomy, is not usually indicated or recommended, but will provide permanent relief.

It is important to remember that although tonsil stones can be uncomfortable and inconvenient, they are rarely dangerous.

Prevention

Prevention methods include gargling with salt water, cider vinegar, dissolvable paracetamol or a non-alcohol-, non-sugar-based mouth wash.

Some alternative practitioners state that reducing the amount of white sugar or dairy in the diet will reduce the frequency of buildup. There are, however, no reliable data that support this theory.

Slang and foreign terms

• Vomit varmints, American slang
• Crater critters, American slang
• Puss balls, American slang
• Kusaidama, a Japanese slang term which literally means "stink balls"

See also

• Tonsils
• Tonsillitis
• Cryptic tonsillitis

References

1. ^ McFarlane Mirande,T. and Bissell,K: "Champioship Swimming:", McGraw Hill, 2005

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