Tonsil Stones (Tonsilloliths)

Tonsilloliths, also known as a Tonsil Stones, are clusters of calcified material that form in the crevasses of the tonsils. While they occur most commonly in the palatine tonsils, they may also occur in the lingual tonsils. Tonsilloliths have been recorded weighing from 300 mg to 42 g. They are composed mostly of calcium, but may contain other minerals such as phosphorus and magnesium, as well as ammonia and carbonate.

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

While true tonsillar stones are rare, small areas of calcification or concretions are relatively common.

Tonsilloliths may produce no symptoms, be associated with bad breath, or may produce pain when swallowing.

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 CAT scans.

Other symptoms include a metallic taste, throat closing or tightening, coughing fits, and choking.

Larger tonsilloliths may cause 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 in patients with a certain type of recurrent tonsillitis. 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.

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.

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).