Tonsillolith

Overview
A tonsillolith (also called tonsil stone 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 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
 * overactive salivary glands

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. They are one possible cause of halitosis.

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, bad taste in the back of the throat, 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, referred 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.

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

Tonsilloliths can be removed by the patient. Using a medicine dropper (especially one with a curved tip) can help to suck out the stones if they are small enough. 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 (only use an adjustable unit on the low pressure setting as you may damage tissue with the high pressure units). Use a solution of salt water, or a mixture of hydrogen peroxide with mouthwash in the water pick tank instead of (or combined with) water to cleanse the tonsil crypts and help prevent future tonsilloliths. 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 a finger 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. 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 hair grip (bobby pin) or a cotton swab.

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 vaporises 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 permanent relief.

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, alcohol, or dairy in the diet will reduce the frequency of buildup. There are, however, no reliable data that supports this theory.