Tonsil stones, also known as tonsilloliths, are mineralizations of debris within the crevices of the tonsils. When not mineralized, the presence of debris is known as chronic caseous tonsillitis (CCT). Symptoms may include bad breath, foreign body sensation, sore throat pain or discomfort with swallowing, and cough. Generally there is no pain, though there may be the feeling of something present. 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 throat infections. Tonsil stones contain a biofilm composed of a number of different bacteria, calcium salts either alone or in combination with other mineral salts. While they most commonly occur in the palatine tonsils, they may also occur in the adenoids, lingual tonsils and tubal tonsil. Tonsil stones have been recorded weighing from 0.3g to 42g, and they are typically small in size. However, there are occasional reports of large tonsilloliths. They are often discovered during medical imaging for other reasons and more recently, due to the impact and influence of social media platforms such as TikTok, medical professionals have experienced an increase in patient concern and tonsillolith evaluations.
They are usually benign, so if tonsil stones do not bother the patient, no treatment is needed. 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. Chlorhexidine or cetylpyridinium chloride may also be tried. Surgical treatment may include partial or complete tonsil removal. Up to 10% of people have tonsil stones. Biological sex does not influence the chance of having tonsil stones, but older people are more commonly affected. 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, etc.
Signs and symptoms
Tonsil stones may produce no symptoms or they may be associated with bad breath. 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. Tonsil stones tend to happen most often in people with longterm inflammation in their tonsils.
Occasionally there may be pain when swallowing. 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, itchy throat, and choking.
Larger tonsil stones may cause recurrent bad breath, 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 the throat. The condition may also be an asymptomatic condition, with detection upon palpating a hard intratonsillar or submucosal mass.
Pathophysiology
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—sometimes in association with persistent chronic purulent tonsillitis.
In 2009, an association between biofilms and tonsilloliths was shown. Central to the biofilm concept is the assumption that bacteria form a three dimensional structure, dormant bacteria being in the center to serve as a constant nidus of infection. This impermeable structure renders the biofilm immune to antibiotic treatment. By use of confocal microscopy and microelectrodes, biofilms similar to dental biofilms were shown to be present in the tonsillolith, with oxygen respiration at the outer layer of tonsillolith, denitrification toward the middle, and acidification toward the bottom.