Tonsil Stones

What are the Tonsils?

The tonsils are two structures located in the back of the throat, one on each side. They are masses of tissue and have an oval shape, resembling some glands. The exterior of the tonsils is made up of pink mucosa similar to the one in the mouth. Inside the tissue of the tonsils, there are some cells designed to protect against infections, known as lymphocytes, which make the tonsils part of the lymphatic system.

Because each individual has their own characteristics in regards to the way their body fights against infection, the tonsils can become quite problematic for some people. Many medical professionals consider that the tonsils work as a barrier against bacteria or viruses that travel through the throat, trapping them inside. However, for some people, the tonsils don’t work quite as smoothly as that, causing more trouble than they actually should.

In the past, a common procedure for people who had problems with their tonsils was tonsillectomy, a surgery to remove the tonsils. This was suggested by doctors as soon as a patient was showing signs of any type of dysfunction of the tonsils. However, in present days, this procedure is not as common, research showing that removing the tonsils doesn’t necessarily make the patient less prone to infections. Nowadays, this surgical procedure is recommended for those who have recurrent tonsil infections or those who have tonsils that are too large, causing discomfort.

Medical conditions of the Tonsils

The most common medical conditions associated with tonsils are acute tonsillitis, chronic tonsillitis, peritonsillar abscess, strep throat, enlarged tonsils, and tonsil stones.

Acute and Chronic Tonsillitis

As the name suggests, tonsillitis is an infection of the tonsils with a bacterium or a virus that makes the tonsils swollen and inflamed. Some of the most common symptoms are throat pain, fever, headaches, the tonsils turning red, difficulty swallowing, changes in the voice, ear pain, blisters on the throat, yellow or white abscess on the tonsils. Depending on how long these symptoms last, tonsillitis can be acute, with the symptoms lasting from 3-4 days up to 2 weeks, recurrent if the person gets infected multiple times in a year, or chronic if the symptoms are persistent over a long period of time.

Peritonsillar Abscess

The infection of the tonsils causes the formation of a pocket of pus around the tonsil, pushing the tonsil toward the middle of the neck, where the uvula is located (uvula is the visible dangling tissue in the back of the neck). This makes the whole area extremely painful, sometimes making it difficult to even open the mouth. In case of peritonsillar abscess, the recommendation is to have it drained as soon as possible because left untreated it can spread the infection deeper in the neck leading to some life-threatening complications (one of them being airway obstruction).

Strep Throat

Strep throat is an infection caused by Streptococcus pyogenes or group A streptococcus. This is usually more common in children and it affects the tonsils, making them red, swollen, painful and, in some cases, it can cause the formation of white or yellow pus on the tonsils or around them. This is a serious condition that needs to be diagnosed and treated properly because if left untreated, it can cause rheumatic fever, affecting the heart valves, joints, and nervous system or glomerulonephritis, affecting the kidneys. This usually occurs later in life and most people when they are young don’t know that these can be serious complications from “just a simple cold” that is poorly treated.

Enlarged Tonsils

Hypertrophic tonsils are enlarged tonsils that determine the obstruction of breathing, affecting mostly the sleep patterns of the person. This condition can be responsible for snoring or, in more serious cases, sleep apnea. Other symptoms can be agitated sleep with frequent awakening, excessive sleepiness, or heart problems. Chronically enlarged tonsils can also lead to sinusitis, nasal obstruction, or ear infections (affecting the Eustachian tube which connects the throat to the internal ear). This medical condition is also considered to be responsible in some cases for malocclusion which is the misalignment between the upper and lower teeth.

Tonsilloliths are parts of bacteria or debris that harden, turning into little formations called tonsil stones. We will go deeper into the subject of tonsil stones as we go on.

Are these medical conditions contagious?

This very much depends on what causes the medical condition associated with the tonsils. For example, viral cases of tonsillitis, such as the one caused by mononucleosis, are contagious. This is also the case for bacterial infections, such as strep throat. However, if tonsillitis is caused by a chronic medical condition (e.g. sinusitis, chronic rhinitis) it is very less likely to be contagious.

Are tonsil stones contagious?

Tonsil stones by themselves are not contagious. However, they often co-occur with tonsillitis which, as discussed before, can be contagious, depending on what’s causing it.

Tonsil Stone definition

Tonsil stones (medically known as Tonsilloliths) are painful, hard formations placed on or inside the tonsils. They can be yellow or white and are usually parts of bacteria or some other type of remains that adhere to the tonsils.

Tonsilloliths are calcified accumulations of cellular debris and bacteria found in the tonsillar crypt. Tonsilloliths are more common in youngsters than in adults. Tonsilloliths range in size from noticeable to pea-sized.

It’s extremely uncommon for people to have large tonsil stones. Typically, people have one or a few tonsil stones, but most of the time people only have small formations in their tonsils that don’t cause any symptoms.

Tonsilloliths are calcifications that develop in the palatal tonsil crypts. Calcium salts, either alone or in combination with other mineral salts, make up these calculi.

Tonsilloliths have the ability to induce halitosis in the mouth. During bacterial metabolism, foul-smelling chemicals such as volatile sulfur compounds and sulfur-derived gases were generated. When the quantity of gases produced reaches a particular level, a characteristic sulfur odor arises.

What do tonsil stones look like?

Tonsiliths are made up of calcium phosphate and/or carbonate salts. These are organized in a structure similar to hydroxyapatite Ca5[OH | (PO4)3 bone crystals. Fluoride, carbonate, or chloride can replace the hydroxyl ion (OH) in hydroxyapatite. The hydroxyapatite crystal has a specific gravity of 3.08 and a hardness of 5 on the Mohs scale. A protein matrix has also been identified as a component of tonsiliths composition.

Epidemiology

Tonsilloliths, also known as tonsillar concretions, affect up to 10% of the population and are commonly caused by bouts of tonsillitis. Small concretions in the tonsils are frequent, but genuine stones are uncommon. They are more prevalent in young people and less common in children.

Tonsilloliths can develop at any age, however, they are more frequent in adults than in children. Some people only develop one, but others might have many at the same time. Even when some individuals get rid of one, another one forms somewhere else.

Risk factors for tonsil stones

Given the structure of the tonsils, people who have more crypts are more likely to develop tonsil stones because there is more space for the debris to build up. Also, another risk factor can be multiple tonsil infections during a period of time or age, because tonsil stones are more commonly found in children and teens.

Tonsil stone causes

Besides having lymphocytes that fight against bacteria and viruses, the tonsils have a structure consisting of tunnels and nooks, called crypts. These are the places where any type of debris, such as bacteria, dead cells, saliva, food remains, and mucus get stuck and start to accumulate. By now, you might be asking yourself “how tonsil stones form”. Well, in time, this build-up is the one that hardens or calcifies into a tonsil stone. This process is more common, however, in people with recurrent tonsillitis (usually chronic) or in those who tend to have their tonsils inflamed for long periods of time.

Pathophysiology

The process by which these calculi form is unknown, although they appear to be caused by the buildup of material trapped inside the crypts, as well as the growth of bacteria and fungus - often in conjunction with recurrent chronic purulent tonsillitis.

A connection between biofilms and Tonsilloliths was discovered in 2009. The notion that bacteria create a three-dimensional structure, with dormant bacteria in the core to serve as a continuous nidus of infection, is central to the biofilm concept.

Because of its impenetrable structure, the biofilm is resistant to antibiotic therapy. Biofilms comparable to dental biofilms were found in the tonsillolith using confocal microscopy and microelectrodes, with oxygen respiration at the tonsillolith's upper layer, denitrification in the center, and acidification at the bottom.

Classification

Tonsilloliths, also known as tonsil stones, are calcifications that develop in the palatal tonsil crypts. They have also been shown to develop on the roof of the mouth and in the throat. Tonsils have crevices that bacteria and other materials, such as dead cells and mucus, can become stuck in. When this happens, the debris might get concentrated in the pockets, resulting in white formations.

Tonsilloliths occur when trapped material collects and is expelled from the tonsil. They are typically soft but can be rubbery at times. This is more common in persons who have chronic tonsil irritation or have had several bouts of tonsillitis. They are frequently linked to post-nasal drip.

Giant Tonsilloliths

Giant Tonsilloliths are far more uncommon than normal tonsil stones. Giant Tonsilloliths are frequently misdiagnosed as other oral diseases such as peritonsillar abscesses and tonsil tumors.

Tonsil stones symptoms

Sometimes it can be difficult for the naked eye to spot a tonsil stone, even when they are of considerable size. However, these stones can cause a lot of trouble for people, some of the symptoms including:

Bad breath – halitosis or bad breath is one of the main signs of tonsil stones; tonsil stone bad breath is caused by the fact that bacteria and fungi feed on the accumulation of debris leading to a distinct, specific odor (tonsil stones smell); this particular smell is determined by high levels of volatile sulfur compounds in the breath that have been found in most of the patients who have some type of tonsillitis;
Tonsil stones infection– considering that the infection of the tonsils can lead to the formation of tonsil stones, some people experience them at the same time; this makes it difficult to assess which of the two conditions causes the pain in the throat; however, tonsil stones can cause a great deal of discomfort and pain (tonsil stone pain), especially if they are larger;
Coughing – depending on the size and location, a tonsil stone can irritate the throat, causing the person to cough repeatedly
White debris – one physical symptom of a tonsil stone is it they can be visible upon inspecting the area as a white lump in the back of the throat (of course, keeping in mind that some tonsil stones are so small that can only be found during X-ray or CT scans)
Difficulties swallowing –depending on the size and location of the tonsil stone, it can cause difficulties in swallowing, making it painful to eat or drink
Ear pain – this can be a result of a tonsil stone alone or of the combination of tonsil stones and tonsillitis; if the patient has a tonsil stone, depending on where in the tonsil it is located, it can trigger some nervous pathways that are common with the ear; as a consequence, the pain might irradiate in the ear as well, this being more of a sensation, a “false” pain, considering the cause is located in the throat; however, if the tonsil stone co-occurs with tonsillitis, ear pain might also be a consequence of the latter, being possible for the infection in the tonsil to spread to the ear as well
Tonsil swelling – a tonsil stone might cause the tonsil to inflame, but it can also get infected, causing the tonsil to swell.
Tonsil stones pain

Diagnosis of Tonsillitis

Diagnosing a tonsil stone very much depends on the size and location of this calcified build-up. Typically, the diagnosis for tonsillitis is usually based on a physical exam. The doctor looks in the back of your neck to assess the state of your tonsils (if they are red, inflamed, or have pus on or around them), takes your body’s temperature, and checks for signs of infection in your nose and ears.

Make sure to distinguish between a tonsil stone and a spot of white pus, common in tonsillitis. However, if the stone is not visible, but the physician has a suspicion, they can perform a scan in order to confirm the diagnosis or to better assess the number, position, and dimensions of the stones.

In addition to the physical exam, your doctor might want to run some tests in order to determine the cause of the infection. The two most common tests are the throat swab which checks for infection with group A streptococcus and blood tests which are typically used to diagnose mononucleosis.

Radiology of Tonsiliths

Although a Pantomograph is a trustworthy and conventional modality for evaluating the presence of tonsiliths, superimposition of a lesion involving one side of the jaw may result in a pseudotonsilith or ghost picture on the contralateral side, leading to misinterpretation of bilateral lesions.

When an item is placed between the X-ray source and the cassette's center of rotation, a ghost picture is generated. Tonsiliths are often seen on the pantomograph as many, small, and ill-defined radiopacities.

It is also common for a healthcare provider to discover a tonsil stone during an exam for another medical condition (or even during a routine physical exam). They can also notice a tonsil stone during a CT scan or X-ray for something else. Even your dentist can spot a tonsil stone during a dental exam.

Tonsil stone in the throat

Now, let’s tackle one of the medical conditions associated with the two oval-shaped structures in our throats: tonsil stones.

Tonsil stones vs. Tonsillitis

Don’t get the two confused! As we’ve seen before, tonsillitis is an infection of the tonsils caused either by a bacterium or a virus, while tonsil stones can be a consequence of recurrent infections of the tonsils.

To sum up, some tonsil stone causes enlarged tonsils or inflamed tonsils (acute or chronic tonsillitis) that make it easier for the debris to build up, chronic sinus issues, or poor dental hygiene.

See more about Symptoms of Flu

Differential diagnosis

Imaging diagnostic methods can detect a radiopaque mass that may be misidentified as a foreign body, misplaced teeth, or calcified blood arteries. A CT scan of the tonsillar zone may reveal nonspecific calcified pictures.

In the setting of Eagle syndrome, the differential diagnosis must include acute and chronic tonsillitis, tonsillar hypertrophy, peritonsillar abscesses, foreign bodies, phleboliths, ectopic bone or cartilage, lymph nodes, granulomatous lesions, or calcification of the stylohyoid ligament.

Foreign body, calcified granuloma, cancer, an enlarged temporal styloid process, or, more rarely, isolated bone, which is generally formed from embryonic remnants coming from the branchial arches, are all possible differential diagnoses for tonsilloliths.

Tonsil stones treatment

If tonsil stones do not bother a person, no treatment is needed. There isn’t a specific tonsil stone cure, however, you can treat the symptoms in case they are causing you discomfort. In case of pain and swelling, painkillers and anti-inflammatory medication is advised.

However, if tonsil stones are a consequence of tonsillitis, keep in mind that the treatment options for infection depend on its type: bacterial, in which case antibiotics are mandatory or viral, in which case OTC pain medication and good hydration are the go-to strategies for treatment.

Nevertheless, your doctor is able to assess your condition and integrate your symptoms to better understand their cause, so don’t wait too long before consulting with a healthcare provider that can help you figure out what would work best in alleviating your symptoms.

Tonsil stone removal

Manual removal. This is not recommended to be done at home because it can lead to serious complications, such as tonsil stones bleeding, or infection. If the stones become large and are causing serious discomfort, it’s best you seek medical assistance, given that there are minor procedures designed to remove tonsil stones.
Tonsil stones removal tool. Tonsil stone removers that are manually pressured are also available. The water pressure of a manual pump-type tonsil stone extractor may be adjusted based on the number of pumps, efficiently eliminating tonsil stones.

Tonsil stones home remedy

While there are no exact treatment options for tonsil stones, there are some remedies and medical procedures that help remove tonsil stones. Even though tonsil stones don’t cause much trouble most of the time, patients still want them removed especially for the bad tonsil stones smell they cause. Another reason for removing tonsil stones is that they can get infected.

Next, we present a list of remedies and procedures that can help to manage tonsil stones.

Gargling. Gargling intensely with salty, warm water is a remedy for tonsil stone that can help with the discomfort and pain, as well as with the bad odor the stones are responsible for. What’s more, gargling can also be useful in case a tonsil stone is stuck, helping to dislocate it.

Mouthwash can be used instead of salt water when gargling. Make sure the mouthwash is alcohol-free since alcohol can dry out the oral mucosa, increasing cell shedding and aggravating the development of tonsil stones. If at all feasible, use oxygenating mouthwashes, which help to prevent the growth of anaerobic bacteria, which can cause tonsil stones and foul breath.
Gargling with warm, salty water can also help relieve the pain of tonsillitis, which is commonly accompanied by tonsil stones. The tonsil crypts can also be kept free of all but the most stubborn Tonsilloliths by vigorous gargling every morning.

Coughing. Some people discover that they have tonsil stones when they cough up in a tissue. Continuously coughing can also help with loosening tonsil stones stuck in the throat.
Antibiotics. Usually, antibiotics are not recommended for tonsil stones, as they don’t treat the cause. However, your doctor might prescribe you some antibiotics in case your tonsil stones have developed a bacterial infection. Keep in mind, though, the side effects of antibiotics and that you should never take them without consulting with a medical professional.
Hydrate. To avoid tonsil stones, stay hydrated by drinking lots of water. Water can also assist to alter the chemistry in your mouth by increasing natural saliva production.
Quit smoking. Eliminate smoking and other tobacco products from your diet, since they may be contributing to the bacteria in your throat that is generating tonsil stones.
Laser tonsil cryptolysis and coblation cryptolysis. These procedures are used to eliminate and scar the tonsil crypts where tonsil stones are located. While laser tonsil cryptolysis uses a laser to achieve this result, coblation cryptolysis doesn’t use any type of heat, achieving the same results, but without the burning sensation of the laser. These procedures are usually done under local anesthesia, with minimal discomfort and very little recovery time.
Curettage. Larger tonsil stones may require curettage (scooping) or other methods of removal, while smaller fragments may still require extensive irrigation to be thoroughly washed out. Larger lesions may necessitate local excision, however, these treatments may not be enough to alleviate the foul breath that is typically associated with this disease.
Tonsillectomy. Tonsil stone tonsillectomy is a procedure designed to remove the tonsils altogether. Generally, there are two main reasons for wanting to remove your tonsils: the first one, if your tonsils’ dysfunction is making breathing difficult, especially during sleep, and the second one, if your throat gets infected multiple times in a year, causing your tonsils to get infected as well (tonsillitis). This is a procedure that is most commonly done in kids, but there are also cases of adults who get their tonsils out.

Patients may experience a painful throat and ear soreness for several days after surgery, making recuperation difficult. Another alternative is to use a laser to do a partial tonsillectomy, a procedure known as tonsil cryptolysis, which closes the fissures in the tonsils where particles can collect, preventing tonsil stones from forming.

While in the past tonsillectomy was recommended and done almost as soon as someone showed any sign of throat infection, nowadays this procedure is not as common as it used to be. Healthcare professionals recommend tonsillectomy for patients who have recurrent tonsil infections (chronic tonsillitis) that can cause a great deal of discomfort and disruption of the day to day life activities.

How exactly is tonsillectomy performed?

It takes about 20 to 30 minutes for the doctor to remove your tonsils, while you are under general anesthesia, meaning you won’t feel a thing. There are a few different methods, depending on what’s best suited for the patient and what the doctor is specialized in. Some of the ways tonsillectomy can be done include scalpel dissection (the tonsils are removed with a scalpel and the bleeding is managed with electrocautery and eventually sutures), electrocautery (removes the tonsils and stops the bleeding using only heat), harmonic scalpel (removes the tonsils and stop the bleeding at the same time), laser or coblation techniques.

The recovery process takes usually 10-14 days, the pain being the most uncomfortable symptom that can last even for two weeks after the surgery.

How to prevent tonsil stones?

The best thing you can do to prevent viral or bacterial infection of the tonsils is to have a good hygiene regimen. This implies washing your hands frequently and avoiding sharing items that have come in contact with your saliva or fluids (e.g. cutlery, food, bottles, toothbrush) with other people. Also, if you are feeling sick, avoid contact with other people, always sneeze or cough into a tissue and wash or sanitize your hands and consult with your doctor regarding your symptoms.

There are some things you can do in order to prevent the formation of tonsil stones, such as maintaining good and healthy oral hygiene (brush and floss regularly), don’t smoke or quit smoking if it’s the case, gargle with warm, salty water after eating and stay hydrated. All these help remove bacteria and prevent build-up in the tonsils.

When to Worry About Tonsil Stones?

Sure, they're inconvenient and unpleasant, but how can you determine if your tonsil stones need to be treated by a doctor? It all boils down to the stone's size and placement, as well as your level of discomfort.

If you're unsure, see your dentist and ask if you should consider having your tonsils removed. A tonsillectomy may be the answer to your reoccurring symptoms if you have persistent tonsil infections or tonsil stones.

Tonsil stones complications

Usually, tonsil stones aren’t very problematic, but in some cases, they can lead to serious complications, such as tonsil stone infection that can turn into an abscess that requires immediate removal. Also, depending on the size, big tonsil stones can harm the tissues around them (tonsils are very sensitive) and cause swelling, inflammation, and even infection of the tonsils (tonsillitis).

Conclusion

Tonsil stones are more common than we think, especially since sometimes they don’t cause any symptoms. Maintaining good oral hygiene prevents the development of tonsil stones and if they still appear and cause discomfort, there are several ways to have them removed by a doctor. Keep an eye on the recommendations for treatment since there is no specific cure for tonsil stones (apart from removing them) and don’t fall in the trap of (over) using antibiotics to treat tonsilloliths.

Tonsillolith patients have increased halitosis and a foreign body feeling. Tonsillolith is a live biofilm as well as a stone. Tonsillolith development is caused by bacteria forming a three-dimensional structure with dormant bacteria in the middle serving as a continuous biofilm nidus.

Tonsillolith's precise etiology and pathophysiology are not yet fully understood. As a result, the current instance of tonsillolith was investigated, and tonsillolith was examined using physical, chemical, and microbiological methods.