Tonsillolith or Tonsillar Stone

A tonsillolith or tonsillar stone is a piece, or more commonly, clusters of calcareous matter that forms in the crypts or crevasses of the palatine tonsils (commonly known as the tonsils). They are white or cream in colour and range in size from a pinhead to the size of a pea. They often have an unpleasant odour because of Hydrogen Sulfide, Methyl Mercaptan or other substances contained within the debris. Large tonsillar stones or tonsilloliths often give the sensation of a foreign object lodged in the tonsillar crypt. Often they cause patients concern because they think they represent acute or chronic infection. They are often associated with bad breath but are usually not harmful.

Tonsil Stones Symptoms

Tonsillolith - before Tonsillectomy

Tonsilloliths occur more frequently in adults than in children. Symptoms range from an incidental finding of bad breath, a sensation of coughing or irritation to a foul or metallic taste in the mouth. Many small tonsillar stones don’t cause any noticeable symptoms, even when they are quite large. Some stones are only discovered incidentally on X-Ray, or patients notice them and think they have an infection in the tonsils. Larger tonsilloliths usually present with multiple symptoms including recurrent bad breath, sore throat, bad taste in the back of the throat, difficulty swallowing and occasionally referred otalgia.

Tonsillolith Treatment

Definitive treatment varies from minimally invasive Diode Laser Cryptolysis, through Carbon Dioxide Laser Cryptolysis to Tonsillectomy.

The most definitive surgical option for tonsilloliths is Tonsillectomy. It is permanently effective but is usually only considered when less aggressive options fail or the patient elects to proceed directly to the definitive option.

After Tonsillectomy

Tonsillectomy remains the most frequently performed operation in the world. The operation dates back to the time of Celsus and is probably one of the oldest operations in surgery. The main indication for tonsillectomy remains recurrent tonsillar Infections with oropharyngeal obstruction/obstructive sleep apnoea a close second.

Indications for tonsillectomy remain –

  • Five bouts of acute tonsillitis in one calendar year.
  • Three bouts of acute tonsillitis a year for three consecutive years.
  • Failure of long course low dose antibiotics to prevent recurrent tonsillar infection
  • Upper airway obstruction/sleep apnoea.
  • Complications of tonsillitis such as -
    • Peritonsillar or parapharyngeal abscess.
    • Long suppurative complications such as Scarlet Fever Acute Rheumatic Fever Post Streptococcal Glomerulonephritis
    • Upper airway obstruction/obstructive sleep apnoea
    • Significant tonsillar asymmetry/clinically indicated suspicion for malignancy.

The risks and complication of Tonsillectomy

The risks and complication profile of Tonsillectomy for tonsilloliths is the same as it is for any other implication for Tonsillectomy including recurrent infection and/or airway obstruction.

Primary Haemorrhage (bleeding occurring within the first 24 hours)

  • Incidence one to two hundred cases.
  • Between half and two percent.
  • Approximately one half of these cases require to be returned to the operating room for a second anaesthesia for the arrest of bleeding.

Secondary Haemorrhage (bleeding occurring between the fifth and tenth post operative day)

  • Incidence approximately from one to three percent.
  • Nearly always associated with decreased oral intake poor oral hygiene relative dehydration
  • Rarely requires return to operating room.
  • Virtually never requires blood transfusion and is treated conservatively with antibiotics oral hygiene local hydrogen peroxide/antiseptic gargles.

Peri-Operative Analgesia

This remains the major challenge of anaesthesia for tonsillectomy. It is the greatest cause of morbidity of this procedure.

If you or a loved one is having regular tonsillar infections, or thinks ienlarged tonsils may be the cause of obstructive sleep apnoea, contact us.