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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 30  |  Issue : 3  |  Page : 324-327

A giant tonsillolith: An incidental finding


Department of Oral Medicine and Radiology, PDU Dental College, Solapur, Maharashtra, India

Date of Submission05-Apr-2018
Date of Acceptance21-Jul-2018
Date of Web Publication18-Oct-2018

Correspondence Address:
Dr. Abdullah Zakaria Kazi
Department of Oral Medicine and Radiology, PDU Dental College, Solapur, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_53_18

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   Abstract 


Tonsilloliths are infrequent calcified concretions that develop in tonsillar crypts within the parenchyma of the tonsils or surrounding it. They are typically single and unilateral, but rarely may be numerous or bilateral. Large tonsilloliths can mimic many conditions including abscesses or neoplasms. It is difficult to diagnose tonsilloliths unless there is a considered emphasis on thorough history taking, careful inspection, and a detailed characterization of the lesion through digital palpation. This may be further supplemented with investigations such as plain film radiography and/or 3D imaging. Here, we present a case of asymptomatic tonsillolith where the patient presented for a painful tooth in mandibular anterior region and was incidentally diagnosed as having with a large tonsillolith on right side of posterior mandible.

Keywords: Dystrophic calcifications, oro-pharyngeal mass, tonsillitis, tonsillolith


How to cite this article:
Kulkarni AS, Birangane RS, Kazi AZ, Channe RC. A giant tonsillolith: An incidental finding. J Indian Acad Oral Med Radiol 2018;30:324-7

How to cite this URL:
Kulkarni AS, Birangane RS, Kazi AZ, Channe RC. A giant tonsillolith: An incidental finding. J Indian Acad Oral Med Radiol [serial online] 2018 [cited 2019 Dec 11];30:324-7. Available from: http://www.jiaomr.in/text.asp?2018/30/3/324/243658




   Introduction Top


Tonsilloliths are infrequent calcified concretions that develop in tonsillar crypts or within the tonsillar tissue proper of the tonsils or surrounding it. Small concretions in the tonsils are not rare, but a giant tonsillolith is quite uncommon. Lang in 1560 was the first to describe a tonsillolith.[1] The most common age of presentation for tonsilloliths ranges between 10 to 77 years, with a mean age of 50 years.[2] No sex predilection has been noted. The presenting symptoms of these patients usually are halitosis, dysphagia or odynophagia, and foreign body sensation in the throat.[3]


   Case Report Top


A male patient aged 22 years presented to the outpatient department of Oral Medicine and Radiology with the chief complaint of pain in his lower front teeth region since 1 month. On intraoral examination there were deep proximal caries and root pieces associated with mandibular incisors and halitosis. On further examination of the oral cavity and the oropharynx a small yellowish white raised area was observed near the distolingual aspect of third molar in the region of anterior faucial pillar on right side [Figure 1]. Palpatory findings revealed it to be a large mass which was hard in consistency, non-tender, superficial, freely movable, and the surrounding mucosa showed no induration. On eliciting history, the patient informed about tonsillectomy performed 8 years ago because of repeated tonsillitis. The patient gave a 2-year history of halitosis. The patient was not aware of this mass in posterior region of oral cavity.
Figure 1: Yellowish white raised lesion in right anterior faucial pillar

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With the provisional diagnosis of tonsillolith and differential diagnosis of ectopic supernumerary tooth and odontome were kept in mind. The patient was subjected to radiographic examinations which included intraoral and panoramic radiographs [Figure 2], [Figure 3], [Figure 4]. These revealed a uniformly radiopaque mass, and had well-defined borders, in the right mandibular third molar region.
Figure 2: Digital intraoral periapical radiograph with 48 showing a radiopaque mass associated distal to it

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Figure 3: Panoramic radiograph

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Figure 4: Cropped panoramic radiograph showing the maximum dimensions of the radiopaque lesion

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It was removed using a small incision under local anesthesia [Figure 5] and [Figure 6]. The soft tissue sac surrounding the tonsillolith appeared well epithelized and hence no sutures were placed to close the cavity for the risk of cyst formation [Figure 7]. The specimen while retrieving fragmented into two large chunks (13 × 11 × 10 mm 12 × 10 × 8 mm) and multiple small pieces [Figure 8].
Figure 5: Intraoperative photograph

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Figure 6: Tonsillolith being removed in pieces

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Figure 7: Postoperative photograph after 7 days

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Figure 8: Removed tonsilloliths in two large pieces and multiple small bits

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   Discussion Top


Tonsilloliths are rare calcified concretions of varying size and consistency which can occur within the substance of the tonsil or in the peritonsillar region. Mesolella et al. found tonsilloliths were located in the tonsillar fossa (21.2%), in the tonsillar tissue (69.7%), and in the palatine region (9%).[2] These tonsillolith were ranging from a few millimeters to several centimeters.[2] Cooper's group has previously described that small tonsillar concretions may be encountered on routine sectioning of gross tonsil specimens, although large tonsillar concretions are relatively uncommon.[4] Large tonsilloliths are relatively uncommon.[1],[5],[6],[7] The size of the tonsillolith can vary and giant tonsilloliths have been reported in the literature.[7] The weight of such lesions ranges from 0.56 g to 42 g (mean 9.5 g).[2] Although tonsilloliths usually present as single stones of hard consistency, multiple bilateral small calculi can also be observed, with a more friable consistency and indeed the stones may be irregular or present in an inverted pyramidal shape.[8] Tonsilloliths occur more frequently in adults than in children, most commonly between 20 to 68 years with no gender predilection.[4] According to a CT scan study on 150 consecutive scans demonstrated that palatine tonsilloliths could affect approximately one-quarter of the population and that this prevalence is likely to be underestimated in daily clinical practice because they are asymptomatic and not visible on panoramic radiographs.[9]

Tonsillolith arises from dystrophic calcification despite normal serum calcium and phosphate levels.[10] The mechanism by which these calculi form is still disputed, though they appear to result from the accumulation of material retained within the tonsillar crypts, along with the growth of bacteria and fungi – sometimes in association with persistent chronic purulent tonsillitis.[8] It has been stated that they originate as a result of repeated tonsillitis which lead to fibrosis of ducts of crypts and retention of epithelial debris thereof. Accumulated bacterial and epithelial debris within these crypts contributes to the formation of retention cysts.[11] Calcification occurs subsequent to the deposition of inorganic salts and the enlargement of the formed concretion takes place gradually, with phosphate and carbonate of lime and magnesia derived from saliva.[10] Alternative mechanisms have been proposed for calculi that are located in peritonsillar areas and lateral pharyngeal wall, such as the existence of ectopic tonsillar tissue, the formation of calculi secondary to salivary stasis within minor salivary gland secretory ducts, or the calcification of abscess accumulations.[8] Using confocal microscopy, Stoodley's group showed that tonsilloliths were morphologically similar to dental biofilms, containing corncob structures, filaments, and cocci.[12]

Clinical signs and symptoms are usually absent with small tonsilloliths due to the small size of the calcifications; small lesions are thus usually detected incidentally during panoramic radiographic examination.[10] Larger tonsilloliths can mimic abscesses or neoplasms and may have multiple symptoms including recurrent halitosis, sore throats, white debris, dysgeusia, irritable cough, dysphagia, otalgia, and tonsil swelling.[11] A thorough history is invaluable and one needs to be very suspicious of malignancy, when there is pain and induration in combination with a positive smoking history. Certainly, these cases warrant close scrutiny through examination under anesthesia.[11] Protruding tonsilloliths may also have the look and feel of a foreign object as in our case.[11] If a tonsillolith is suspected but still doubtful in the absence of clear-cut manifestations, a panoramic radiograph can be considered.[11] However, a radiopaque mass can signify differentials other than a tonsillolith depending on its relation with surrounding structures which can include foreign body, odontoma, sclerosing osteitis, Garre's osteomyelitis, fibrous dysplasia, idiopathic osteosclerosis, and osteoma.[13]

Treatment usually involves removal of the tonsillolith by curettage; larger lesions may require local excision.[11] If there is evidence of chronic tonsilloliths, tonsillectomy offers definitive therapy.[4] However, understanding the morphology and biofilm characteristics of tonsilloliths may stimulate scientists to use limited or targeted remedies in the future.[12]


   Conclusion Top


With this case study and review of literature we concluded that:

  1. The hypothesis of recurrent tonsillitis followed by tonsillectomy which left a sac like defect in the region appeared to be reason for the tonsillolith in our case
  2. All the patients presenting with positive history, long-standing halitosis, foreign body sensation in throat, dysphagia or odynophagia should have thorough tonsillar examination including digital palpation to rule out any concretion or stone in tonsil as a cause of above mentioned symptoms and radiographs should be taken to confirm this rare diagnosis.


Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initial will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Pruet CW, Duplan DA. Tonsil concretions and tonsilloliths. Otolaryngol Clin North Am 1987;20:305-9.  Back to cited text no. 1
    
2.
Mesolella M, Cimmino M, Di Martino M, Criscuoli G, Albanese L, Galli V, et al. Tonsillolith. Case report and review of the literature. Acta Otorhinolaryngol Ital 2004;24:302-7.  Back to cited text no. 2
    
3.
Thakur JS, Minhas RS, Thakur A, Sharma DR, Mohindroo NK. Giant tonsillolith causing odynophagia in a child: A rare case report. Cases J 2008;1:50.  Back to cited text no. 3
    
4.
Caldas MP, Neves EG, Manzi FR, de Almeida SM, Bóscolo FN, Haiter-Neto F, et al. Tonsillolith – Report of an unusual case. Br Dent J 2007;202:265-7.  Back to cited text no. 4
    
5.
Cooper MM, Steinberg JJ, Lastra M, Antopol S. Tonsillar calculi. Report of a case and review of the literature. Oral Surg Oral Med Oral Pathol 1983;55:239-43.  Back to cited text no. 5
    
6.
Marshall WG, Irwin ND. Tonsilloliths. Oral Surg Oral Med Oral Pathol 1981;51:113.  Back to cited text no. 6
    
7.
Hiranandani LH. A giant tonsillolith. J Laryngol Otol 1967;81:819-22.  Back to cited text no. 7
    
8.
Silvestre-Donat FJ, Pla-Mocholi A, Estelles-Ferriol E, Martinez-Mihi V. Giant tonsillolith: Report of a case. Med Oral Patol Oral Cir Bucal 2005;10:239-42.  Back to cited text no. 8
    
9.
Fauroux MA, Mas C, Tramini P, Torres JH. Prevalence of palatine tonsilloliths: A retrospective study on 150 consecutive CT examinations. Dentomaxillofac Radiol 2013;42:20120429.  Back to cited text no. 9
    
10.
de Moura MD, Madureira DF, Noman-Ferreira LC, Abdo EN, de Aguiar EG, Freire AR, et al. Tonsillolith: A report of three clinical cases. Med Oral Patol Oral Cir Bucal 2007;12:E130-3.  Back to cited text no. 10
    
11.
Chan J, Rashid M, Karagama Y. An unusual case of a tonsillolith. Case Rep Med 2012;2012:587503.  Back to cited text no. 11
    
12.
Stoodley P, Debeer D, Longwell M, Nistico L, Hall-Stoodley L, Wenig B, et al. Tonsillolith: Not just a stone but a living biofilm. Otolaryngol Head Neck Surg 2009;141:316-21.  Back to cited text no. 12
    
13.
Sezer B, Tugsel Z, Bilgen C. An unusual tonsillolith. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;95:4-471, 473.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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