|Year : 2008 | Volume
| Issue : 3 | Page : 107-109
A giant tonsillolith
Anil Kumar Bhoweer
Department of Oral Medicine and Radiology, ITS Centre for Dental Studies and Research, Delhi - Meerut Road, Mural Nagar, Ghaziabad - 201 206, India
|Date of Web Publication||16-Jun-2009|
Anil Kumar Bhoweer
Department of Oral Medicine and Radiology, ITS Centre for Dental Studies and Research, Delhi - Meerut Road, Mural Nagar, Ghaziabad - 201 206
Source of Support: None, Conflict of Interest: None
| Abstract|| |
An extremely rare case of giant tonsillolith is presented here. Large tonsillolith are rare to be seen now and the cases reported in the literature are very few in number. When they appear on routine radiograph, they are usually labeled as non-specific calcifications or confused with other calcifying conditions. A possibility of tonsillar calcifications should be kept in mind since these tonsilloliths often cast shadows over the mandible in routine radiographs, especially lateral oblique view of the mandible and orthopantomograms. Etiology, clinical features, radiographic diagnosis and its confirmation are discussed in this presentation.
|How to cite this article:|
Bhoweer AK. A giant tonsillolith. J Indian Acad Oral Med Radiol 2008;20:107-9
| Introduction|| |
Tonsillolith are calcified structures that grossly resemble sialolith but develop within tonsillar tissue.  Small tonsillolith may not produce alarming symptoms; however large tonsilloliths can produce symptoms. Radiographs of maxillo-facial regions cast opaque shadows over the ramus of the mandible, depending on the size of the calcification. Such shadows are of great concern to physicians, ENT surgeons and dental/oral surgeons. The purpose of this presentation is to alert the clinician and also to show the need to assess these shadows critically for correct diagnosis and to avoid potential complications.
Most tonsillolith develop in tonsillar crypts in which closure of the surface opening leads to entrapment of organic epithelium, serum, food debris and bacterial-fungal colonies. Most commonly cocci, rods and branching organisms of actinomyces are the causative agents. 
The size varies from 0.5 mm to 15 cm.
Tonsilloliths are most commonly seen in adults. However, the incidences have been quoted to occur from adolescent age. The average age is, however, about 45-47 years.
Macroscopic and microscopic appearance
- Grayish white chalky mass with rough surface.
- Mineral contents are commonly found to be calcium, phosphorus and magnesium.
- Compact mass of microcrystalline hydroxyl and carbonate apetite (Ca10(PO4)6 (OH)2, Ca10(PO4)6 Co3) and protein matrix. 
Scanning electron microscopy (SEM) and energy dispersive X-ray analysis (EDX) reveal a rough cortex with appositional laminations.
Its porous interior is composed of numerous calcified masses with fine appositional conglomerates with micro organisms and calcified masses with fine appositional laminations around the conglomerates with a sand grain rather than needle-like shape and plate-shaped octacalcium phosphate (OCP). 
The small tonsillolith may not produce symptoms. However, large tonsillolith produce alarming symptoms as pain, soreness in the throat, disphagia, swelling, heavy or stony feeling in the throat and even halitosis. These concretions are sources for repeated infections and even tonsillar abscesses have been reported. However, dysphagia and stony feeling in the throat are common complaints and rarely pneumonia has been reported. ,
| Case Report|| |
A male patient of age 42 years came with a complaint of discomfort while swallowing and stony feeling in the throat. Clinical examination revealed a creamy mass in the right side of the throat, tonsillar region but a little high up.
The left side tonsillar region, however, did not reveal any abnormality.
Clinical impression of calcified mass in the right tonsillar region was made.
Orthopantomographic examination revealed opaque, oval-shaped shadow in the right ramus of the mandible [Figure 1A] and [Figure 1B]. The similar but more distorted image seen on the left side of the ramus was due to the ghost image of the right side opaque mass.
The right and left side lateral oblique views of the mandible (ramus and body), however, confirmed that the opaque shadow was only on the right side of the ramus [Figure 2] and [Figure 3].
A diagnosis of tonsillolith in the right tonsil was made.
The patient was referred to an ENT surgeon for the removal of the tonsillolith in the right tonsil.
| Discussion|| |
Reports state that common occurrence of tonsillolith is seen in adults. The average age, however, is between 40 and 47 years. However, the incidence has been quoted to occur even in adolescent age. Since infections in the tonsils can lead to calcifications, careful examination and investigation even in the younger age group is essential. It is also true that with increasing age the incidence increases and older people may have complications like aspiration, pneumonia, etc. More careful examination and possibilities of tonsilloliths should be kept in mind.
The most common symptoms, viz. pain, soreness in throat, dysphagia, swelling or heavy or stony feeling in throat and even halitosis may be present.
The size of these calcifications varies from 0.5 mm to 15 cm. Small concretions are usually neglected which may lead to giant-size concretions causing several symptoms. They are also the source of repeated infections in the region. In the older age group of patients, rarely aspiration and pneumonia have been reported.
Cervico-facial calcified bodies are common occurrence and findings during routine radiography of the region. These shadows pose difficulties in diagnosis as the number of conditions in the region can produce such shadows. Sialoliths, phleboliths, antorliths, nasoliths and foreign bodies and calcified lymph glands cast similar shadows in the radiographs of the region. Tonsilloliths are rare to occur and thus not so commonly considered in the diagnosis. Small concretions in the tonsils commonly go unnoticed as non-specific shadows. Large tonsilloliths, however, can occur and should be considered for detailed examination and removal to avoid possible complications.
| Conclusion|| |
Large tonsilloliths are rarely to be seen now. Routine radiographic shadows pose a lot of confusion regarding these shadows which are usually labeled as some other simulating conditions erroneously, unless there are specific symptoms. The possibility of such occurrence should be kept in mind and even routine orthopantomograph revealing such shadows in the ramii of the mandible should make one more suspicious and a thorough examination of the tonsillar region should be advocated rather than labeling them as non-specific conditions.
| References|| |
|1.||Ballendger JJ, Ballenger HC. Diseases of the nose, throat and ear. 11 th ed. Philadelphia: Lea and Febijer; 1969. p. 212. |
|2.||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. |
|3.||Kodak AT. Scanning electron microscopy, energy dispersive X-ray- Microanalysis studies of several human calculi containing calcium phosphate crystal. |
|4.||Marshall WG, Irwan AD. Tosilloliths. Oral Surg Oral Med Oral Pathol 1981;51:113. |
|5.||Hoffman H. Tonsillolith. Oral Surg Oral Med Oral Pathol 1978;45:657-8. |
|6.||Gapany-Gapanaricius B. Peritonsillar abscess caused by a large tonsillolith. Ear Nose Throat 1976;55:343-5. |
[Figure 1A], [Figure 1B], [Figure 2], [Figure 3]