Tonsilloliths are also called as tonsillolithiasis or tonsillar concretions or simply known as liths. It is a cluster of calcareous matter in the crypts of the palatine tonsil. The size of the tonsillolith may vary and are usually cream in color. Small concretions in the palatine tonsils may be found in adults. This tonsillolith is usually originated from the calcium being deposited on the desquamatized cells and bacterial growth in the crypts of the tonsils. Smaller size tonsillolith are often found in routine clinical practice but larger one or giant size tonsilloliths are extremely rare and very few reported in literature. The earliest description for concretion at the oropharynx was documented by Lang in 1560. The tonsilloliths are usually yellow or white-colored stones that consist of calcium salts such as hydroxyapatite or calcium carbonate apatite, oxalates, and other magnesium salts or ammonium radicals. Although majority are asymptomatic, patients with tonsilloliths often give foul smell from the mouth, bad taste, foreign body sensation in throat, referred pain in the ear, neck pain, odynophagia and even dysphagia. Here, we report a case of giant tonsillolith in a 62-year-old man with complaints of long-standing foreign body sensation in throat.
A 62-year-old man attended the outpatient Department of Otorhinolaryngology for foreign body sensation in throat for 6 months. He had occasional left ear pain. Examinations of ear and nose were within normal limits. Examination of the oral cavity and oropharynx showed a large grayish mass arising from the left side of tonsil. It gave a sensation for malignant growth but palpation provided gritty sensation with feeling of the stones. There was no evidence of infection in the both sides of tonsils. On palpation with gloved hands, stony hard consistency felt on the left tonsillar mass. The mass was measured around 5 cm × 4.5 cm [Figure 1]. The tonsillolith was removed under general anesthesia, the mass was palpated intra-operatively and a small incision was placed near to the anterior pillar, the lith was dissected and removed from the surrounding tissue. The oropharynx was better exposed with help of Boyle's Davis mouth gag and the tonsillolith was carefully dislodged with the use of the anterior pillar retractor and Jobson Horne ear probe. There was no bleeding from the tonsillar tissue. The hemostasis was achieved and the mucosa was sutured with vicryl. The tonsillolith with minimal soft tissue surrounding the liths was removed and the liths were in pieces with pitted rough surfaces. The biochemical analysis of the tonsillolith revealed chemical constituent such as calcium, oxalate, and phosphate. The histopathological examination of the soft tissues surrounding the liths showed chronic inflammatory cells and without any evidence of malignancy. The postoperative stay was uneventful. The patient was followed up for 3 months postoperatively. Foreign body sensation in throat and left ear pain subsided completely. No complications were noted after surgery. The patient was discharged on 3rd postoperative day. The tonsils remained normal during follow-up visit.
Giant tonsillolith is an uncommon clinical entity found in the oropharynx, however, smaller size tonsillolith often seen in the tonsillar crypts. It is a cluster of calcareous materials in the tonsillar crypts of the palatine or faucial tonsils. The exact mechanism for formation of the tonsillolith is a subject of debate. Tonsilloliths or tonsillar stones are originated by calcified accumulation of food particles, cellular debris, and microorganisms congregated in the tonsillar crypts. However, the most common accepted hypothesis for the formation of tonsillolith is the retention of caseous secretions in the tonsillar crypts along with filaments of leptothrix buccal which is a common oral saprophyte (sometimes associated with chronic purulent tonsillitis). Other etiologies include hyperactive salivary glands, tobacco chewing (with CaCO3), betel nut chewing, mucous secretions, intolerance of food or dairy products, salivary stasis, and hypercalcemia. The calculi have also been documented in peritonsillar space, lateral pharyngeal wall and were explained on the basis of calcification of peritonsillar abscess, presence of ectopic tonsillar tissue, and calcification of the saliva in obstructed secretory ducts of the minor salivary glands. Smaller size tonsilloliths are often associated with recurrent sore throat. Patients often present with halitosis. The tonsilloliths are often found in the age ranges between 10 and 77 years with mean age of 50 years with male-to-female ratio of 1:1.
The exact location of the tonsilloliths varies from different anatomical sites of the oropharynx. The giant size tonsillolith is usually found in the tonsillar tissue approximately in 67.79% and the tonsillar fossa in 21.2% and approximately 9% in palate and only 1% is documented in the lingual tonsil. Although there are several explanations for the development of this tonsillar stone, it has been thought that these originate as a result of repeated tonsillitis which results in fibrosis of the duct of crypt, presence of filaments, and cocci. One study detected anerobic bacteria in the tonsillolith including eubacterium, fusobacterium, megasphere, prevotella selenomonas all of which are associated with sulfur production.
Patients with small tonsilloliths are usually asymptomatic. Large size tonsillolith may present with foreign body sensation in throat, halitosis, odynophagia, and referred otalgia. The large size tonsillolith may produce symptoms such as choking sensation, tonsilloliths, sore throat, dysphagia, and headache. It is one of the common causes for bad breath and more common in adult age groups than pediatric age. The tonsilloliths may be seen as single piece or multiple pieces and embedded in the tonsillar tissue or tonsillar crypts. The tonsillolith appears as grayish yellow to dark green, black or red brown on the basis of its chemical composition. It can be palpated as hard mass which embedded in the tonsillar fossa.
The diagnosis is usually done by palpation but in case of doubtful case require imaging which shows radio opaque shadow in the tonsillar fossa. It is sometimes detected accidently during oral examination or performing computed tomography scan or X-ray of the oral cavity or head and neck region. The differential diagnosis of the tonsillolith includes foreign bodies in the tonsillar fossa, calcified granulomas, malignancy, elongated styloid process or less commonly isolated bone originating from branchial arch, odontomas, sclerosing osteitis, fibrous dysplasia, osteomas, and idiopathic osteosclerosis. In this case, the tonsillar mass confused with malignant mass but confirmed after palpation of the mass with gritty sensation.
The treatment options include local excision by the curettage. Large size or giant tonsillolith may require removal of it under local or general anesthesia. It is associated with chronic tonsillitis; tonsillectomy provides definitive treatment to the patient. In this case, the giant tonsillolith was removed under general anesthesia in piece meals.
Although small size tonsilloliths are common in routine clinical practice, a large or giant size tonsillolith is extremely rare and may manifest some long-standing symptom like foreign body sensation in throat. Hence, clinician keep this symptom such as long standing foreign body sensation in throat in mind during evaluating patient with tonsillolith. Timely surgical removal of the tonsilloliths provides a good cure. Further research is needed to know the exact etiology and other treatment modalities. In old age, the grayish mass in the tonsillar region sometimes gives thinking towards malignancy, so can be ruled out by proper examination and biopsy of the tissue. A correct diagnosis is an important part for eliminating the further radiography and detail clinical examinations.
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