This case was a little like the unfortunate customer who brings his chronically noisy car into the shop, only to have the vehicle purr like a kitten for the expectant mechanic. My patient was a teenage girl with a moderately severe sore throat as well as a complaint of a white chunk in one of her tonsils.
At the time of the exam, of course, the white spot was nowhere to be found, and after performing what turned out to be a negative strep test, I sent the teen on her way without antibiotics and with a diagnosis of viral pharyngitis.
The young lady visited again a few months later, this time for her annual physical. After discussing her progress in school and reviewing a variety of medical issues, the girl and her mother brought up the subject of recurring white spots in the tonsils. I looked closely, but once again, the tonsils were devoid of any white debris.
While throat problems rarely caused her to run fevers or miss school, the high school student felt that her tonsil spots were not only annoying, but embarrassing as well. She could often feel the little tonsil spots when she swallowed, found herself coughing up small white pebbles with some frequency, and was pretty sure that the tonsil condition was at the root of her bad breath.
Italian physician M. Mesolella and colleagues explain that these tonsil stones or tonsilloliths are hard concretions ranging in size from a few millimeters to several centimeters, though the larger stones are not very common. The cause of tonsilloliths is not well-established but might be related to unresolved tonsillitis or sluggish saliva, and tonsil stones might share a link with similar conditions such as kidney stones, gallstones and salivary gland stones.
Tonsil stone sufferers have an average age of 50 years, but stones can be seen in the pediatric population and have been reported in patients as young as 10. The Italian medical group finds that many tonsilloliths cause no symptoms, but about one quarter of patients do experience throat pain when stones are present.
Since tonsil stones are calcified collections of sloughed skin cells, food debris and sulfur-producing bacteria, medical researchers Nicole E. Myers and her group note that the presence of tonsilloliths can lead to noticeable and distressing halitosis, or bad breath.
Patients are often tempted to pick out small tonsil stones with various common household items such as straws or cotton swabs, but Myers' team stresses that this practice can cause irritation and bleeding. Individuals are instead advised to gargle with salt water or to use pulsating jets of water to dislodge the stones with a minimum of trauma.
If home methods do not work for bothersome tonsilloliths, an otolaryngologist can be consulted to consider curettage - scraping or spooning of the concretions out of tonsillar pockets after the application of a local anesthetic. Tonsillectomy is indicated if tonsilloliths cause severe symptoms and non-surgical methods fail to help, or if stones are associated with chronic tonsillitis.
• Dr. Helen Minciotti is a mother of five and a pediatrician with a practice in Schaumburg. She formerly chaired the Department of Pediatrics at Northwest Community Hospital in Arlington Heights.