Tonsilloliths are rare calcified concretions that develop in tonsillar crypts within the substance of the tonsil or around it. Large tonsilloliths can mimic many conditions including abscesses or neoplasms. Given the wide range of differentials, it is difficult to diagnose tonsilloliths unless there is a considered emphasis on thorough history taking, careful inspection and a detailed characterisation of the lesion through digital palpation. This may be further supplemented with investigations such as plain radiography and computer tomography. Here, we illustrate a case with risk factors of oropharyngeal cancer and a history of fish bone impaction in the throat that was initially diagnosed as a “tonsillar foreign body” which turned out eventually to be a large tonsillolith.
A healthy fifty-two-year-old Bangladeshi man was referred via general practice to the author’s ENT outpatient service due to a short history of odynophagia, and an oropharyngeal foreign body sensation, together with a history of impacted fish bone in his throat. He presented previously in Accident and Emergency with the same symptoms, when a “foreign body” of his right tonsil was diagnosed. He denied dysphagia, dyspnoea, otalgia, or other sinister symptoms. However, exploration of his social history confirmed a moderate smoking pattern and a positive history for chewing betel nuts. Clinical examination did not reveal any fish bones but instead yielded a large tonsillolith ulcerating through the right noninflamed palatine tonsil. Specifically, the protruding lesion appeared hard, mobile, well-delineated, nontender, and yellowish white in colour. Fibreoptic appraisal of the upper aerodigestive tract did not reveal any malignancy and there was no palpable neck lymphadenopathy. No fish bone was evident on lateral neck X-ray, but a uniform calcification of tonsillar area overlapping the mandibular ramus was seen (Figure
Lateral neck radiograph demonstrating a large tonsillolith.
A right tonsillectomy was carried out with a mid-tonsillar incision over the right tonsil with removal of the tonsillolith at a submucosal level (Figures
Intraoperative photograph of the tonsilloliths in right palatine tonsil.
Tonsillolith specimen.
This case highlights the variable nature of patients presenting with lateralising signs and symptoms in the head and neck region. A thorough history is invaluable and one needs to be very suspicious of malignancy, when there is (lateralising) pain in combination with a positive smoking history. Our case was complicated by the fact that the patient had risk factors for potential oropharyngeal cancer as well as a strong history of fish bone impaction in the throat. Certainly, these cases warrant close scrutiny through examination under anaesthesia.
Tonsilloliths are rare calcified concretions that develop in tonsillar crypts within the substance of the tonsil or around it. In a review by Mesolella et al., tonsilloliths were found to be located in the tonsillar fossa in 21.2% of cases, in the tonsillar tissue in 69.7% and in the palatine in 9%, with a variation of sizes ranging from a few millimetres to several centimeters [
Tonsillolith arises from dystrophic calcification despite normal serum calcium and phosphate levels [
Using confocal microscopy, Stoodley’s group showed that tonsilloliths were morphologically similar to dental biofilms, containing corncob structures, filaments, and cocci [
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 [
If a tonsillolith is suspected but still doubtful in the absence of clear-cut manifestations, a panoramic radiograph can be considered. However, a radio-opaque mass can signify differentials other than a tonsillolith depending on its relation with surrounding structures which can include foreign body, odontoma, sclerosing osteitis, Garres osteomyelitis, fibrous dysplasia, idiopathic osteosclerosis, and osteoma [
Treatment usually involves removal of the tonsillolith by curettage; larger lesions may require local excision. If there is evidence of chronic tonsilloliths, tonsillectomy offers definitive Therapy [