Tonsiliths, also known as tonsilloliths and tonsillar concretions or simply called liths, are stones that arise from calcium being deposited on desquamated cells and bacterial growth in the tonsillar or adenoidal crypts and occur in patients with or without a history of inflammatory disorders of either the tonsils or adenoids [
On clinical examination, a superficial tonsilith may be seen as a white or yellowish hard mass within the tonsillar crypt [
Clinical photograph of a patient with small, superficial tonsilith in the left tonsillar crypt (arrow).
Treatment is usually removal of the tonsilith by curettage. Larger concretions may require local excision under topical or local infiltration anesthesia. If there is evidence of chronic tonsillitis, tonsillectomy offers definitive therapy [
Tonsiliths are composed of phosphate and/or carbonate salts of calcium. These are arranged in a structure similar to that of bone crystals of hydroxyapatite Ca5[OH
Although a pantomograph is a reliable and standard modality for interpreting the presence of tonsiliths, superimposition of a lesion involving one side of the jaw may create a pseudotonsilith or ghost image on the contralateral side which could lead to a misinterpretation of bilateral lesions [
Multiple, well-defined calcifications in the right tonsil (circle) in a 79-year-old male.
Multiple, well-defined calcifications in the right tonsil (circle) in a 54-year-old male.
Multiple, well-defined, bilateral calcifications in the angle-ramus region of the mandible (circle) in a 57-year-old male. Note ghost images on the right (arrow).
Multiple, well-defined, and bilateral calcifications in the angle-ramus region of the mandible (circle and arrow) in a 67-year-old female.
Approval for both parts of the study was granted by the University of Iowa Institutional Review Board. This study complied with the Helsinki Declaration as regards human subjects. This was a two-part study. The first part was a prevalence study while the second was a matched pair case-control study. The matched pair case-control study commenced after the prevalence study was concluded. No new or unusual radiographs were made in this study. The study only reviewed radiographs that were made for clinical purposes.
The intended population for the prevalence study comprised all the patients who attended the oral and maxillofacial radiology clinic of the College of Dentistry of The University of Iowa over a four-year period, between January 2000 and December 2003. The study population included both subjects with and without tonsiliths found on pantomographs. The age range was three to ninety years. A total of 1524 subjects were recruited.
Only subjects with diagnostic quality pantomographs were included because these radiographs could potentially show calcifications in the tonsils over the angle and ramus of the mandible.
In order to determine prevalence, subjects with and without tonsiliths demonstrable on the pantomographs were included in the study. Both analog and digital pantomographs were included.
Individuals below the age of three or whose pantomographs were of poor diagnostic quality or with a history of tonsillectomy were excluded.
Tonsiliths measuring 2 mm or less were excluded because this dimension did not give a high confidence level of interpretation.
The radiographs were viewed in the interpretation room in subdued lighting over a clean and bright illuminator or computer screen. A magnifying glass or digital magnification was used to assist in viewing the concretions on the radiographs.
An interpretation of tonsiliths was made when radiopaque masses not deemed to be part of the stylohyoid complex, sialoliths, calcified lymph nodes, phleboliths, or changes in the bone pattern were seen over or near the angle and ramus of the mandible. The concretions needed to have a radiopacity similar to, but demarcated from, the overlying bone. Unilateral and bilateral concretions were recorded. Ghost images were identified to prevent errors of interpretation. The size, site, and number of concretions were recorded. Unique identifiers (chart numbers) of the subjects were recorded.
The principal investigator was calibrated against multiple observers such that a capital value of agreement was established. This was done in order to establish criteria for interpreting tonsiliths. The exercise was repeated halfway through the study to prevent a drift from established standards.
A standardized chart abstraction form was used to extract relevant information from the dental records of the subjects. The information extracted included demographics such as age and sex and radiographic appearance of tonsiliths.
The lack of previous data or studies made it difficult to estimate the sample size. Therefore, a convenience sample inclusive of all the subjects who attended the oral and maxillofacial radiology clinic from January 2000 to December 2003 was used.
Descriptive statistics were computed, and frequency tables were generated. Bivariate analyses were performed to determine if there was a statistically significant difference between two groups of patients (with single tonsiliths versus with multiple tonsiliths) for demographic factors. Chi-square test, Fisher’s exact test, and nonparametric Wilcoxon rank-sum test were conducted for the data analysis.
All tests had a 0.05 level of statistical significance. SAS for Windows (version 9.1, SAS Institute Inc., Cary, NC, USA) was used for the data analysis.
The second part, the matched pair case-control study, included the rolling enrolment of subjects referred to the department over a six-month period (October 2007 to March 2008). The control group comprised subjects without the radiographic evidence of tonsiliths on pantomographs, whose medical history may or may not reveal presence of calcifications or stones in other tissues and organs, including kidneys and salivary glands. The case group comprised subjects with radiographic evidence of tonsiliths on pantomographs, who may or may not have history of calcifications or stones in other tissues or organs, including the kidneys and salivary glands. For each subject with tonsiliths, that was enrolled into the case group, another potential subject without tonsiliths was recruited to the control group. The subjects recruited to the control group were matched for age (±2 years) and sex with the subjects in the case group. The subjects for both case and control groups were enrolled from the patients attending the oral and maxillofacial radiology clinic.
The involvement of subjects consisted of one clinical visit of approximately 30 minutes. No additional clinic follow-ups were necessary. There were no foreseeable risks from participating in the study.
Age range: 3–90 years. Only subjects without tonsiliths on pantomographs were included in the control group. Only subjects with tonsiliths on pantomographs were included in the case group. Diagnostic quality pantomograph.
The features of a diagnostic quality pantomograph include both rami of the mandible visible on the radiograph; proper positioning of the patient in the unit when the radiograph was made; areas of the tonsils included in the image; the overall density of the radiograph acceptable for interpretation; no artifacts over the rami of the mandible to preclude the visualization of tonsiliths.
Subjects below the age of three years. Subjects with poor diagnostic quality pantomographs. Subjects who declined to give informed consent. Subjects with a history of tonsillectomy.
Descriptive statistics were computed and frequency tables were generated. Bivariate analyses were performed to determine whether there was a statistically significant difference between the case and control groups. Chi-square test, Fisher’s exact test, and nonparametric Wilcoxon rank-sum test were used for data analysis.
All tests have a 0.05 level of statistical significance. SAS for Windows (version 9.1, SAS Institute Inc., Cary, NC, USA) was used for the statistical analysis.
To our knowledge, no similar studies have been conducted before and, therefore, no analogous information is currently available for determination of sample size of case-control groups. This initial study, which was completed in approximately 6 months, therefore included all the subjects with a matched pair for case-control study.
The results of the prevalence study that was earlier conducted could not be used to calculate the sample size for the matched, pair case-control study because the data did not include correlations between tonsiliths and other stones in body organs, tissues, and ducts.
A total of 1524 pantomographs were reviewed in the oral and maxillofacial radiology clinic of The University of Iowa. 205 subjects with possible tonsiliths were identified. Of the 205 subjects, 124 had tonsiliths over 2 mm in size with a high confidence level. The 81 subjects eliminated possibly had tonsiliths, but the 2 mm dimension did not give a high confidence level of interpretation.
Therefore, 124 subjects (53 males and 71 females) aged 9.2 to 87 years (mean age 52.6 years) were included for the data analysis. The male-to-female ratio was 0.75 : 1.00. Thirty eight subjects had single tonsiliths whereas 86 subjects had multiple tonsiliths. The prevalence of tonsiliths in the study population was 8.14%.
Table
Frequency distribution of sex, imaging modalities, radiographic appearance, location, side of jaw, ghost images, and size of tonsiliths.
Frequency ( |
Percent (%) | |
---|---|---|
Sex | ||
Male | 53 | 42.74 |
Female | 71 | 57.26 |
Total |
|
|
Imaging modalities | ||
Plain film | 124 | 100.00 |
Digital images | None | 0.00 |
Total |
|
|
Radiographic appearance of tonsiliths | ||
Single, welldefined | 35 | 28.23 |
Single, illdefined | 3 | 2.42 |
Multiple, welldefined | 78 | 62.90 |
Multiple, ill-defined | 8 | 6.45 |
Total |
|
|
Location of tonsiliths | ||
Upper 1/3 of mandibular ramus | 0 | 0.00 |
Middle 1/3 of mandibular ramus | 8 | 6.45 |
Lower 1/3 of mandibular ramus | 116 | 93.55 |
Total |
|
|
Side of jaw | ||
Unilateral left | 41 | 33.06 |
Unilateral right | 50 | 40.32 |
Bilateral | 33 | 26.62 |
Total |
|
|
Ghost images | ||
Present | 8 | 6.45 |
Not present | 116 | 93.55 |
Total |
|
|
Size of tonsiliths (mm) | ||
|
69 | 55.65 |
|
24 | 19.35 |
|
17 | 13.71 |
|
10 | 8.06 |
|
1 | 0.81 |
|
1 | 0.81 |
|
1 | 0.81 |
11 | 1 | 0.81 |
Total |
|
|
Mean of age of subjects and size of tonsiliths for both single and multiple tonsiliths.
Variable | Mean | Standard deviation | Minimum | Maximum |
---|---|---|---|---|
Subjects with both single and multiple tonsiliths ( | ||||
Age (year) | 52.65 | 20.64 | 9.20 | 87.00 |
Size of tonsiliths (mm) | 3.90 | 1.38 | 3.00 | 11.00 |
|
||||
Subjects with single tonsiliths ( | ||||
Age (year) | 50.32 | 21.67 | 9.20 | 84.00 |
Size of tonsiliths (mm) | 4.18 | 1.54 | 3.00 | 11.00 |
|
||||
Subjects with multiple tonsiliths ( | ||||
Age (year) | 53.68 | 20.21 | 13.20 | 87.00 |
Size of tonsiliths (mm) | 3.78 | 1.29 | 3.00 | 10.00 |
Based on chi-square test or Fisher’s exact test, the data revealed that there was a significant difference between the two groups for the unilateral right side of the jaw (
Based on the nonparametric Wilcoxon rank-sum test, the data showed that there was no significant difference in mean age and mean size of tonsiliths between the two groups of subjects (with single tonsilith versus multiple tonsiliths) (
Based on chi-square test or Fisher’s exact test, the data revealed that there was no significant difference between the two groups for sex (
No significant results were found (
A total of 20 subjects were included in this study, comprising 10 each for the matched pair case and control groups. The age range was 17–83 years, with a mean age of 42.95 years and standard deviation of 22.09. The sex ratio was 4 : 1 for both the case and the control groups.
A total of 8 subjects (40%) provided a history of recent episodes of tonsillitis. But 2 out of the 8 subjects (10%) did not provide a record of the date of the last episode of tonsillitis. Out of the 6 subjects with a record of the last date of tonsillitis, 4 (67%) were in the case group while 2 (33%) were in the control group (Table
Frequency distribution of history of tonsilitis for the matched pair case-control study.
Variable | Frequency ( |
Percent (%) |
---|---|---|
Subjects in case group ( | ||
Previous history of tonsilitis | 6 | 60 |
No previous history of tonsillitis | 4 | 40 |
|
||
Subjects in control group ( | ||
Previous history of tonsilitis | 2 | 20 |
No previous history of tonsillitis | 8 | 80 |
Frequency distribution of unilateral and bilateral tonsilitis for the matched pair case-control study.
Side affected | Frequency ( |
Percent (%) |
---|---|---|
Subjects in case group ( | ||
Unilateral | 1 | 10 |
Bilateral | 5 | 50 |
Not applicable | 4 | 40 |
|
||
Subjects in control group ( | ||
Unilateral | None | 0 |
Bilateral | 2 | 20 |
Not applicable | 8 | 80 |
Frequency distribution of the number of episodes of tonsilitis per year for the matched pair case-control study.
Number of episodes |
Frequency ( |
Percent (%) |
---|---|---|
Subjects in case group ( | ||
1 | 4 | 40 |
2 | 1 | 10 |
6 | 1 | 10 |
Not applicable | 4 | 40 |
|
||
Subjects in control group ( | ||
1 | 2 | 20 |
Not applicable | 8 | 80 |
The subjects gave varied responses to questions about the symptoms of tonsiliths. The symptoms included the history of chronic sore throat, chronic cough, difficulty in swallowing, pain in the ear, chronic halitosis, foreign body-like sensation in the throat, and bad/altered taste. The observations are presented in Table
Frequency distribution of symptoms of tonsilitis (
Variable | Frequency | |
---|---|---|
Case ( |
Control ( | |
Sore throat | 2 | 0 |
Chronic cough | 2 | 0 |
Difficulty swallowing | 1 | 0 |
Pain in ear | 1 | 0 |
Chronic halitosis | 1 | 0 |
Foreign body-like feel | 2 | 0 |
Altered taste | None | None |
Previous history of tonsilith | None | None |
Two subjects gave a history of tonsillectomy for the management of tonsillitis. These subjects were excluded from the data. Two other subjects (10%) gave a history of antibiotic regimen for the management of tonsillitis. There was no record of curettage in the observations.
The medical history of stones in other body tissues, organs, and ducts was sought by asking questions about sialoliths, phleboliths, arteriosclerosis, calcified lymph nodes, dacryoliths, antroliths, rhinoliths, nasopharyngeal stones, nephroliths, and gall bladder stones. One subject each had a history of phlebolith and calcified lymph nodes, respectively. There was no other history of body tissue concretions.
A total of 5 (25%) gave a history of cigarette smoking. Out of the sample, only three still smoke regularly. The date of last dental cleaning at a dental facility and calculus distribution on the lingual and facial surfaces of the mandibular incisors and maxillary molars were recorded for each subject. The date of last professional cleaning from a dentist ranged from less than 1 week to 10 years. The observations are presented in Table
Frequency distribution of dental calculus.
Calculus | Case |
Control |
---|---|---|
Lingual surfaces of mandibular incisors | 1 | 1 |
Facial surfaces of maxillary molars | 0 | 2 |
Lingual surfaces of the mandibular incisors and facial surfaces of the maxillary molars | 5 | 2 |
No calculus | 4 | 5 |
A total of 13 (65%) pantomographs were analog, whereas 7 (35%) were digital. A total of 18 (90%) pantomographs were made on the OC 100-3-1-2 machine, whereas the remaining 2 (10%) were made on the OP 100-3-1-2 machine.
The radiographic appearance of tonsiliths was categorized as single, well-defined (
Frequency of radiographic appearance, location, side of jaw, ghost images, and size of tonsiliths.
Case |
Control | |
---|---|---|
Radiographic appearance | ||
Single, welldefined | 3 | 0 |
Multiple, welldefined | 7 | 0 |
Nil tonsiliths (control group) | 0 | 10 |
Location of tonsilith(s) | ||
Lower third of mandibular ramus | 10 | 0 |
Nil tonsiliths (control group) | 0 | 10 |
Side of the jaw with tonsilith | ||
Unilateral left | 1 | 0 |
Unilateral right | 6 | 0 |
Bilateral | 3 | 0 |
Nil tonsiliths (control group) | 0 | 10 |
Ghost images | ||
Present | 2 | 0 |
Not present | 8 | 0 |
Nil tonsiliths (control group) | 0 | 10 |
Size of tonsilith seen on radiographs (mm) | ||
3 | 2 | 0 |
4 | 3 | 0 |
5 | 3 | 0 |
6 | 2 | 0 |
Nil (control group) | 0 | 10 |
The tonsils were examined clinically. The observations showed that all the tonsiliths (
The largest tonsilith in the radiographic observation was 6 mm, whereas the smallest was 3 mm (Table
The mean values of observations for the case and control groups are presented separately on Tables
Mean values of observations for the case group.
Variable | Subjects ( |
Mean | Standard deviation | Minimum | Maximum | Median |
---|---|---|---|---|---|---|
Last tonsillitis (weeks ago) |
|
3.75 | 3.10 | 1.00 | 8.00 | 3 |
Episodes of tonsillitis per year | 5 | 2.00 | 2.35 | 0.00 | 6.00 | 1.00 |
When quit smoking (weeks ago) | 3 | 312.00 | 187.49 | 156.00 | 520.00 | 260.00 |
Num. of cigarettes per day | 3 | 7.33 | 10.97 | 1.00 | 20.00 | 1.00 |
Last dental cleaning (weeks ago) | 8 | 226.88 | 162.92 | 43.00 | 520.00 | 234.00 |
Size of tonsiliths (mm) | 10 | 4.50 | 1.08 | 3.00 | 6.00 | 4.50 |
Age of subject (years) | 10 | 42.70 | 22.39 | 17.00 | 82.00 | 39.00 |
Mean values of observations for the control group.
Variables | Subjects ( |
Mean | Standard deviation | Minimum | Maximum | Median |
---|---|---|---|---|---|---|
Last tonsillitis (weeks) | 2 | 30.00 | 31.11 | 8.00 | 52.00 | 30.00 |
Episodes of tonsillitis per year | 2 | 1.00 | 0.00 | 1.00 | 1.00 | 1.00 |
When quit smoking (weeks) | 1 | 104.00 | 0.00 | 104.00 | 104.00 | 104.00 |
Number of cigarettes per day | 2 | 6 | 1.41 | 5.00 | 7.00 | 6.00 |
Last clean (weeks) | 10 | 43.50 | 46.22 | 2.00 | 156.00 | 52.00 |
Size of tonsiliths (mm) | 0 | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
Age of subjects (yr) | 10 | 43.20 | 22.99 | 17.00 | 83.00 | 39.00 |
Based on the nonparametric Wilcoxon rank-sum test, the data revealed that there was a significant difference between case and control as the date of a last professional cleaning was received from a dental facility (
Based on Fisher’s exact test, the data revealed that there was no significant difference between case and control groups for tonsillitis, side(s) affected, sore throat, chronic cough, difficulty swallowing, pain in ear, chronic halitosis, foreign body feel, antibiotics, phlebolith, calcified lymph node, use of tobacco products, and dental calculus (
Based on the nonparametric Wilcoxon rank-sum test, there was no significant difference between case and control groups for the date of last episode of tonsillitis (
This study was designed as a two-part study to determine the prevalence of tonsiliths and the relationship between tonsiliths and concretions in other body organs, tissues, or ducts in the patients attending the oral and maxillofacial radiology clinic of The University of Iowa. In the first part of the study, a total of 1524 charts, representing pantomographs made between January 2000 and December 2003, were reviewed. One hundred and twenty-four (8.14%) cases of tonsiliths, measuring above 2 mm on a linear scale were included in the final analysis. Eighty-one cases with possible tonsiliths, measuring 2 mm and below, were removed from the data because this dimension does not give a high confidence level of interpretation. Therefore, the prevalence of tonsiliths in patients attending the oral and maxillofacial radiology clinic of The University of Iowa was observed to be 8.14%. This figure is similar to what was reported by Cooper and his coworkers in 1983 [
The earliest known description of concretions in the oropharynx is thought to be recorded by Lang in 1560 [
Out of the 124 cases of tonsiliths in our study, 53 were males and 71 were females. The male-to-female ratio was 0.75 : 1.00 and there is no sex predilection. The age range of subjects was 9.2–87 years (mean 52.6 years). The average size of tonsilith was 4 mm (range: 3–11 mm). The incidence of large tonsiliths is low. They are seen mainly in elderly patients [
The radiographic appearance of tonsiliths in this study was predominantly multiple and well defined (
The majority of the cases were located in the lower one-third of the mandibular ramus (
The mean age of subjects with multiple and well-defined concretions was slightly higher (53.68 years) when compared to the mean age of subjects with single, well-defined concretions (50.32 years). A similar pattern was observed with the average size of tonsiliths, which is 4.18 mm for single concretions and 3.78 mm for multiple concretions.
For the matched pair case-control study, the age range of subjects was 17–83 years (
The observations in this study do not indicate any statistical difference in tobacco use between the case and control groups. It is not clear if any association exists between tobacco use and tonsiliths.
Patients with tonsiliths may be asymptomatic and their tonsiliths may be discovered incidentally on pantomographs or other imaging modalities, including CTs and MRIs [
There has been growing interest in the association between tonsiliths and halitosis [
The observations in our study do not support any correlations between tonsiliths and calcifications in other body organs, tissues, or ducts. One subject gave a history of calcified lymph nodes and phlebolith. The study population did not indicate any history of sialoliths, dacryoliths, antroliths, nephroliths, or gall bladder stones. When correlated with calculus in the oral cavity, 11 of the subjects (55%) had calculus on the surfaces of the mandibular incisors and maxillary molars. The facial surfaces of the maxillary molars and the lingual surfaces of the mandibular incisors were selected because the high concentration of calcium at the opening of the Stenson and Warthon’s ducts translates to higher concentration of calculus at the locations. Saliva is supersaturated with calcium and phosphate and calculus derives its calcium from saliva. Inasmuch as saliva also percolates the tonsils and tonsillar crypts, it is assumed that the calcium and phosphate content of saliva may play a role in the formation of tonsiliths. Furthermore, the salivary calcium regulatory protein, statherin, may also have a role to play in the formation of tonsiliths. It is, therefore, possible that there is a correlation between salivary calcium and tonsiliths.
Furthermore, the responses to the history of possible calcifications in other body tissues, ducts, or organs were based solely on study subject recall of past medical history. This information was rather subjective and a better assessment may have been obtained if the history provided by the study subject was compared to medical records.
This study was done to, first, determine the prevalence of tonsiliths in patients attending the University of Iowa Dental Clinic and, secondly, to investigate a correlation between tonsiliths and other concretions. Tonsiliths are a major source of halitosis that is often overlooked by clinicians.
The authors declare that they do not have conflict of interests.