Tonsil stones

Definition/diagnostic criteria Tonsil stones, also known as tonsilloliths, are calcified or hardened masses that form in the crevices or crypts of the tonsils. These stones typically consist of bacteria, dead cells, and debris that accumulate and become trapped in the tonsil crypts, leading to the formation of small, white or yellowish structures.

Tonsil stones can vary in size and may be asymptomatic or cause symptoms such as bad breath, throat discomfort or a foreign body sensation. Diagnostic criteria for tonsil stones primarily rely on clinical assessment and patient-reported symptoms.

Epidemiology Tonsil stones are a relatively common condition, although their prevalence is not extensively documented in the UK-specific literature. The available evidence suggests that tonsil stones are more frequent in individuals who have had recurrent tonsillitis or chronic inflammation of the tonsils. Additionally, they tend to occur more frequently in adults than in children. Patients with deep tonsil crypts are also more prone to developing tonsil stones.

Diagnosis
Clinical features: The diagnosis of tonsil stones is mainly based on clinical features and patient history. Common clinical features include:

• Bad breath (halitosis): Persistent bad breath is often a prominent symptom of tonsil stones, as the accumulated debris and bacteria emit foul-smelling gases.
• Sore throat: Some patients may experience a persistent sore throat or discomfort due to the presence of tonsil stones.
• Difficulty swallowing: Larger tonsil stones may lead to a sensation of a foreign body in the throat or difficulty swallowing.
• Visible tonsil stones: In some cases, tonsil stones may be visible on examination as small, white or yellowish masses within the tonsil crypts.
• Recurrent tonsillitis: Patients with a history of recurrent tonsillitis or chronic tonsil inflammation may be at a higher risk of developing tonsil stones.

Investigations: Diagnosis is via clinical assessment of the throat. CT scans or ultrasound may be considered in complex or severe cases to evaluate the extent and size of tonsil stones.

Treatment The management of tonsil stones focuses on relieving symptoms and preventing recurrence. Treatment options may include:

• Oral hygiene: Encourage patients to maintain good oral hygiene practices, including regular brushing and use of an alcohol-free mouthwash, to reduce bacterial growth in the mouth and minimise bad breath.
• Gargling: Suggest gargling with warm, saltwater or a non-alcoholic mouthwash to help dislodge and flush out tonsil stones.
• Tonsil stones removal: In cases where tonsil stones are causing significant discomfort or recurrent issues, manual removal by an ENT specialist may be considered.
• Tonsillectomy: For individuals with severe and recurrent tonsil stones, a tonsillectomy may be considered as a more definitive treatment option.

Prognosis Most cases can be managed effectively with conservative measures, such as improved oral hygiene and symptom relief. However, the recurrence of tonsil stones is possible, particularly in individuals with deep tonsil crypts or a history of recurrent tonsillitis. For those with persistent and bothersome tonsil stones, the option of tonsillectomy can offer long-term relief.