(1) Unidad de Estomatología, Hospital Universitario Dr. Peset (Valencia), Departamento de Estomatología de la Universidad de Valencia
(2) Servicio de ORL del Hospital Universitario Dr. Peset de Valencia

Address:
Prof. F. Javier Silvestre Donat
Sección Pacientes Especiales
Clínica Odontológica Universitaria
C/ Gascó Oliag 1, 46010-Valencia.
E-mail: Francisco.silvestre@uv.es

Received: 7-12-2003  Accepted: 14-03-2004

INTRODUCTION

Small calcifications known as tonsilloliths or tonsil stones are commonly found in the crypts of the palatal tonsils. However, large tonsillar calculi or peritonsillar stones are much less frequent (1). Tonsilloliths are difficult to diagnose in the absence of clear manifestations, and often constitute casual findings of routine radiological studies (2).

These calculi are composed of calcium salts such as hydroxyapatite or calcium carbonate apatite, oxalates and other magnesium salts or containing ammonium radicals, and macroscopically appear white or yellowish in color (3). The mechanism by which these calculi form is subject to debate, though they appear to result from the accumulation of material retained within the crypts, along with the growth of bacteria and fungi such as Leptothrix buccalis – sometimes in association with persistent chronic purulent tonsillitis. Other authors have proposed alternative mechanisms when the calculi are located in peritonsillar areas, such as the existence of ectopic tonsillar tissue, the formation of calculi secondary to salivary stasis within the minor salivary gland secretory ducts in these locations, or the calcification of abscessified accumulations (4,5).

Tonsilloliths tend to present in young adolescents and can manifest with bad breath and swallowing pain accompanied by a foreign body sensation and – in some cases – reflex ear pain. The condition may also prove asymptomatic, with detection upon palpating a hard intratonsillar or submucosal mass (6).

Imaging diagnostic techniques can identify a radiopaque mass that may be mistaken for foreign bodies, displaced teeth or calcified blood vessels. Computed tomography (CT) may reveal nonspecific calcified images in the tonsillar zone. The differential diagnosis must be established with acute and chronic tonsillitis, tonsillar hypertrophy, peritonsillar abscesses, foreign bodies, phlebolites, ectopic bone or cartilage, lymph nodes, granulomatous lesions or calcification of the stylohyoid ligament in the context of Eagle’s syndrome (elongated styloid process)(5,7).

Treatment consists of surgical removal of the stone, with a tonsillectomy in the event the calculus is lodged within the tonsil tissue and is of large size (8).

A 55-year-old woman presented with an approximately one-year history of slight dysphagia and swallowing pain, with a foreign body sensation. She referred repeat pharyngitis in the past few years. The discomfort had worsened in the last 15 days.

Exploration revealed a submucosal mass protruding from the soft palate at right anterior tonsillar pillar level. The lesion appeared hard, well delimited, slightly painful to the touch, and with a somewhat erythematous overlying mucosal layer. There were no palpable adenopathies.

The patient had a history of arterial hypertension currently controlled with doxazosin (4 mg/day) and indapamide (2.5 mg/day), type 2 diabetes mellitus subjected to dietary control, and a hemithyroidectomy about 10 years before due to a normofunctional goiter with hyperthyroidism since then (well controlled for the past 4 years, and currently without medication). She also presented a hiatal hernia, appendectomy and tonsillectomy approximately 30 years before.

The preoperative laboratory blood test parameters proved normal.

Computed tomography of the head revealed the presence of a calcified oval mass measuring approximately 2.5 x 1.5 cm (Figure 1). Surgical removal of the tonsillolith was carried out at soft palatal level, anterior to the right anterior tonsillar pillar, performing an incision parallel to the latter with removal of the stone at submucosal level and resecting the surplus mucosa (Figures 2 and 3).

Large tonsil stones are very infrequent, and are described in the literature as calculi that may be lodged within the palatal tonsillar tissue or in its vicinity (6). We have described the case of a 55-year-old woman with a large tonsillolith similar to those reported by other authors (9). However, differences were observed in relation to the shape of the stone (completely oval in our case) and as regards its anterior peritonsillar location.

Although tonsilloliths usually present as single stones of hard consistency, multiple small calculi can also be observed, with a more friable consistency. The stones may be irregular or present an inverted pyramidal shape (5). In our patient the stone was completely oval in shape and symmetrical.

The patient characteristics in terms of age and sex vary considerably – the disorder having been reported in patients between 20 and 77 years of age (9,10).

The conditions of diagnosis also vary considerably; in effect, while some cases are entirely asymptomatic, and the calculi constitute casual findings of radiological studies conducted for other reasons, in other cases minor symptoms appear and progressively intensity over time, as in our patient - who decided to seek medical help due to persistent discomfort, with swallowing pain and a foreign body sensation (10).

A correct differential diagnosis is important in such situations, in order to define a correct management approach. Although many possible disorders have been postulated, the differential diagnosis should focus on the existence of vascular calcifications of phlebolites, calcified lymph nodes and foreign bodies (5,10).

Following diagnosis of the lesion, treatment invariably consists of removal of the calculus. Nevertheless, controversy exists regarding the pathogenesis of these stones (4,11).

Many authors have suggested that tonsilloliths originate as a result of persistent chronic tonsillitis. However, this origin would not explain the existence of calculi in peritonsillar zones – except in the presence of ectopic tonsillar tissue. Two mechanisms have thus been proposed. On one hand, peritonsillar abscesses may calcify and yield a large stone (12,13). On the other hand, calculi may develop secondary to salivary stasis within the minor salivary glands of the palatal region, with calcification of the accumulated intraductal material. Few data are available to support this hypothesis, however (14).

It should be taken into account that while few giant tonsilloliths have been described in the literature, the description of large stones in peritonsillar areas is even less common. Our case corresponds to a large calculus located outside the tonsillar tissue, anterior to the anterior tonsillar pillar. Moreover, this patient had been subjected to tonsil removal 30 years previously. A third interesting feature was the completely oval shape of the stone. In coincidence with Cogolludo et al. (5), we consider that abscessified peritonsillar accumulations may transform into ectopic calcifications. However, when these calcified structures are long-evolving, it can be very difficult to identify the precise tissue origin involved.

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