A giant tonsillolith

Discussion

Tonsillar stones (tonsilloliths) are products of calcified accumulates of food, cellular debris, and microorganism aggregates in the crypts of palatine tonsils.3 Tonsillar crypts are fissure-like invaginations in the medial side of the palatine tonsils and serve to increase the surface area of the tonsils with more than 10 crypts in each tonsil. Small tonsilloliths are common findings associated with recurrent sore throat and if symptomatic, usually present with a chief complaint of halitosis or bad breath.3 However, large tonsilloliths are rare entities and a few cases are reported in literature.4 The exact mechanism of development of tonsillar stones is not well understood. However, several hypotheses exist to explain formation of these calculi. One hypothesis attributes stone formation to recurrent tonsillitis and subsequent crypt fibrosis that lead to epithelial cell retention, which creates an environment for microorganism overgrowth and calcification due to deposition of inorganic salts from salivary gland secretions.5 Stoodley et al6 concluded that tonsilloliths share common characteristics with biofilms. Biofilms are aggregates of aerobic and non-aerobic microorganisms enclosed in an extracellular matrix. Due to the nature of biofilms, it is difficult to treat the microorganisms with antibiotics. In fact, a biofilm serves as a nidus for acute infections rendering it a source of recurrent ENT infections.7 Cases of giant tonsillolith have not been reported in Saudi Arabia. Literature review shows that the largest tonsillolith was reported in a 12-year-old female child in the left tonsil and measured 4.2 × 3.6 × 2.1 cm. A majority of the cases of giant tonsilloliths reported a left tonsil stone rather than the right. Two reported cases showed bilateral giant tonsilloliths.8,9 A patient with tonsillar stone is approached through history taking, physical examination, and imaging studies. A giant tonsillolith may be an incidental finding in asymptomatic patients or maybe associated with common symptoms and signs of tonsilloliths.9 Reported clinical presentations of giant tonsilloliths include recurrent sore throat, halitosis, foreign body sensation, painful swallowing (odynophagia), hoarseness, and rarely, upper airway obstruction. Differential diagnosis of tonsillar stones include foreign body, calcified granulomas, tonsillar malignancy, enlarged styloid processes, embryonic rests originating from the branchial arches.10 Imaging studies may be helpful to identify the size, extension, and location of the stone. Symptomatic giant tonsilloliths are usually treated with tonsillectomy with the pathology report on type of the stone and disease process.

In conclusion, Tonsilloliths are common findings associated mainly with halitosis. However, giant tonsilloliths are rare with few cases reported in the literature. This case supports the hypothesis of tonsillollith formation secondary to recurrent tonsillitis and subsequent crypt fibrosis that lead to epithelial cell retention in the crypts of palatine tonsils. Differential diagnosis of tonsillar stones include foreign body, calcified granulomas, tonsillar malignancy, enlarged styloid processes, embryonic rests originating from the branchial arches. Imaging studies might be necessary to identify the size and extension of the stone beyond the palatine tonsils. This case was managed with tonsillectomy and pathology report on disease process.