Volume 1, Issue 1 , Pages 19-21, March 2006
Giant tonsillolith in a child
Article Outline
Summary
Tonsilloliths are calcifications that form in the crypts of the palatine tonsils. These are usually seen in adults but are uncommon in children. A case with a large tonsillolith measuring 35
mm×22mm×22mm in a child is presented, which is the largest reported in pediatric age group. Surgical treatment and sometimes-even tonsillectomy may be needed in such a large tonsillolith.
Keywords: Giant tonsillolith, Child, Tonsillectomy
1. Introduction
Tonsillar concretions are not uncommon, however clinically significant tonsilloliths are infrequent. These arise from retained food materials, secretions and bacterial growth in the crypts of tonsils. These may exist in patients with or without a history of tonsillar inflammation. These are usually seen in the age group of 20–68 years, with equal sex distribution and are uncommon in children [1]. Small tonsilloliths may be asymptomatic, while large tonsilloliths usually present with symptoms of throat irritation, dyphagia, otalgia, and foreign body sensation. Most of the reported cases of giant tonsilloliths belong to the adult population [2], [3]. We present an unusual case of a giant tonsillolith in a child, which to the best of knowledge appears to be the largest reported in literature in pediatric age group.
2. Case report
A female child aged 11 years presented to us with a history of swelling in the right side of the soft palate, pain in the throat and dysphagia. Clinical interrogation revealed history of recurrent attacks of sore throat for last three years, which used to subside by treatment taken from the local physician in the form of antibiotics.
Her general physical examination was essentially normal. Oro-phyrangeal examination revealed a bulge in the soft palate. A grayish-white mass, of about 1cm×1cm was seen embedded in the right tonsil. On palpation this mass was hard with tenderness in the surrounding area. The mass was immobile on bimanual palpation. There was no associated significant lymph-adenopathy. A CT scan of the oro-pharyngeal area revealed a hyper dense lesion in the right posterior oro-pharyngeal region (Fig. 1). A diagnosis of tonsillolith was made and patient was posted for surgery under general anesthesia. Tonsillollith was found to be lodged in the right palantine tonsil and causing bulge in the soft palate (Fig. 2). It was shelled out easily and a bilateral tonsillectomy was performed. The removed tonsillolith measured 35mm×22mm×22mm, was hard with rough and irregular surface (Fig. 3). The patient made an uneventful recovery and she was discharged on the second day.
Fig. 1.
Plain axial CT scan showing a hyperdensity in the right parapharyngeal space medial to the ramus of the mandible indenting the oro-pharynx.
Fig. 2.
Tonsillolith seen during the surgery.
Fig. 3.
Giant tonsillolith measuring 35
mm×22mm×22mm seen after removal.
3. Discussion
Tonsilloliths are relatively uncommon findings. These are calcifications that form in the crypts of the palatine tonsils, usually small in size but large tonsilloliths have been reported [1], [2]. Tonsilloliths can occur at any age but it is more frequent in adults with a mean age in early forties with no sex predilection [1], [2], [3]. The occurrence of tonsillar concretions or tonsillolith is unusual in children [1], [2], [3], [4], [5].
Tonsillar concretions arise from retained materials and bacterial growth in the tonsillar crypts and may exist with or without a history of recurrent tonsillitis. The clinical presentation of fetor-oris and sore throat as well as the presence of whitish expressible foul smelling and foul tasting cheesy lumps from the tonsils characterizes many patients with tonsillar concretions [1], [2], [3], [4], [5]. These may present with otalgia, odynophagia, swelling in the tonsillar fossa and foreign body sensation [1], [2], [3], [4], [5], [6], [7]. Our patient had a history of recurrent sore throat but sought advice only when significant swelling in the neck ensued.
On clinical examination the tonsillolith may be seen as a white or yellowish hard object within the tonsillar crypts [1], [2], [3], [4], [5], [6], [7] as was the case in our patient. Sometimes the visual examination of the oro-pharynx may be normal and the presence of the tonsillolith is discovered by palpation of a firm mass in the tonsillar fossa or on radiology [1], [2], [3], [4], [5], [6], [7].
The chemical composition of the tonsillolith is primarily calcium salts; specifically calcium hydroxyapatite and calcium carbonate apatite. Microscopically, deminaralized sections reveal a core of eosinophillic material and microbial colonies consistent with the leptothrix and actinomycosis species. It has been suggested that these microbes along with retained caseous secretions in the tonsillar crypts form the nidus for the formation of concretions with gradual deposition of inorganic salts [1], [2], [3], [4], [5], [6], [7], [8].
Tonsilloliths may present on panoramic radiographs as radio-opaque objects superimposed on the mid-portion of the ascending mandibular ramus and may be misinterpreted as a lesion of the mandible. Further normal structures like prominent pterigoid hamulus and elongated styloid process, calcification of the stylohyoid ligament, unusual prominence of the maxillary tuberosity or mandibular ramus may simulate tonsillar calculi when only a single CT section is evaluated. Evaluation of successive scans is helpful to reveal the true nature of these structures [2], [9], [10].
The differential diagnoses of tonsillolith include tonsillitis, peritonsillar abscess, tuberculosis, syphilis, mycosis, keratosis pharynges, foreign body, elongated styloid process, isolated bone or cartilage derived from embryonic cell rests, neoplasia [1], [2], [3], [4], [5], [6], [7], [8], [9], [10] and even a displaced tooth [11].
Surgical removal of the tonsillolith is needed to alleviate symptoms. Small tonsilloliths can be managed by simple manual expression from the tonsils with gentle pressure or by curettage under local anesthesia [1], [2], [3], [4], [5], [6], [7], [8]. Pulsatile jets of water can be used to clean the pockets of debris mechanically [1]. Topical silver nitrate may be applied to the tonsillar crypts to chemically cauterize and obliterate them [1], [8]. Patients having persistent problems of pain, halitosis and foreign body sensation, recurrent attacks of tonsillitis may need tonsillectomy [1], [2], [3], [4], [5], [8].
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PII: S1871-4048(05)00010-9
doi:10.1016/j.pedex.2005.11.003
© 2005 Elsevier Ireland Ltd. All rights reserved.
Volume 1, Issue 1 , Pages 19-21, March 2006
