We commonly are asked to evaluate patients with the complaint of sore throat.  Many times our primary objective is to make sure that a peritonsillar abscess or a retropharyngeal abscess is not the cause.  Occasionally there is posterior pharyngeal trauma that warrants special consideration.  With that being said, however, the primary issue the patient and the family want to know is whether or not the sore throat is “Strep Throat.”  So when you look in the kid’s mouth and see something white, you often get excited to start talking about antibiotics… but first consider one other thing: Tonsilloliths.

Tonsilloliths

• Small concretions within the tonsillar pillars are common in adults (typically after age 20).
• They are not as common in children.

• Tonsilloliths are white or yellow colored stones.
  • They are composed of calcium salts, oxalates, and other magnesium salts.
  • Can contain ammonium radicals.
• Can be friable or hard as a stone.

Where Do They Come From?

• The pathogenesis is unclear, but thought to be due to repeated bouts of tonsillar inflammation.
• This can lead to fibrosis of the ducts of the tonsillar crypts and retention of debris.
• This can also lead to bacterial overgrowth and deposition of inorganic salts from saliva.

• So, while they are rare in kids, if the patient has had multiple episodes of inflammation of the tonsils, then they may develop tonsilloliths early.

Presentation

• Pain during swallowing
• Foreign body sensation
• Foul breath
• Bad taste in mouth
• Can by asymptomatic
  • Occasionally detected on xray or CT scan.

Therapy

• Many require no therapy.
• Salt-water gargle to help release the stone.
• Some people can tolerate simple remove with cotton swabs (carefully).
• Large stones may actually require surgical removal.

So, while these are more likely to be encountered in our older patients, make sure that what you are calling an “exudate” is really that and not a Tonsillolith — antibiotics won’t really help the large stone sitting in the tonsil!

References