J Oral Maxillofac Surg 66:148-150, 2008
Multiple Bilateral Tonsilloliths:
Case Report
Louis Mandel, DDS*
Tonsilloliths, calcifications within a tonsillar crypt, involve primarily the palatine tonsil. Tonsilloliths are not uncommon, but they tend to be microscopic.
Weller1reported that during routine histologic exam- ination of excised tonsils, microscopic tonsilloliths were found in 8% of the specimens. Macroscopic calculi, whose size varied from barely visible to pea size, represent an intermediate form and were identi- fied by Weller in 2% of the excised tonsils.1 Aspes- trand and Kolbenstvedt2 reviewed computerized to- mographic (CT) scans and reported an incidence of 16% with the calcifications varying in size from 1 to 7 mm. Because of its eye-catching presentation, authors have centered their attention on the relatively rare, but very large, tonsillolith whose size can approach 3 cm.3-16
The surface of the palatine tonsil is marked by the presence of many crypts. Organic debris, consisting of dead bacteria and debris from inflammation, epi- thelial tissue, and food, can be trapped at the base of the crypt and act as a nidus for salt precipita- tion.1,2,6,8,17,18The salts, consisting mainly of carbon- ates and phosphates of calcium and magnesium, are derived from the surrounding bathing saliva and in- flammatory exudate.5-8,11,13,16With salt deposition, a tonsillolith forms and tends to grow with the addition of further salt accretions.
Most reports in the literature concern the large tonsilloliths. These reports indicate that these tonsillo- liths occur in males and females equally8,13,18during the fifth decade of their life.8,18 Tonsilloliths may occur singly or in multiples and may be unilateral or bilateral in their presentation. The larger tonsilloliths seem to occur alone whereas the smaller calculi are
often seen in multiples.16 Tonsilloliths, particularly the very large, can cause recurrent bouts of sore throat, dysphagia, bad taste and odor, otalgia, and a foreign body sensation noted on swallowing. How- ever, they are frequently totally asymptomat- ic.13,15,16,18-20
Because tonsilloliths can be asymptomatic, it is of- ten during routine imaging procedures that their pres- ence is uncovered. Panoramic radiographs taken by dentists have been an efficient tool to incidentally show the existence of macroscopic tonsilloliths. The axial computed tomography (CT) scan, taken in the head and neck region, serves as another source for unexpectedly showing calcifications in the palatine tonsil. Imaging often shows that the 4 to 7 mm ton- sillolith has a lucent core surrounded by a concentric opaque ring pattern.1,3,21
This article presents a case that is highly unusual in that multiple bilateral and asymptomatic macroscopic tonsilloliths were found during a routine panoramic radiograph examination. No similar case could be found in a review of the literature.
Report of a Case
A 51-year-old healthy male visited his dentist for routine dental care. During the examination, a panoramic radio- graph was taken. Multiple bilateral calcified nodules, mea- suring 2 to 7 mm in diameter, were observed superimposed on the right and left posterior mandibular rami (Fig 1). The patient was referred to the Salivary Gland Center for further study regarding a possible diagnosis of parotid sialolithiasis.
Questioning indicated that the patient was in excellent health. There was no history of any systemic disease. No swellings or discomfort had ever been present in the head or neck areas. Clinically, no extraoral swellings were evi- dent. Palpation of the face, with particular attention to the parotid areas, showed the tissues to be normal in tone and painless. There was no cervical lymphadenopathy. There was no trismus.
Intraorally, some dental caries was present but no acute infectious processes were evident. The posterior mandibu- lar soft tissues were not inflamed nor were they swollen or painful. Close scrutiny of the posterior regions of the right and left mandibles showed no abnormalities laterally or medially. The orifices of the Stensen’s duct were patent and free, and clear salivary flows were produced when the parotid glands were massaged aggressively.
*Director, Salivary Gland Center, and Assistant Dean and Clinical Professor, Oral and Maxillofacial Surgery, Columbia University Col- lege of Dental Medicine, New York-Presbyterian Medical Center (Columbia Campus), New York, NY.
Address correspondence and reprint requests to Dr Mandel:
College of Dental Medicine, 630 West 168th Street, New York, NY 10032; e-mail: Lm7@columbia.edu
©2008 American Association of Oral and Maxillofacial Surgeons 0278-2391/08/6601-0025$34.00/0
doi:10.1016/j.joms.2006.05.047
148 MULTIPLE BILATERAL TONSILLOLITHS
The panoramic film was studied carefully. Three calcified nodules measuring 2 to 3 mm were present on the right side. Two were superimposed on the ramus whereas 1 seemed to be in soft tissue close to the gonial angle. On the left side, 6 calcifications measuring 2 to 7 mm were ob- served. Two of these calcifications were in soft tissue whereas 4 were superimposed on the posterior ramus above the gonial angle.
To determine the exact anatomic location of these calci- fications, a CT scan with no contrast was ordered. The axial CT scan showed clearly that these calcifications were lo- cated in the right and left palatine tonsils (Fig 2). A diagnosis of multiple asymptomatic bilateral tonsilloliths was made.
Discussion
Initially a diagnosis of multiple bilateral parotid stones was considered. However, the random pattern of their distribution and their multiplicity argued against sialolithiasis. Furthermore, there was no indi- cation of any history or presence of a parotitis. Ob- structive parotid swellings or pain were not part of the story, and the salivary return was observed to be adequate and clear rather then diminished and sup- purative.
Another calcified entity that was considered was phlebolithiasis. Phleboliths are calcified thrombi and are often found in association with hemangiomas.
Skeletal muscle hemangiomas do occur in the head and neck region and usually involve the masseter muscle. Consequently phleboliths can be seen in the anatomic area occupied by the masseter muscle and mandibular ramus. However no swellings marking the existence of a hemangioma were observed.
Lymph node calcifications represent another pro- cess that entered into the differential diagnosis. Scrof- ula, tuberculous lymphadenitis, is often hallmarked by multiple calcifications that involve the cervical chain of lymph nodes. Tuberculosis and other granu- lomatous diseases that may involve the cervical nodes were eliminated by the absence of any medical his- tory or symptomatology indicating their existence. In addition, the calcifications seen in this case do not follow the anatomic configuration of a cervical node chain. Differential diagnosis also must include the presence of anatomic structures such as an elongated styloid process, calcification of the stylohyoid appara- tus or even a prominent hamular process. Arterial calcifications and foreign bodies also must be brought into the equation. A granulomatous disease of the tonsil, which has progressed to calcification, is an- other possibility.19 This group of opacities can be
FIGURE 1. Panoramic radiograph shows multiple tonsilloliths (encircled) in region of right and left mandibular rami.
Louis Mandel. Multiple Bilateral Tonsilloliths. J Oral Maxillofac Surg 2008.
FIGURE 2. Computed tomography scan. Axial view with no contrast.
Multiple tonsilloliths (arrows) involving right and left palatine tonsils.
Louis Mandel. Multiple Bilateral Tonsilloliths. J Oral Maxillofac Surg 2008.
LOUIS MANDEL 149
confused with a single tonsillolith, but certainly not with the numerous opacities seen in this reported case.
The panoramic radiograph can not be expected to show the exact location of observed opacities. A 3D investigation is necessary. The CT scan with its axial and coronal views was indicated. No contrast was required because the resulting vascular opacities can conflict with the pathologic opacities that are of in- terest. The axial CT scan definitively solved the prob- lem of anatomically locating the multiple bilateral calcifications. They were clearly shown to be bilater- ally placed in the palatine tonsils.
Treatment
Single large tonsilloliths are removed surgically even if they are asymptomatic because recurrent episodes of tonsillitis can be anticipated.19Removal can be accom- plished with manual compression, curettage or a simple incision to release the calcified body. When tonsillitis is present, a tonsillectomy with the contained tonsillolith, is carried out. In this reported case the patient had no subjective symptoms. Individual removal of these nu- merous tonsilloliths is not a feasible approach. Bilateral tonsillectomy would be the only viable procedure to eliminate the tonsilloliths. Because the patient was asymptomatic, observation certainly was a legitimate option. Therefore no treatment was offered, but the patient was alerted to the possible development of a tonsillitis with its need for surgical intervention.
Acknowledgment
The author wishes to thank Dr Richard Berg for making this patient available for study.
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