Caseous Tonsillitis and Tonsil Stones

Caseous tonsillitis is a benign condition characterized by the buildup of small white to yellowish masses on the tonsils, known as tonsil stones or tonsilloliths. It is not exactly a disease or an infection, but it can cause considerable discomfort and affect quality of life, mainly because of persistent bad breath and the sensation of a foreign body in the throat. It is a common finding: on CT scans, tonsil stones appear in roughly 16% to 40% of people, although most are small and cause no symptoms.

What tonsil stones are and why they form

Tonsil stones form in the tonsillar crypts, the small folds and natural cavities on the surface of the tonsils. Shed cells, food remnants, mucus, and bacteria become trapped in these crypts and, over time, compact and partly calcify. The term “caseum” comes from the Latin word for “cheese,” because of the consistency and appearance of these formations.

More than an inert little stone, a tonsil stone is a living biofilm, an organized colony of bacteria, largely anaerobic, that settles into the crypt. It is precisely these bacteria that produce the characteristic odor. Tonsils with deeper crypts tend to accumulate more tonsil stones.

A tonsil stone is not the same as infectious tonsillitis

It is worth clearing up a common confusion. A tonsil stone is a chronic, localized process, usually without signs of acute infection, and most of the time it does not require antibiotics. Acute bacterial tonsillitis, on the other hand, comes with a severe sore throat, fever, and patches of pus, and in that case it may require antibiotic treatment. Recognizing this difference avoids the unnecessary use of medication.

Symptoms

Patients with tonsil stones frequently present:

• Persistent bad breath, caused by the release of volatile sulfur compounds (the “sulfur-smelling” substances) by anaerobic bacteria present in the tonsil stones;
• A sensation of a foreign body in the throat, as if something were stuck;
• Expulsion of small white or yellowish balls, with an unpleasant odor, when speaking, coughing, or sneezing;
• Discomfort or mild pain when swallowing, especially when the tonsil stones are larger;
• A bad taste in the mouth.

Symptoms usually ease after the tonsil stone comes out, but they tend to return in predisposed people. It is worth remembering that most bad breath originates on the tongue and gums; the tonsils are a recognized but less frequent cause. For this reason, when bad breath persists, it is important to evaluate the mouth as well.

Causes and risk factors

The formation of tonsil stones is linked to several factors:

• Tonsil anatomy: people with deeper crypts have a greater predisposition;
• Inadequate oral hygiene, which makes it easier for bacteria and food remnants to accumulate;
• Dry mouth, from low saliva flow or from medications that dry out the mouth (some antihypertensives and antidepressants, for example);
• Reflux and changes in the pH of the mouth;
• Respiratory infections and allergies (rhinitis, sinusitis), which increase mucus production;
• Smoking and alcohol consumption;
• A history of recurrent tonsillitis.

Diagnosis

The diagnosis is essentially clinical, made by the otolaryngologist based on the symptoms and the examination of the throat (oroscopy), which allows the tonsil stones to be seen directly. Often, gentle pressure on the tonsil during the examination is enough to expel the tonsil stone, confirming the condition. Complementary tests are generally not necessary. The important step is to distinguish it from acute infectious tonsillitis, which comes with active inflammation and symptoms such as fever.

Treatment

Treatment always begins with the simplest measures and is individualized according to the intensity and frequency of the symptoms.

Conservative measures (first line). These are the foundation for mild or occasional cases. They help control symptoms and reduce their frequency, but it is important to be clear: they relieve, they do not cure, since the problem is anatomical and the crypts remain in place. They include:

• good oral hygiene, with brushing, flossing, and tongue cleaning;
• gargling with warm salt water and mouth rinses, which temporarily reduce the bacterial load and the odor;
• good hydration throughout the day;
• careful dislodging of visible tonsil stones, preferably with a low-pressure water jet.

Tonsil stones should not be removed by poking at them with objects, as this can injure the mucosa and favor inflammation. The scientific evidence for these measures is limited, but they are safe and are usually the first step.

Surgical treatment (when conservative measures are not enough). When tonsil stones are recurrent, bad breath persists despite proper care, and there is a real impact on quality of life, surgery may be considered. There are two strategies, with a trade-off between lower morbidity and the risk of recurrence:

Laser or radiofrequency (coblation) cryptolysis: a procedure that seals and reduces the crypts, shrinking the pockets where tonsil stones accumulate while preserving the tonsil. It is usually done on an outpatient basis, with less pain and a quick recovery. Because it preserves the tonsil, there is a possibility that the tonsil stones will return over time.

Total (extracapsular) tonsillectomy: complete removal of the tonsils is the only definitive solution for tonsil stones, because it eliminates the tissue and the crypts where they form. Studies that measured the sulfur compounds in the breath before and after surgery showed a significant drop in these compounds after tonsillectomy. On the other hand, it is the technique with the most postoperative pain and a higher risk of bleeding than tonsil-preserving techniques, so it is reserved for the most intense or refractory cases.

The choice between preserving the tonsil (less morbidity, with a risk of recurrence) and removing it completely (definitive, but with a more demanding recovery) is always individual, discussed case by case.

When to see an otolaryngologist

It is worth seeking an evaluation when:

• bad breath persists even with good oral hygiene;
• the tonsil stones are frequent and bothersome;
• there is a sore throat or difficulty swallowing;
• the symptoms cause social or professional embarrassment;
• conservative measures do not bring improvement.

On the other hand, occasional tonsil stones without symptoms, often noticed by chance, generally do not require surgery: observation and hygiene are enough.

Prevention

It is not always possible to completely prevent the formation of tonsil stones, but some measures help reduce how often they occur:

• maintaining good oral hygiene, with regular brushing, flossing, and tongue cleaning;
• gargling with warm salt water regularly;
• staying well hydrated throughout the day;
• avoiding smoking and excessive alcohol consumption;
• properly treating respiratory problems such as rhinitis and sinusitis;
• keeping up regular dental follow-up.

At the office of Dr. José Eduardo Marcondes, an ENT physician (CRM SP 107711 | RQE 43840), you will find a careful evaluation and an individualized plan for tonsil stones, from conservative management to surgical options when necessary. Schedule your appointment at the medical centers in Faria Lima, Morumbi, and Alphaville.

References

1. Bai KY, Kumar BV. Tonsillolith: A Polymicrobial Biofilm. Medical Journal Armed Forces India. 2012.
2. Choi KY, et al. Assessment of Volatile Sulfur Compounds in Adult and Pediatric Chronic Tonsillitis Patients Receiving Tonsillectomy. Clinical and Experimental Otorhinolaryngology. 2018.
3. Sedgwick J, Saunders C, Bateman N. Intracapsular Tonsillectomy Using Plasma Ablation Versus Total Tonsillectomy: A Systematic Review and Meta-Analysis. OTO Open. 2023.
4. ENT Scotland. Consensus Statement on the Management of Tonsil Stones. 2019.

This content is informational and does not replace a medical consultation.