Diagnosis and treatment
Caseous Tonsillitis and Tonsil Stones
Tonsil stones (caseous tonsillitis) cause bad breath and throat discomfort. Learn the symptoms, causes, and treatment options with an ENT in São Paulo.
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:
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.
- 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.
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:
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. Because the problem is anatomical, and the crypts are where tonsil stones form, the treatment of choice is tonsillectomy, that is, removal of the tonsils.
There are several techniques for performing this surgery, but what really matters is how the tonsillar capsule is handled, a layer that separates the tonsil from the muscles and vessels of the pharynx, and how much tissue is removed. The page on tonsillectomy with radiofrequency details how each technique is performed, the day of surgery, the risks and the recovery for each one.
Intracapsular tonsillectomy with radiofrequency. It removes the tonsillar tissue with the crypts and preserves the capsule, the layer that separates the tonsil from the vessels and muscles of the pharynx. Because it does not reach that deeper layer, it tends to hurt less and to bleed less in the postoperative period than complete removal (Sedgwick and colleagues, 2023). On the other hand, tonsillar tissue remains next to the capsule, and there is the possibility of regrowth and of tonsil stones coming back over time.
Total (extracapsular) tonsillectomy. It removes the tissue and the capsule. No tonsil remains, and for that reason there is no recurrence from regrowth of tonsillar tissue. A study that measured the sulfur compounds in the breath before and after surgery found a significant drop in these compounds after tonsillectomy (Choi and colleagues, 2018). On the other hand, it is the technique with the most postoperative pain and the highest risk of bleeding, and for that reason it is usually reserved for the most severe or refractory cases.
The choice between the two is not automatic. It weighs the intensity of the symptoms, how often the tonsil stones come back, the history of tonsillitis, age and what each person is prepared to face in the postoperative period. It is an assessment that has to be made individually, by a specialist, after a proper conversation and a detailed examination.
- 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.
If tonsil stones have already gone past the stage of an occasional nuisance and you are weighing up surgery, the step that settles the question is the examination of the throat, which shows the depth of your crypts and the state of your tonsils. Book a Consultation and bring your history: how long they have been appearing, how often, whether there has been recurrent tonsillitis and what you have already tried.
When to see an otolaryngologist
It is worth seeking an evaluation when:
On the other hand, occasional tonsil stones without symptoms, often noticed by chance, generally do not require surgery: observation and hygiene are enough.
- 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.
Prevention
It is not always possible to completely prevent the formation of tonsil stones, but some measures help reduce how often they occur:
At the office of Dr. José Eduardo Marcondes, an ENT physician (CRM-SP 107.711 | RQE 43.840), 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 Itaim Bibi, Morumbi, and Alphaville.
- 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.
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, does not replace a medical consultation, and does not supersede the plan of care defined by your own physician.
Frequently Asked Questions about Caseous Tonsillitis
What are tonsil stones?
Tonsil stones are small whitish or yellowish accumulations that form in the natural cavities (crypts) of the tonsils. They result from the deposit of shed cells, saliva, food remnants, and bacteria, and act as a biofilm, a colony of bacteria that produces a bad smell. They can cause discomfort and bad breath.
What causes tonsil stones to form?
It is usually related to the anatomy of the tonsils, especially when there are deeper crypts that favor the accumulation of material. Dry mouth, inadequate oral hygiene, reflux, respiratory allergies, and a history of recurrent tonsillitis also contribute.
Are tonsil stones dangerous? Are they an infection?
No. A tonsil stone is a benign condition, it is not an acute infection, and it generally does not require antibiotics. The main nuisance is bad breath and the sensation of a foreign body. It is different from bacterial tonsillitis, which comes with fever, severe pain, and patches of pus.
Can I remove tonsil stones at home?
It is not recommended to try to remove tonsil stones with objects, because this can hurt the throat and favor inflammation. The safest measures are good oral hygiene, gargling, hydration, and, at most, dislodging them with a low-pressure water jet. If the problem is frequent, see an otolaryngologist.
Is bad breath always the tonsil stones' fault?
Not always. Tonsil stones are a recognized cause of bad breath, but most halitosis originates on the tongue and gums. For this reason, when bad breath persists, it is important to evaluate the mouth as well, and not just the tonsils.
When is tonsil surgery indicated to treat tonsil stones?
Surgery may be considered when tonsil stones are recurrent, cause persistent bad breath or significant discomfort, and do not improve with conservative measures. The indication is individualized, taking into account the frequency of symptoms and the impact on quality of life.
Can tonsil stones come back after treatment?
They can, and that depends on what was done. Conservative measures relieve the problem but do not change the anatomy, so tonsil stones keep forming. The intracapsular tonsillectomy removes the tissue with the crypts, but preserves the capsule, and tissue remains next to the capsule, with the possibility of regrowth of tonsillar tissue over time. The total tonsillectomy leaves no tonsil behind, and for that reason there is no recurrence from regrowth of tonsillar tissue, and it is usually reserved for the most severe cases.
Dr. José Eduardo Marcondes, physician, otolaryngologist (ENT), CRM-SP 107.711, RQE 43.840. This content is informational, does not replace a medical consultation, and does not supersede the plan of care defined by your own physician.
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