OVERVIEW

What is tonsil stone?

The surface of the tonsils contains many glands that normally produce secretions, which contain inorganic salts such as calcium.

At the same time, there are many small depressions on the surface of the tonsils, called "tonsillar crypts." Some crypts are deep with narrow openings, making them prone to accumulating secretions.

Over time, the inorganic salts like calcium in these secretions deposit and aggregate, forming small, granular, white, hard substances known as tonsil stones (Tonsil stone)^[1,2].

Stones are more common bilaterally, while single stones are often found on the right side. Smaller tonsil stones usually cause no clinical symptoms, but as they grow, they may lead to sensations of foreign bodies, throat pain, and swelling. Tonsil stones are also one of the causes of bad breath^[2].

Are tonsil stones common?

Yes.

Tonsil stones have been reported in all age groups, with more cases occurring in middle-aged and elderly individuals. Statistics show that the incidence of tonsil stones larger than 2 mm in diameter is 8.14%, meaning approximately 8 out of 100 people have tonsil stones exceeding 2 mm in diameter^[2].

However, since most stones do not cause discomfort, they rarely attract attention. Of course, some observant individuals may notice them on their own^[2].

Which department should you visit for tonsil stones?

Otolaryngology (ENT).

SYMPTOMS

What are the symptoms of tonsil stones?

1. Small tonsil stones: Usually do not cause discomfort and are often accidentally discovered as white spots on the tonsils when looking in the mirror^[2].
2. Larger tonsil stones: Can cause a foreign body sensation in the throat. If accompanied by infection, symptoms may include throat swelling and pain, coughing, ear pain, fever (axillary temperature > 37.3°C), difficulty swallowing, slurred speech, increased saliva, and even difficulty opening the mouth or spitting out sand-like particles^[2].
3. Additionally, tonsil stones can easily attract bacteria, and some stones are formed by bacterial accumulation. These bacteria can produce foul odors, leading to bad breath^[2].

What complications can tonsil stones cause?

Tonsil stones themselves do not cause complications or other diseases.

However, for individuals with pre-existing pharyngitis or tonsillitis, tonsil stones may worsen the sensation of a foreign body in the throat. This sensation includes various abnormal feelings such as obstruction, itchiness, or burning, excluding pain.

Attempting to squeeze or pick out the stones may lead to bleeding or infection^[1].

CAUSES

What are the causes of tonsil stones?

1. Disease factors: Including acute and chronic tonsillitis, chronic pharyngitis, and other conditions. Tonsil stones primarily occur due to narrowed or blocked crypt openings and excessive retention of secretions. In repeatedly inflamed tonsils, increased secretion retention in the crypts is common. Over time, the accumulation of bacteria, dead cells, food debris, and other materials in the crypts can calcify, forming tonsil stones^[2].

2. Medication factors: Certain clinical medications for hypertension, pain relief, and depression (such as nifedipine, aspirin, amitriptyline, etc.) can cause dry mouth as a side effect. This reduces saliva flow, which is needed to wash away food particles and bacteria. When food debris, mucus, and bacteria accumulate in the tonsil crypts, they can form tonsil stones^[3].

What are the risk factors for tonsil stones?

1. Poor oral hygiene: Failing to brush or rinse after meals allows food debris to remain in the tonsil crypts. Under bacterial action, the debris gradually decays and hardens, increasing the risk of tonsil stones^[3].

2. Obesity: Obese individuals (BMI ≥ 28) tend to have larger tonsils with more uneven crypt surfaces, making food particles more likely to become trapped and increasing the risk of tonsil stones^[3].

Are tonsil stones hereditary?

No.

Tonsil stones result from multiple acquired factors and are generally not hereditary.

Are tonsil stones contagious?

No.

Tonsil stones form due to the retention of secretions in the crypts, where insoluble inorganic salts like calcium deposit around a core of bacteria, dead cells, and food debris. They are not contagious^[1,2].

Which groups are more prone to tonsil stones?

1. Individuals with certain diseases: Such as acute or chronic tonsillitis or chronic pharyngitis. These conditions lead to increased calcium deposition around bacteria and dead cells in the tonsil crypts, raising the risk of tonsil stones.

2. Obese individuals: Their larger tonsils and uneven crypt surfaces make food retention more likely, increasing susceptibility.

3. People taking certain medications long-term: Such as painkillers, antihypertensives, or antidepressants (e.g., nifedipine, aspirin, amitriptyline). These drugs can cause dry mouth, leading to the accumulation of food and bacteria in the crypts, forming stones.

4. Individuals with poor oral hygiene: Failing to brush or rinse after meals allows food debris to accumulate in the tonsils, where bacteria cause decay and hardening, increasing the risk.

DIAGNOSIS

What tests are needed for tonsil stones?

Tonsil stones usually do not require special tests. Doctors can typically diagnose them visually based on clinical experience.

In some cases where the stones are atypical, further tests such as a biopsy for pathological examination may be needed to rule out other conditions and avoid delaying treatment^[4].

What conditions resemble tonsil stones?

Tonsillar keratosis and certain tonsil tumors (e.g., tonsil cancer) may present similarly to tonsil stones and require differentiation by a doctor^[4].

1. Tonsillar keratosis: Both conditions can cause throat discomfort, a foreign body sensation, bad breath, and white spots in the throat. However, tonsillar keratosis may also lead to ulceration and purulent discharge, which helps doctors distinguish it clinically.

2. Tonsil tumors: Both may cause a foreign body sensation, sore throat, and whitish patches. However, tonsil tumors may also present with tonsil surface erosion and neck lumps. Doctors differentiate them through clinical evaluation and histopathological examination^[4].

In most cases, doctors can distinguish these conditions by reviewing medical history and visual examination. However, atypical cases may require pathological testing of a small white granular sample or the entire tonsil for a definitive diagnosis.

TREATMENT

Do tonsil stones require a hospital visit?

If tonsil stones are diagnosed at the hospital, follow-up visits are usually unnecessary.

However, if you notice small white particles resembling stones on the surface of your tonsils at home, it's best to visit a doctor first to confirm whether they are indeed tonsil stones.

Do tonsil stones require treatment? How are they treated?

Not all tonsil stones require treatment. If there is persistent throat discomfort or chronic bad breath, and a doctor confirms it is related to tonsil stones, treatment is recommended.

Treatment options include conservative and surgical approaches:

1. Conservative treatment: Tonsil stones generally do not require medication. Rinsing with saline or boric acid solution may help maintain oral hygiene. If caused by acute pharyngitis or tonsillitis, targeted anti-inflammatory medication can be used. Larger stones can also be removed by a doctor^[5].

2. Surgical treatment: If there are numerous stones and conservative treatment shows no improvement, a tonsillectomy may be considered. This not only eliminates the problem but also allows pathological examination of the removed tonsils for further diagnosis^[6].

Are there any medications for tonsil stones?

Tonsil stones usually do not require medication, as there are no specific drugs with confirmed efficacy^[5].

However, if the patient has conditions like pharyngitis or tonsillitis, targeted anti-inflammatory medications can be used.

What are the risks of tonsillectomy for tonsil stones?

The main risks for adults after a tonsillectomy are pain and bleeding^[6]. If the patient has a history of recurrent acute tonsillitis or particularly enlarged tonsils, the risks of pain and bleeding may increase.

However, maintaining a liquid/semi-liquid diet, avoiding forceful coughing, and rinsing the mouth with water after each meal to keep the wound clean can minimize bleeding risks^[7].

Do tonsil stones require regular follow-ups?

1. If there are no symptoms, regular follow-ups are unnecessary after diagnosis.

2. If there are numerous stones or suspicion of other conditions like tonsillar keratosis or tumors, follow-ups may be advised to monitor changes.

Can tonsil stones be completely cured? Do they recur?

A tonsillectomy can permanently resolve tonsil stones. Conservative treatment with medication may not completely eliminate existing stones but aims to relieve symptoms like throat discomfort and bad breath^[2,6].

Even if all visible stones are removed through conservative treatment, recurrence is possible^[1-3].

DIET & LIFESTYLE

What should patients with tonsil stones pay attention to in daily life?

1. Brush teeth regularly and develop the habit of using mouthwash or saline solution to rinse the mouth after eating to maintain oral hygiene;

2. Patients who have been diagnosed with tonsil stones by a doctor can periodically check in the mirror. If the stones increase significantly, or if symptoms like bleeding or ulcers occur, seek medical attention promptly^[7].

What should patients with tonsil stones pay attention to in their daily diet?

1. Avoid irritating foods: Since the formation of tonsil stones is related to acute/chronic tonsillitis and chronic pharyngitis, the diet should be light and nutritious. Avoid excessive consumption of irritating foods, such as overly hot, cold, or hard foods like spicy hot pot, ice cream, nuts, etc.^[8].

2. Avoid alcohol: Strong liquor can irritate the throat. If obvious throat discomfort occurs after drinking, it should be avoided as much as possible^[8].

What should patients with tonsil stones pay attention to in their postoperative diet?

If tonsil stones are excessive or recur frequently, doctors may recommend a tonsillectomy.

1. No food or water is allowed for six hours after surgery. After six hours, if there is no active bleeding, cold liquid foods like cold rice soup or cold milk can be consumed to help constrict blood vessels, reduce bleeding and swelling, and relieve pain;

2. Starting the day after surgery, warm and soft semi-liquid foods like thin porridge can be eaten;

3. Three days after surgery, a normal-temperature diet can be resumed, with the principle of eating small, frequent meals. Avoid fruits, irritating foods, and acidic foods like chili, onions, yogurt, etc., for half a month after surgery^[7,9].

PREVENTION

Are there ways to prevent tonsil stones?

1. For the general population:

   • Maintain oral hygiene by brushing and rinsing regularly. When gargling, tilt your head back to allow the mouthwash to clean the back of the throat.

   • Develop good exercise habits, stay physically active, and avoid excessive obesity.

2. For those with risk factors such as acute/chronic pharyngitis or tonsillitis:

   • Avoid excessive consumption of irritating foods like chili peppers, spicy hot pot, or grilled foods, and limit alcohol intake to prevent throat irritation, worsening inflammation, and stone formation^[8].

   • Maintain a regular sleep schedule, avoid staying up late, and exercise regularly to strengthen immunity and reduce recurrent tonsillitis.

   • If experiencing side effects like dry mouth while taking long-term medications such as nifedipine or aspirin, seek medical advice promptly to adjust the treatment if necessary.

These are all excellent preventive measures. While they may not completely eliminate the occurrence of tonsil stones, they can significantly minimize the likelihood of developing them.