Say ahhh for the doctor! They are checking out your tonsils, an organ that is vital for your systemic immunity. Chronic inflammation of the tonsils can cause the development of tonsil stones, and large tonsil stones can lead to a variety of troublesome symptoms. People with particularly severe symptoms may even have to have their tonsils surgically removed.

Read on to learn more about what the tonsils do, why tonsil stones develop, and how you can prevent and treat them.

What are Tonsils?

The tonsils are an important organ for the immune system. They are located towards the back of the throat and are made up of connective tissue, lymphoid tissues, and blood vessels covered by epithelial cells. Running throughout the tonsils are deep, branched pockets and folds called “crypts.” Inhaled or ingested foreign substances trapped in these pockets can cause an immune response [1].

Because of its role in the immune system, the tonsils tend to become inflamed when the immune system is activated by an infection. For this reason, the level of inflammation in the tonsils can be used as an indicator of the status of the immune system.

The tonsils can also become inflamed due to the activity of foreign bacteria. This becomes especially likely when the folds and pockets of the tonsils get filled up by bits of cellular “junk” from dead or dying cells. These dead remains of cells create an ideal environment for the growth of various bacteria (especially anaerobic bacteria), which can lead to further inflammation or even full-blown infection [2].

What are Tonsil Stones?

Tonsil stones are calcified structures that form on the cellular debris and bacteria present in enlarged tubular glands of the tonsils. The bacteria on the surface of the tonsils can start to form biofilm. Tonsil stones progress from a gel-like structure to a hard mineral structure made up of calcium [3, 4, 5].

Small tonsil stones are common in adults, while it is rare for adults to develop large tonsil stones. People with small tonsil stones don’t usually experience symptoms. However, people with large tonsil stones often experience painful symptoms [6].

Symptoms of Tonsil Stones

Tonsil stones can cause a variety of symptoms, ranging in severity from bad breath to chronic pain, and can even result in severe infections.

Some species of bacteria that can collect in and around the folds and pockets of the tonsils produce large amounts of compounds such as volatile sulfur, which can cause chronic bad breath (halitosis) [5, 7].

The build-up of bacteria that causes bad breath can sometimes also result in a lingering sensation of foul taste. This affects about 3% of tonsil stone sufferers and usually occurs alongside bad breath [3, 8].

As they grow in size, tonsil stones can also begin to cause pain throughout the mouth, jaw, and face. This can result in attacks of pain that last anywhere from a few seconds to several minutes, and which can be triggered by specific activities such as talking, coughing, or swallowing [9].

Pain can be triggered by many activities including talking, coughing and swallowing [9].

If they’re large enough, tonsil stones can also block up the throat, causing difficulties with swallowing [10, 11].

The painful symptoms of tonsil stones can also spread beyond the throat and mouth. The tonsils are connected to the ears by the glossopharyngeal nerve (also known as Jacobsen’s nerve). This connection may cause the pain from tonsil stones to spread to the ear, resulting in a chronic earache [6, 12].

Sleep-disordered breathing (dyspnea) is a very rare symptom associated with large tonsil stones and infection [13, 10].

Tonsil stone symptoms can also include:

  • Sore throat [3]
  • Cough [3]
  • Abscesses [14]

Causes of Tonsil Stones

Chronic tonsillitis causes tonsil stones

Chronic inflammation of the tonsils can lead to thickening and scarring of the connective tissue. This scarring leads to stiff tissues where cellular debris and bacteria become trapped in the folds and pockets of the tonsils. Calcification of the trapped material forms tonsil stones. Chronic inflammation is enough to promote the formation of tonsil stones [9, 15].

Chronic inflammation of the tonsils results in rare calcium salt deposits in the soft tissue of the tonsil. This deposition occurs despite normal blood levels of calcium and phosphatase and results in the development of tonsil stones [16].

Chronic saliva stasis causes tonsil stones

The “chronic saliva stasis hypothesis” was first presented in 1965 when analysis of the tissue next to a tonsil stone revealed a small salivary gland surrounded by lymphoid tissue. From this observation, they concluded that scarring of the tonsils could block the salivary gland flow resulting in a build-up of saliva. Saliva stasis can give rise to the formation of tonsil stones [15].

In support of this, a recent case report of a 32 year-old-man with a large tonsil stone reported finding blocked saliva and a local accessory salivary duct during the tonsillectomy surgery. Despite the lack of tonsil inflammation, these doctors attributed the formation of the tonsil stone to saliva build-up. This accumulation of deposits from the saliva resulted in tonsil stones [15].

Risk Factors for Tonsil Stones

Chronic tonsillitis is the primary cause of tonsil stones [10].

Risk factors for chronic tonsillitis include:

  • Bacterial infections [17]
  • Smoke exposure (cigarettes) [18, 19]

How To Prevent Tonsil Stones

Good oral hygiene including gargling with salt water is important to wash out the tonsil folds and pockets [20].

Removal of the tonsils is the only known cure for tonsil stones [21].

How To Treat Tonsil Stones

The majority of people with tonsil stones don’t have symptoms and may not know they have tonsil stones [22].

Doctors should monitor patients with known tonsil stones that have no symptoms [23].

More natural treatments

Salt water gargling may flush out the tonsil folds and pockets [20, 3].

In some cases, applying pressure to tonsils using a sterilized swab can release a tonsil stone [20, 24].

More invasive treatments

Tonsillectomy, or taking out tonsils is usually recommended for patients who have recurrent tonsil stones. It is associated with a significant risk of illness that can last for weeks after the procedure, but it also may provide immediate relief from pain associated with tonsil stones [21, 10, 24].

In some cases, a tonsil incision can enable the release of the tonsil stone [23].

There are some types of laser surgery for tonsil stones. It requires that the patient has small tonsils and a controllable gag reflex. Some disadvantages of this procedure include high costs, the potential of burns, and the possibility of retinal damage [25, 21].

Radio frequencies (coblation cryptolysis) is also a treatment used to remove the tonsil stones. Pain lasts for only a few days following procedure and patients can return to their normal routine in one week. A single coblation cryptolysis procedure can entirely remove tonsil stones in some cases [21, 26].

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