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Clinical Problem Solving: Radiology
September 2009

Radiology Quiz Case 2: Diagnosis

Author Affiliations


Arch Otolaryngol Head Neck Surg. 2009;135(9):943. doi:10.1001/archoto.2009.134-b

Tonsilloliths, or tonsil stones, are calcified bodies that develop in enlarged tonsillar crypts that are packed with bacteria and organic debris.1 They arise as a result of dystrophic calcification in the crypts of the palatine tonsils owing to chronic inflammation of the tonsils. They are usually single and unilateral but occasionally may be multiple or bilateral. They are composed of calcium salts such as hydroxyapatite or calcium carbonate apatite, oxalates, and other magnesium salts and ammonium radicals2 and are usually of small size, although there have been occasional reports of large tonsilloliths or calculi in peritonsillar locations. Small stones are asymptomatic, but large tonsilloliths can produce a variety of symptoms, eg, halitosis, referred otalgia, and foreign body sensation in the throat, and some may mimic an abscess or neoplasia. Tonsilloliths are difficult to diagnose in the absence of definite clinical symptoms and are often incidentally found on radiographs and computed tomograms that have been obtained for other purposes. Computed tomography might sometimes be necessary, especially when the lesion is covered by a mandibular ramus in a plain film. It is also helpful in distinguishing tonsilloliths from pathologic calcifications of arteries, lymph nodes, and salivary glands; displaced mandibular molars; or other anatomical structures of the pharyngeal region.3 A review of the literature revealed that the present case might indeed represent one of the largest tonsilloliths reported to date (search keywords: giant tonsillolith, largest tonsillolith, tonsillolith, and tonsillar stones). It is not surprising to note that such large tonsilloliths can cause dysphagia.4