Med. J. Cairo Univ., Vol. 80, No. 1, September: 427-434, 2012
www.medicaljournalofcairouniversity.com
Tonsillar Calcification, Computed Tomography and Clinical Findings,
A Case Study
HOSAM A. YOUSEF, M.D.*; HAZEM A. YOUSEF, M.D.*; MOHAMED K.M. OMAR, M.D.*;
MOHAMED K. AHMAD, M.D.** and TALAAT M. FARGHALY, M.D.***
The Departments of Radiodiagnosis*, Ear, Nose & Throat**, Faculty of Medicine, Assiut University and
Ear, Nose & Throat***, Al-Azhar University, Assiut
Abstract
tissue throughout the remainder of the pharynx,
but especially behind the posterior pharyngeal
pillars and along the posterior pharyngeal wall.
Lymphoid tissue located between the palate-glossal
fold (anterior tonsillar pillar) and the palatepharyngeal fold (posterior tonsillar pillar) forms
the palatine tonsil. This lymphoid tissue is separated
from the surrounding pharyngeal musculature by
a thick fibrous capsule. The adenoid is a single
aggregation of lymphoid tissue that occupies the
space between the nasal septum and the posterior
pharyngeal wall [1] .
Introduction: Tonsillar calcification or tonsil stones (tonsilloliths) are foul smelling lumps of whitish or yellowish
color. They are usually asymptomatic but can be associated
with halitosis and bad taste, foreign body sensation, dysphagia
and odynophagia, otalgia, and neck pain. They are a common
incidental imaging finding in adults, especially in computed
tomography (CT).
Aim of the Work : This is a case study about palatine
tonsillar and nasopharyngeal calcifications which require
awareness from radiologists, especially in patients with clinical
symptoms and signs which may suggest their presence.
Material and Methods: The routine CT studies done for
paranasal sinuses or the neck were carefully inspected for
presence of tonsillar and/or adenoids calcification. Positive
cases with incidentally found calcifications were referred for
evaluation by the ear, nose and throat specialists.
Tonsillar calcification or tonsil stones (tonsilloliths) are foul smelling lumps of whitish or
yellowish color. Its consistency ranges from soft
and friable to hard as stone. These calculi are
composed of calcium salts such as hydroxyapatite
or calcium carbonate apatite, oxalates and other
magnesium salts, or containing ammonium radicals
[2] .
Results : Incidental calcifications were found in 31 patients;
30 of them had tonsilloliths and only one patient had calcification within the adenoids remnants without concomitant
palatine tonsillar calcification.
Conclusion : Tonsilloliths are tiny stones lodged in the
pharyngeal tonsils, incidentally discovered during CT examinations. The awareness of the presence of these calcifications
is important for the radiologists to avoid overlooking of these
pathological entities which could be of clinical value.
Key Words:
Tonsilloliths are a common incidental imaging
finding in adults, in some series it has been detected
in up to 16% of patients [3] . On computed tomography (CT), tonsilloliths appear as solitary or
multiple clustered "rice grain" like ovoid homogeneous dense calcifications immediately superficial
to the lateral oro-pharyngeal airway space [4] .
Tonsillolith – CT – Adenoids – Halitosis.
Introduction
WALDEYER ring consists of lymphoid tissue that
surrounds the opening of the oral and nasal cavities
into the pharynx and includes the palatine tonsils,
the pharyngeal tonsil or adenoid, lymphoid tissue
surrounding the Eustachian tube orifice in the
lateral walls of the nasopharynx, the lingual tonsil
at the base of the tongue, and scattered lymphoid
They are usually asymptomatic but can be
associated with halitosis and bad taste, foreign
body sensation, dysphagia and odynophagia, otalgia, and neck pain. Other symptoms include a
metallic taste, throat tightening, coughing fits, and
choking [5] .
Correspondence to: Dr. Hosam A. Yousef, The Department
of Radiodiagnosis, Faculty of Medicine, Assiut University
427
One of the prime clinical indicators of a tonsil
stone is bad breath, or halitosis, that accompanies
428
Tonsillar Calcification, Computed Tomography & Clinical Findings
a tonsil infection. A study conducted by Stoodley
et al., [6] found an association between tonsilloliths
and bad breath in patients with a certain type of
recurrent tonsillitis. Among those with bad breath,
75% of the subjects had tonsilloliths of patients
with a form of chronic tonsillitis used a special
test to see if volatile sulfur compounds were contained in the subjects' breath. The presence of these
foul-smelling compounds provides objective evidence of bad breath. The researchers found that
75% of the people who had abnormally high concentrations of these compounds also had tonsil
stones.
Pathophysiology :
The mechanism by which these calculi form is
subject to debate. They appear to result from the
accumulation of materials retained within the
crypts of tonsils, along with the growth of bacteria
and fungi such as Leptothrix buccalis, sometimes
in association with chronic purulent tonsillitis. It
has been stated that tonsilloliths originate as a
result repeated tonsillitis which leads to fibrosis
of ducts of crypts and retention of epithelial debris
thereof. This epithelial debris forms the ideal media
for the growth of bacteria, and fungi such as Leptothrix buccalis and actinomyces. Finally, calcification occurs subsequent to the deposition of
inorganic salts and the enlargement of the formed
concretion takes place gradually. The tonsilloliths
derive their phosphate and carbonate of lime and
magnesia from saliva secreted by three major
salivary glands and about 400 to 500 minor salivary
glands [5,7,8] .
The resultant tonsillar calculi are usually of
small size, though there have been occasional
reports of quite large tonsilloliths which may even
ulcerate through the tonsillar surface [9] .
Stoodley et al., [6] , studied the morphology and
biological activity of tonsilloliths extracted from
tonsillectomy specimens using histological, bacteriological, and biofilm studies using confocal
microscopy and microelectrodes to measure aerobic
/anaerobic respiration and acid production. They
found that, biologically, tonsilloliths were similar
to dental biofilms, containing corncob structures,
filaments, and cocci. Microelectrodes showed that
the microorganisms respired oxygen and nitrate.
The oxygen concentration in the center of the
tonsillolith was depleted to approximately onetenth of that of the overlying fluid. The addition
of sucrose resulted in acid production within the
tonsillolith, dropping the pH from 7.3 to 5.8. The
data showed stratification with oxygen respiration
at the outer layer of tonsillolith, denitrification
toward the middle, and acidification toward the
bottom. The depletion of oxygen and acid production following addition of sucrose may allow the
proliferation of anaerobic/acidophilic bacteria,
while Fluoride suppressed acid production in the
presence of sucrose. This biofilm concept raises
the assumption that bacteria form a three dimensional structure; dormant bacteria being in the
center serving as a constant nidus of infection.
This impermeable structure renders the biofilm
immune to antibiotic treatment.
The occurrence of tonsillar or peri-tonsillar
calcification can be related to lithiasis in other
regions of body, as described by Giudice et al.,
[10] , who described a tonsillolith accidentally detected in a patient with a lithiasis of left submandibular gland. Calculi have been reported in the
peri-tonsillar region [11] and lateral pharyngeal
wall [12] ; and were explained by calcification of
peritonsillar abscess, presence of ectopic tonsillar
tissue and calcification of saliva in blocked secretory ducts of minor salivary glands [13,14] .
Aim of the study :
Tonsilloliths are a common cause of calcification in the pharynx, but there is a general lack of
awareness of this entity among radiologists [15] .
This is a case study about these pharyngeal calcifications. Palatine tonsillolith as well as nasopharyngeal tonsilloliths (adenoidolth) are relatively
common incidental findings that require awareness
from radiologists, especially in patients who suffer
from halitosis or present with other complaints
like choking, odontophagia, foreign body sensation
in the throat. These tiny calcifications might be
overlooked in routine CT examinations of the paranasal sinuses or the neck.
Material and Methods
The CT scans of patients referred for examinations that include the oro-/naso-pharynx were
reviewed searching for calcifications within the
region of the palatine tonsils and or the region of
the adenoids. The CT examinations were done
using a 16-slice multi-detector CT (BrightSpeed
GE, Milwaukee, USA). The detected calcifications
were described according to the number (single or
multiple), laterality (unilateral or bilateral) and the
diameter in mm. Patients with depicted calcifications were referred for evaluation by the ENT
specialists.
Hosam A. Yousef, et al.
429
Table (2): Distribution of the studied patients according to
sex.
Results
The age of patients ranges from 29 to 68 years,
with mean age and SD of 44.45±10.80 years respectively (Table 1). Incidental tonsillar and/or
adenoids calcifications were detected in 31 patients.
There were 12 female patients and 19 male patients
(Table 2). Among the 30 patients with tonsilloliths,
12 patients had single tonsillolith; unilateral in 7
patients, and bilateral in the other 5 patients. The
other 18 patients had two or more calcifications
on one side (5 patients) or both sides (13 patients)
(Tables 3,4). Thirty patients had tonsillar calcification, 3 of them had concomitant calcification in
the adenoids remnants. Only one patient had calcification within the adenoids without associated
tonsillar calcification (Table 5). The dimensions
of the detected tonsillar calcifications range from
1.5 to 7mm. The detected nasopharyngeal calcifications measured 1.5 to 4.5mm.
Clinically, 24 patients (77.4%) were found to
have bad breath, with 14 of them (45.1%) complaining of bad taste. Eleven of the patients (35.4%)
had history of recurrent tonsillitis. Three patients
(9.6%) experienced difficulty in swallowing of
solid food and two (6.4%) patients had foreign
body sensation in the throat. On examination, the
white-yellowish calcifications could clearly be
seen at the region of the palatine tonsils in 8 out
of the 31 patients (25.8%). Seven out the 31 patients
with incidental tonsillar calcifications had no specific complaints, and showed no abnormal finding
on ENT evaluation.
No. (n= 31)
<40
40 - <50
50
Mean±SD (Range)
No.
(n=31)
%
Male
19
61.3
Female
12
38.7
Table (3): Distribution of the tonsiloliths according to affected
side.
No.
(n=30)
%
Unilateral
12
40.0
Bilateral
18
60.0
Table (4): Distribution of patients according to the number
of tonsiloliths.
No.
%
(n=30)
Single
12
40.0
Multiple
18
60.0
Table (5): Distribution of the studied patients according to
presence of adenoids.
No.
Adenoid
Table (1): Distribution of the studied patients according to
age.
Age (years)
Sex
%
(n=43)
Yes
4
12.9
No
27
87.1
%
11
35.5
12
38.7
8
25.8
44.45±10.80 (29–68)
87.1
90
80
70
50 years
25.8%
<40 years
35.5%
60
%
50
40
30
12.9
20
10
40-<50 years
38.7%
0
Yes
No
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Tonsillar Calcification, Computed Tomography & Clinical Findings
Case (1): Non-enhanced axial CT; a 32y man with single 2mm calcification in the right palatine tonsil.
Case (2): Non-enhanced axial CT; a 39y lady with multiple bilateral tonsilloliths.
Case (3): Non-enhanced axial CT; a 44y man with right parotid mass (pleomorphic adenoma), with incidental
multiple bilateral tonsilloliths.
Hosam A. Yousef, et al.
431
Case (4): Non-enhanced coronal CT; a 51y man with bilateral multiple tonsilloliths.
Case (5): Non-enhanced coronal CT; a 46y woman with bilateral tonsilloliths.
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Tonsillar Calcification, Computed Tomography & Clinical Findings
Case (6): Non-Enhanced coronal CT; a 63y man with adenoidolith and multiple left tonsilloliths,
the largest is 7mm.
Case (7): Non-Enhanced coronal CT; a 49y man with adenoidolith and multiple small left tonsilloliths.
Case (8): Non-Enhanced axial CT with sagittal reformatted image; a 66y woman with an adenoidolith
without associated tonsillar calcification.
Hosam A. Yousef, et al.
Discussion
Tonsilloliths are accumulations of bacteria and
tissues that collect in the crypts of tonsils. While
some cases are entirely asymptomatic, and the
calculi constitute casual findings of radiological
studies conducted for other reasons, in other cases
minor symptoms appear and progressively intensify
over time, as halitosis and bad taste, with swallowing pain and foreign body sensation or earache
[16] .
Panoramic radiographs taken by dentists have
been an efficient tool to incidentally show the
existence of macroscopic tonsilloliths. CT serves
as another source for unexpectedly showing calcifications in the palatine tonsil [17] .
The clinical and imaging findings of tonsil's
calculi seem to be a function of the size of these
calculi; infra-millimetric calculi are much frequent,
according to tonsillectomy specimens, and much
often asymptomatic, but are not visible by imaging;
small calculi from 1to 7mm are frequent and visible
by imaging; big ones superior of 7mm are rare,
becoming exceptional and much often symptomatic.
When the tonsillar calcifications get large enough,
they may irritate the tonsil, make it become enlarged, causing recurrent tonsillitis, bad breath and
bad taste in the mouth [18] .
The age of the patient population in this study
ranges between 29 and 68 years, and the incidentally detected calcifications were found to be single
or multiple, unilateral or bilateral. These findings
are concordant with those described by other studies
[3,16,19] , who found that tonsilloliths are usually
single and unilateral, but occasionally may be
multiple or bilateral, and occur between 20 and 77
years of age. The largest tonsillolith found in this
study measures 7mm. Thakur et al., [20] stated that
giant tonsillolith is a rare clinical entity.
Although it is relatively easy, especially with
CT, to distinguish tonsilloliths from other more
important causes of pharyngeal calcifications by
demonstrating their typical location, both radiologists and clinicians should consider other pathologies as differential diagnosis [9] .
Differential diagnosis of tonsilloliths includes
foreign body, calcified granuloma, malignancy, or
rarely, isolated bone which is usually derived from
embryonic rests originating from the branchial
arches [21] .
In this study, three patients had concomitant
tonsillar and adenoids calcification which might
433
support the postulation of Giudice et al., [10] , who
stated that tonsillar or peri-tonsillar calcification
can be related to lithiasis in other regions of body.
Conclusion :
Tonsilloliths are tiny stones lodged in the pharyngeal tonsils. Some patients have no symptoms
or present with fetor oris or odynophagia. It is
often during routine imaging procedures that their
presence is uncovered. The awareness of their
presence is important for the radiologists to avoid
overlooking of these pathological entities which
could be of clinical value.
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