Multiple bilateral tonsilloliths: case report.

Tonsilloliths, calcifications within a tonsillar crypt, involve primarily the palatine tonsil. Tonsilloliths are not uncommon, but they tend to be microscopic. Weller reported that during routine histologic examination of excised tonsils, microscopic tonsilloliths were found in 8% of the specimens. Macroscopic calculi, whose size varied from barely visible to pea size, represent an intermediate form and were identified by Weller in 2% of the excised tonsils. Aspestrand and Kolbenstvedt reviewed computerized tomographic (CT) scans and reported an incidence of 16% with the calcifications varying in size from 1 to 7 mm. Because of its eye-catching presentation, authors have centered their attention on the relatively rare, but very large, tonsillolith whose size can approach 3 cm. The surface of the palatine tonsil is marked by the presence of many crypts. Organic debris, consisting of dead bacteria and debris from inflammation, epithelial tissue, and food, can be trapped at the base of the crypt and act as a nidus for salt precipitation. The salts, consisting mainly of carbonates and phosphates of calcium and magnesium, are derived from the surrounding bathing saliva and inflammatory exudate. With salt deposition, a tonsillolith forms and tends to grow with the addition of further salt accretions. Most reports in the literature concern the large tonsilloliths. These reports indicate that these tonsilloliths occur in males and females equally during the fifth decade of their life. Tonsilloliths may occur singly or in multiples and may be unilateral or bilateral in their presentation. The larger tonsilloliths seem to occur alone whereas the smaller calculi are often seen in multiples. Tonsilloliths, particularly the very large, can cause recurrent bouts of sore throat, dysphagia, bad taste and odor, otalgia, and a foreign body sensation noted on swallowing. However, they are frequently totally asymptomatic. Because tonsilloliths can be asymptomatic, it is often during routine imaging procedures that their presence is uncovered. Panoramic radiographs taken by dentists have been an efficient tool to incidentally show the existence of macroscopic tonsilloliths. The axial computed tomography (CT) scan, taken in the head and neck region, serves as another source for unexpectedly showing calcifications in the palatine tonsil. Imaging often shows that the 4 to 7 mm tonsillolith has a lucent core surrounded by a concentric opaque ring pattern. This article presents a case that is highly unusual in that multiple bilateral and asymptomatic macroscopic tonsilloliths were found during a routine panoramic radiograph examination. No similar case could be found in a review of the literature.