Correspondence Address:
Dr. Thirunavukkarasu Arun Babu
Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), Mangalagiri - 522 503, Andhra Pradesh
India

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A 4-year-old boy presented with complaints of dry cough, throat pain, and bad breath for 2 weeks (that did not respond to antiseptic mouth rinses). There was no history of fever, coryza, earache, rashes, respiratory distress, toothache, or difficulty in chewing or swallowing. There was no past history of recurrent episodes of pharyngotonsillitis, dental caries, or oral ulcers. The child brushed his teeth every morning, assisted by his parents. He was fully immunized, and the acquisition of developmental milestones was normal. The child was afebrile and hemodynamically stable. The anthropometric parameters were appropriate for age. Oral examination revealed irregular, shiny, dirty yellowish white-colored calcareous concretion visible in the right tonsillar crypt [Figure 1]. The tongue was normal, and the posterior pharyngeal wall was not congested. There were no dental caries. Systemic examination did not reveal any abnormal findings. A diagnosis of tonsillolith was made and it was removed with gentle pressure using a sterile swab under local anesthesia. Two tonsillar stones measuring 4 mm × 4 mm were removed [Figure 2], and the procedure was tolerated well. The follow-up period was uneventful.{Figure 1}{Figure 2}

Tonsilloliths are calcareous concretions found in the crypts of tonsils. The exact pathogenesis is unknown, but it is often associated with recurrent tonsillitis. Repeated inflammation can lead to fibrosis of the tonsillar crypt openings and accumulation of bacterial and epithelial debris that undergo dystrophic calcification and result in the tonsillolith.[1] Thus, it is an anaerobic polymicrobial biofilm,[2] the common organisms being Fusobacterium, Eubacterium, Porphyromonas, Prevotella, Selenomonas, Megasphaera, and Tannerella. Tonsilloliths are usually asymptomatic, or can present with foreign-body sensation, throat discomfort, odynophagia, halitosis, or referred ear pain.[3] It is imperative to do a proper oral examination as the diagnosis is established clinically. Tonsilloliths are common in adults, and are, therefore, mostly attended to by ENT or dental surgeons. Since they are extremely uncommon in children, pediatricians often lack awareness about this condition.

The common differential diagnoses that should be excluded based on the presentation include oral candidiasis, an embedded foreign body like a fishbone, keratin or mucous cyst, acute tonsillitis or tonsillar abscess, and diphtheria. Asymptomatic, small tonsilloliths are often expelled spontaneously; vigorous salt water gargling can dislodge some stones, while symptomatic large ones may require surgical removal, as in this case. Antibiotics are indicated in associated tonsillitis. Tonsillectomy may be curative in chronic tonsilloliths. Recently, coblation cryptolysis, i.e., ablation of the tonsillar crypts, is gaining popularity as a safer alternative to tonsillectomy.[4]

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