Tonsil Stones (Tonsilloliths)

The tonsils are gland-like structures in the back of your throat made of tissue that plays a role in the body’s immune system. They function like nets trapping incoming bacteria and virus particles that are passing through your throat.

Tonsil stones occur when food debris, bacteria and dead cells gets trapped in the crevices and pits of the tonsils. This debris can then become calcified, a process that transforms it into hard white or yellow deposits often referred to as “stones”.

In general, tonsil stones cause minimal symptoms. However occasionally patients report bad breath (halitosis) and/or discomfort in the throat due to the presence of these accumulations and may even cough up a tonsil stone as a small, irregular lump of offensive cream/white matter.

Tonsil stones are not typically associated with acute infection such as bacterial tonsillitis, although they can co-exist in patients with a history of recurrent tonsillitis.

It is estimated that around 10% of the population will experience tonsil stones at some point but they tend to clear from the throat on their own.

There is no evidence that the presence of tonsil stones leads to long-term health issues.

Cause

Causes of tonsil stones include:

  • Chronically inflamed tonsils
  • Large tonsils (which enable more build-up within their pits and crevices)
  • Poor oral hygiene (which allows bacteria to continuously interact with the tonsils)
  • Sinus issues (which increase the accumulation of mucus in the throat via post-nasal drip and catarrh)

With good oral hygiene you can remove food debris and plaque bacteria from the surfaces of your teeth, gums, and tongue which in-turn will reduce the likelihood of build-up within the tonsillar pits.

Symptoms

Tonsil stones can vary in size, but most people may not even realise they have them and will experience no symptoms at all.

In cases where the tonsil stones are larger in size, symptoms may include:

  • Swollen or enlarged tonsils
  • Painful swallowing
  • Sore throat
  • Bad breath from the bacteria build-up
  • Persistent cough
  • White or yellow debris at the back of the throat

Diagnosis

Usually, tonsil stones can be seen at the back of the mouth and no special tests are needed to confirm the diagnosis. Sometimes they are seen coincidentally on X-rays or scans which have been done for other reasons.

Treatment

Self-care

Tonsil stones are usually harmless and go away on their own. Whilst several self-administered treatments for tonsil stones are described in the literature and on social media, there is little firm evidence to recommend any of these as definitive.

Common self-management strategies include:

  • Regular gargling with a salt-water rinse
  • Drinking carbonated beverages to assist in loosening the makeup of stones so that they eventually come out on their own.
  • Coughing to loosen the stones
  • Maintaining good oral hygiene
  • Managing any allergies causing increased nasal mucus

However, the use of water jet irrigation and manual stone removal (either by using a finger or a makeshift tool such as a cocktail stick) should be avoided as they risk damaging the tonsils and can lead to significant complications such as bleeding, infection and inhalation of a foreign body.

Tonsillectomy

There is currently no clinical evidence to support the role of tonsillectomy in treating tonsil stones and good evidence that the potential risks and harms associated with tonsillectomy outweigh any perceived benefits.

Whilst there is good evidence to support the role of tonsillectomy in treating cases of recurrent tonsillitis and obstructive sleep apnoea in children, the natural history of tonsillitis is that it tends to become less frequent as we move toward adulthood and the body’s immune system matures leading to shrinkage of the tonsils (a process known as involution).

Tonsillectomy is an invasive surgical procedure that carries a small but significant risk of complications as well as peri-operative pain and malaise. In very rare instances, post-operative haemorrhaging (bleeding) has led to deaths following routine tonsillectomy.

There has therefore been a gradual move away from routine tonsillectomy in recent years.

Local commissioning policies are in place for this condition

NHS Devon has determined that surgical tonsillectomy for patients presenting with tonsil stones alone is not a good use of local NHS resources and cannot be justified on clinical grounds. This position is in line with the national consensus on the role of tonsillectomy within the NHS.

Please follow this link for full details: Tonsillectomy.

Other Surgical treatments

There is currently little evidence to support the use of Laser Tonsil Cryptolysis or Coblation Cryptolysis (minimally invasive medical procedures that aim to shrink or remove the pits found within the tonsils to minimise build-up opportunity) in the treatment of tonsil stones and these procedures are not available through the NHS.

When to consult your GP

Tonsil stones are harmless and in the absence of associated symptoms suggestive of infection or other abnormalities they do not warrant medical assessment or intervention.

However, you should consult your GP if you are experiencing any of the following:

  • A chronic sore throat that lasts more than a month
  • Recurrent bouts of tonsillitis that are interfering with daily activities such as school or work
  • Associated breathing problems
  • Trouble swallowing
  • Severe pain, especially on one side. This could be a sign of an infection such as Quinsy (a peri-tonsillar abscess)
  • One tonsil is larger than the other (in rare circumstances this may be a symptom of cancer)

Prevention

The accumulation of food and cell debris and bacterial build-up in the mouth and throat can be offset by following a thorough oral hygiene routine. This may help reduce the formation of tonsil stones although they are not, in themselves, evidence of poor oral hygiene.

  • Brush your teeth twice a day or after meals: Use an anti-bacterial toothpaste to better neutralise plaque and limit the spread of oral bacteria into the throat.
  • Floss at least once a day: Food and plaque gets trapped between teeth throughout the day, flossing helps remove that debris from hard-to-reach areas.
  • Clean your tongue regularly: Plaque bacteria can lurk anywhere in the mouth, especially on the surface of the tongue. Consider switching to an electric toothbrush equipped with a tongue cleaning mode.
  • Rinse and gargle with saltwater or an alcohol-free mouthwash in the morning, night, and after meals to neutralise bad breath.
  • See your dentist regularly for cleanings and check-ups.

In addition to a thorough oral care routine, it’s important to drink plenty of water to help prevent tonsil stones. Hydration helps limit build-up and keep saliva production up for a healthy mouth.