TONSIL STONES AND BAD BREATH (HALITOSIS)

JOSEPH R. ANTICAGLIA,
MD Medical Advisory Board

We’re familiar with gall stones, kidney stones, but what are ‘Tonsil Stones’?

Peggy, a 29 year old wife of a Veterinarian saw her physician because of “pus pockets” on her tonsils and “my breath stinks.” At times, white stuff pops out of the tonsil with an awful smell and taste.” It had worsened over the previous eight months in spite of the use of over the counter medications and home remedies. Now her husband is complaining about her bad breath. It has had a terrible effect on how she feels about herself.

The tonsils (palatine tonsils) are two oval-shaped soft tissue masses on each side of the tongue. They contain crypts (pits or recesses) where stuff can accumulate (1). Ordinarily, the contents of the crypts drain into the oral cavity. At times, the stuff forms a yellow-white cheesy material that fills the crypt, stagnates and causes problems.

When the cheesy (caseous) material becomes hard, it’s referred to as tonsil stones or (tonsilloliths or tonsil calculi). Not infrequently, tonsil stones are seen in patients with previous infections of the tonsils that pinch off the mouth of the crypt allowing the cheesy stuff to accumulate with no exit. These stones can cause localized tonsil pain, difficulty swallowing or more frequently bad breath (halitosis).

Halitosis is the perception of a foul odor emanating from a person’s mouth (eeewww!). Tonsil halitosis is bad breath associated with caseous tonsillitis and tonsil stones. According to the MDS, one in four Americans are bothered by chronic halitosis and over ten billion dollars is spent annually in the US to treat bad breath. (2) Much of the money is spent on products that don’t work.

People joke, “That guy’s bad breath is so bad it comes into the room before he does.” But it’s no laughing matter. It’s big business and on a personal basis it’s a big problem. In addition, the character of the odor can have medical significance. A fruity odor may be present in diabetic patients, a rotten egg odor has been recorded in tonsil halitosis and a foul odor has been noted in patients with a peritonsillar abscess, cancer of the throat and other areas (e.g. tonsil, base of the tongue, larynx).

Bad breath can make you the target of hurtful remarks, affect your social life, be a problem at work and lower your self esteem. Ninety percent of halitosis originates in the mouth and is manageable. (3) What is of paramount importance is an accurate diagnosis, since the respiratory, gastrointestinal and urinary systems and other factors can cause bad breath. So what do you do with a problem like Peggy’s?

Peggy practiced good oral hygiene, cleaned the back of her tongue, rinsed and gargled her mouth with numerous preparations, used a water pik and a q-tip to remove the cheesy mess from her tonsils – but they came back. She eliminated certain foods from her diet (garlic, onions), brushed her teeth regularly and wasn’t taking medication that could cause halitosis. Her problem didn’t go away. . What’s next?

Clinicians talk about Tonsillectomy and Cryptolysis (stay with me) to treat persistent tonsil halitosis. These procedures are RARELY needed and are contraindicated if the problem can be managed with medical treatment.

Tonsillectomy, the surgical removal of the tonsils, is the only known 100% cure for halitosis due to tonsil stones. . No tonsils, no tonsil stones! In adults, the surgery is done under general or local anesthesia – you’re back to non-physical work in a week to ten days and full recovery in about two to three weeks.

Cryptolysis is the use of lasers or another modality to destroy or smooth out the tonsil crypts so that the cheesy material does not collect or be trapped in the crypts. It’s done in adults usually under local anesthesia, the pain is less (it still hurts) and recovery time is shorter, but there is no guarantee that the tonsil stones will not once again show their smelly face. (4)

It needs to be emphasize these procedures are extremely rare but carefully screened individuals can be helped by these interventions. Finally, consider a dental consultation for other causes of oral halitosis.

REFERENCES:

  1. Stoodley, P. et al; Tonsillolith: Not just a stone but a living biofilm; Oto HHS; 2009 Sep 14.
  2. Take Your Breath Away; Massachusetts Dental Society
  3. J Natl Sci Biol Med Jan-June 2013 4(1) 14-23
  4. Chang, Christopher; Thrasher, Richard; Coblation Cryptolysis to Treat Tonsil Stones; ENT Journal, Jun.4, 2012.