I’ve often found it interesting when patients complain they have tonsil stones, considering that tonsil stones don’t really exist. Well, they’re not actually stones. The term is a misnomer. Unlike kidney stones or salivary stones, which are calcified and therefore hard, tonsil stones are soft and stinky, white or yellow balls of solid pus, which form in the crypts of the tonsils. The proper medical term is exudate. They consist of bacteria, white blood cells and protein. At any rate, they’re not particles of food stuck in the tonsils.
Generally, viruses don’t cause exudate. A cold can cause the tonsils to be red, swollen and sore, but tonsillar exudate usually means a bacterial infection. So, what is the source of the bacteria? Sometimes, it’s community acquired, as in the case of strep throat. Other times, it’s a bacterial suprainfection following a viral infection. Acute tonsillitis in these situations often causes pain and fever. However, most of the time, it’s the bacteria in the nose and sinuses, which drip down the back of the throat. These are more long standing conditions. Allergies are a common cause of tonsillar exudate caused by sinus bacteria and post-nasal drip. Chronic tonsillitis is usually less painful. More commonly, patients describe a foreign body sensation, or a feeling like something is stuck in their throat. They will often cough up or hack out these so-called tonsil stones. These malodorous nuggets can be a frequent cause of bad breath.
In the case of viral pharyngitis without exudate, such as a simple cold or sore throat, supportive measures should suffice. Tylenol or Motrin can be given with adequate hydration and rest. The initial treatment of bacterial tonsillitis with exudate involves antibiotics. Most cases of acute tonsillitis will respond to a single course of the properly chosen antibiotic. However, acute tonsillitis may become recurrent, thus making it similar to chronic tonsillitis. In the latter situation, several rounds of antibiotics may be necessary. Chronic tonsillitis presents a more challenging problem. Patients may attempt to dislodge and remove tonsillar exudate with soft, non-dangerous tools, such as Q-tips. However, this is usually futile, as the exudate frequently recurs.
Gargling with warm, salt water or antiseptic mouthwashes is acceptable, but again the relief is usually short lived. Allergy treatment with medications or immunotherapy can be effective at reversing chronic tonsillitis. The goal is to prevent the post-nasal drip, which carries the bacteria to the tonsils. Still, there will always be those cases where none of the aforementioned treatments will solve the problem. Tonsillectomy remains the final solution when tonsillitis persists or recurs, or when peritonsillar abscess develops.
Surgery to remove the tonsils, and the adenoids if present, is an outpatient procedure performed with minimal risk. Recurrent acute tonsillitis is more often the indication in children, whereas chronic tonsillitis is more often the indication in adults. The surgery remains elective, as tonsillitis is rarely a life-threatening problem when no abscess is present. However, it ultimately becomes a quality of life matter, to live with tonsillitis or to be free of tonsillitis.
So, in essence, tonsil stones exist, but they’re not actually stones. They’re balls of solid pus, representing a bacterial infection of the tonsils. Just how far to treat them depends on the symptoms and the patient’s intolerance of the problem.
