Tonsillolith speculation....

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art456

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I ran across this forum while researching tonsilloliths online.

From what I have found, tonsilloliths seem to be poorly understood and I have a hypothesis regarding them.

Let me state at the outset that I am a layman, and I AM NOT SEEKING MEDICAL ADVICE. Rather, I want to foster some discussion because I think tonsilloliths might be misunderstood and if my hypothesis about their formation is correct, it may help doctors treat them.

There have been a number of threads on this forum regarding the topic before and I encourage any readers of this thread to read them.

Unfortunately, the other threads seem to get shut down due to writers crossing the line regarding medical advice, so please try to avoid that on this thread.

Given that I am a layman, I plan to stay out of the discussion after starting this thread unless someone has something they want to ask me.

What interested me in the topic is that I have had tonsilloliths for some time. I've mentioned them to doctors when getting exams and no doctor has expressed any familiarity with their cause.

While I must apologize in advance for the length of this post, I think it might be helpful to present the reader with an account of my case prior to offering up my hypothesis.

The first time I noticed them was 19 years ago at the age of 25 when I hacked a couple up. I didn't know what they were and after puzzling over them for a while, I washed them down the sink and didn't think about them for about 10 years.

At about the age 35, I was driving to work and had been experiencing a localized irritation on the right side of my throat for a few days. I also had a stuffy right ear and my lymph nodes under my jaw on that side were swollen. The sun was low in the morning sky dead ahead and traffic was light, so I said, "Aaah," and tilted me head back and took a look at my throat in the rear view mirror. Back on the right side of my throat was a large white spot the size of a pencil eraser. It looked like the head to a giant zit and freaked me out.

When I got to work, I located an emergency flashlight and locked myself in the bathroom. After checking it out in the mirror for a bit, I did what I'm sure every doctor dreads their patients will do - I decided to experiment a bit rather than make an appointment with a doctor.

Since it sure looked like a big zit, I located a paperclip and unfolded it and figured that by sticking it into what I thought was a whitehead, I'd drain it. As I gently pushed the end of the bit of metal wire into it, I felt no sensation at all. When I removed the wire, a whitish/yellowish lump the size of a cooked pea came out, transfixed by the wire, and I found myself holding what looked like a miniature lollipop, a metal stick with a cream-colored lump at the end. The lump was cauliflower-like. When I squished the lump between my fingers, to see what, exactly, I was dealing with, I found it had a pastlike texture and smelled extremely foul.

I don't know if any of the readers have gone out camping for a few days without a toothbrush, but it smelled just like the plaque that I scraped off my teeth after such an experience.

After removing the tonsillolith, I could see that the part of the tonsil right around the hole where I'd removed the tonsillolith was very red and irritated. By the end of the day, the irritated feeling in that spot subsided a bit and the stuffiness in my ear lessened.

A day later, at home, I used a flashlight to check the spot out again in the mirror because it was irritated again and noticed another white spot on what I had by then learned was my right tonsil.

This time, I was a bit smarter. I unfolded another paperclip, leaving the smallest u-shaped section intact, and taped the straightened-out part to the end of a plastic pen. This way, I figured, I wouldn't poke myself and cause bleeding/infection if my aim was off.

I used some rubbing alcohol to sterilize the rounded end of the paperclip and used it to dislodge the tonsillolith. This one was bigger than the first, and had the same texture and smell.

Over the next few hours, several trips to the bathroom resulted in several more tonsilloliths, these much smaller. Gargling water would bring them to the point where I could remove them and sometimes gargling itself would remove them. They were also smoother and lighter in color, rounded, and more flexible. While the first two had been lumpier and yellowed to the point of almost an orange tint, these later ones were pale, yet smelled the same when squished (they had no odor when whole).

For months, I'd check my tonsil just about every day and when I saw a white spot, I'd remove the tonsillolith. Then I decided to get proactive.

Now, both of my tonsils are larger than average (I've been told this by a few doctors). Both of them have a large hole that is usually obscured by the flap of tissue in front of the tonsil (please forgive the lack of correct anatomical terminology). Yet, the tonsilloliths only occured on my right tonsil.

Instead of waiting for a tonsillolith to protrude to the point of visibility, I decided to go looking for them. I could insert the u-shaped unfolded paperclip into the hole a bit and push to one side, so I could get a look well inside the tonsil, like a good 3/8 inch. Unlike a cavity, it seemed more like the end of a tube, of sorts. Sometimes there was nothing in sight, sometimes there was a little tonsillolith.

I got the impression that tonsilloliths were passing out of my tonsil all the time on their own and that only when they occasionally got stuck and built up into larger ones that a problem arose.

When I read about tonsilloliths, the writers often describe them as forming in seemingly-random cavities in tonsils. Now, I don't know anatomy as well as you doctors, but the hole in each of my tonsils is in exactly the same spot on both of them. There is just one hole on each tonsil that I can see and on both tonsils, the hole is the same size in both. These holes don't gape, but rather appear as a vertical slit about as tall as a pencil is thick.

When I insert my now-ten-year-old paperclip-turned-homemade-medical-instrument into them and push to the side, both holes go way back and appear to be the end of some sort of tube that drains something.

The tonsil seems somewhat tough and rubbery and when I see a tonsillolith, if i push the U-shaped wire to the side and past it, it easily slides out when I pull the wire forward again.

After the initial rush of tonsilloliths when I first discovered them protruding, they tapered off and didn't occur too often. It was as though they had backed up in there for a while.

Like some of the others who have posted in other threads, I learned to identify the sensation of a stuck tonsillolith and would remove it when necessary.

Then came my eureka moment. I was swimming in a pool and inhaled a bit of water. I clung to the side of the pool hacking and coughing and spluttering for some time, nearly to the point of vomiting. I've never hacked that hard before or since at any point in my life. At the end of this fit of lung clearing, I felt something dislodge from my right tonsil. It landed on the pool tile and I picked it up.

It was made of the same material (as far as I could tell) as a tonsillolith, but was more flexible and seemed, for lack of a better word, fresher.

It was also a very different shape than the tonsilloliths I'd been dealing with. It was over 1/2 inch long and was tubular and about half the diameter of a pencil and had a feature that was hard to describe, but I'll try...

Picture a plastic pipe with something that could feed bacteria or yeast flowing through it. As the bacteria/yeast colony grows on the inside of the pipe and builds up, gravity will make the distribution uneven. The layer of slime will be thicker at the bottom, thinner on the sides, and thinnest at the top. Over time, as the slime thickens, it may reach a point where the force of gravity detaches the layer from the roof of the pipe and it collapses down onto the bottom layer, effectively closing off the pipe.... plugging it.

The thing in my hand looked like it had collapsed once, then broken at the upstream end, and had a new layer form with the top of the collapsed layer forming the base of the newer, smaller, tube before breaking off and passing out through my tonsil.

It sure looked like the small tonsilloliths that I could find if I went searching for them within the tonsil were bits that had broken off the end of this thing and got rounded as they passed down and out of the tonsil.

One of the posters in another tonsillolith thread mentioned that tonsilloliths seem to be layered.

So, here's the hypothesis...

At some point or another, some bacteria or yeast or whatever, possibly related to the microorganisms that build up as dental plaque, find their way into the hole on the tonsil or tonsils, migrate some distance inside, and establish a colony in the tube.

As the colony grows and coats the inside of the tube, from time to time it reaches a point where it closes off the tube, creating some sort of blockage to whatever is draining through the tube.

Maybe there are a lot of differences in tonsils that are genetic, but the hole in each of mine sure seems to go somewhere as opposed to being a random cavity. That would mean that rather than the problem being a food-up issue, it would be a microorganism-up issue where the growing colony is feeding off whatever is coming down. As my right ear feels stuffed up when my right tonsil has noticeable a tonsillolith, this would make sense.

When this blockage happens, the plug, which I'll call a micro-tonsillolith, eventually breaks free and is carried down the tube, exiting out the tonsil during swallowing and most people never notice it at all. These are the small, smooth ones that I occasionally see if I probe into the hole on the tonsil. For the most part, they seem like they pass out on their own and cause no problems.

Sometimes, for any number of reasons, the micro-tonsillolith becomes lodged near the end of the tube and subsequent micro-tonsilloliths build up into an agglomerated macro-tonsillolith.

In my case, a bicycle accident at the age of 16 resulted in a broken nose through which I don't breathe real well. At night, I mouth-breathe to the point that often I have a dried-out throat in the mornings. I suspect that this might be what sticks the initial micro-tonsillolith in place.

As the micro-tonsillolith builds into a macro-tonsillolith and begins to protrude, some food residue can get between the relatively stationary macro-tonsillolith and the tonsil tissue, fostering bacteria and hence irritation. This is when most people feel irritation, go looking in the mirror and notice it.

Now, I don't know if I'm violating forum rules by bringing this up, but the treatments mentioned in other threads; waiting until a tonsillolith is stuck and in need of manual removal to remove it via palpation or water pik, removing the tonsils, lasering the tonsils, gargling a lot with mouthwash, et cetera, don't really address what may really be causing the tonsilloliths - a colony of something growing well inside the tube that ends at the tonsil.

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There is no "tube" per se. Some tonsils are more cryptic than others. These crypts are indeed random appearing, much like holes in swiss cheese or a kitchen sponge. Perhaps you have some that connect into a tube of sorts. Your theory may indeed be correct for your tonsils, but I don't think your experience is universal, or even common.
 
"Paper clip into the tonsil". Hmm...I should write to my old PMD. I did that back when I was 20. He FLIPPED OUT. Talked about endocarditis and all that that entails.

20 years later, even though I'm a qualified and practicing MD, he still - every single visit with my mother - asks about me and brings up the paper clip. I myself haven't seen him in over 15 years. I had my tonsils out when I was 23.
 
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tonsiliths are very similar to other stones that form in other parts of the body at least in terms of the macro-appearance--they are layered just like nephroliths or sialoliths. The layered appearance is not due to a collapsing phenomenon, but rather due to deposition, hardening, and redeposition, similar to the layers of sedimentary rock. There is nothing new about this in the tonsils. Bacteria colonized within the crypts digest food, mucus, secretions, etc that you swallow. The waste products form the majority of the sediment. Your sizable stone is likely just from a large crypt that built up over a long period of time following the same process. I very much doubt any unusual anatomy, but I'll never say never. The treatment doesn't change in either case. That bacteria is colonized, and as of yet, we do not have a long-term eradication strategy for the bacteria besides removing their home whether by tonsillectomy or tonsillotomy of any fashion.
 
Dude,
just get your tonsils out.
 
Dude,
just get your tonsils out.
I was thinking the same thing:idea: I am no tonsil expert. But, it is my guess that after years of stones, and extraction, and ~permanent sinus development, these crypts & tracts have scar tissue, etc... and tonsils will never be normal. Not sure why anyone would continue with such longstanding diseased tonsils. I am not sure why someone would spend so much time sticking things into their tonsils over such a prolonged period.

I thought we can remove tonsils with limited morbidity in 2010/2011? Also, we have plenty of people getting tonsils out for things like apnea, etc without bacterial colonization, infection, stones, recurrent/chronic pathology.

The only other thing I can say is... "We" find plenty of lay people that start down a path they feel is "self-treatment" for whatever reason. Maybe afraid to get tonsils out or sebaceous cyst removed or etc... Over time (in this case apparently years), individuals develop a fairly convoluted way of thinking about it, postulated theories, hypothesis, sense of self expertise, and classifying what they do and with what they do in terms of medical care.

In the end, your paper clip is not now nor has it been a medical instrument. It is a paperclip you are recurrently inserting into cavities in your mouth and/or tonsils. IMHO, you are, for lack of better comparison/phrasing, ~over complexifying scab picking.... This topic in this manner is not so interesting and requiring such thought process.

In order to get to your point of curiosity, one must ignore appropriate treatments early and allow this disease process to continue inexcusably long. There are previous (unfortunate) points in medical history in which some individuals thought it would be curious and somehow advance medical knowledge by not providing treatment for treatable disease in order to watch late manifestations. Get your tonsils removed and end your study.
 
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Do you guys routinely take tonsils out with tonsilloliths as the only indication? I always thought it was considered a pretty soft indication...

In adults, the indication is the patient wants them out. I do my best to talk them out of it but if they insist even after hearing my horror stories then I take them out.
 
Do you guys routinely take tonsils out with tonsilloliths as the only indication? I always thought it was considered a pretty soft indication...
The OP's scenario seems on the extreme side... but I do not treat tonsoliths. I would be interested in the Oto folks comments if such a protracted course of recurrence and self "treatment" would push them more to tonsilectomy....
In adults, the indication is the patient wants them out. I do my best to talk them out of it but if they insist even after hearing my horror stories then I take them out.
In the OP case, years of smelling, recurrent liths, ~permanent sinus tracts, that is being self treated with paperclip, I image you would not regard as "routinely"? Would you, in such scenario, recommend tonsilectomy?
...I am no tonsil expert. But, it is my guess that after years of stones, and extraction, and ~permanent sinus development, these crypts & tracts have scar tissue, etc... and tonsils will never be normal. Not sure why anyone would continue with such longstanding diseased tonsils...
 
I've done two for tonsilloliths. Both were young woman who were self conscious about having previously expelled them in front of other people, believed they had halitosis as a result of these, and had tried more benign treatments to removed them (waterpick, etc). It is considered a relative indication for tonsillectomy.

As long as they understand the risks of surgery - post op bleeding, severe pain, need for a second operation to stop hemorrhage, death, etc - I don't have a problem offering it.

That being said, I try to talk most adults out of tonsillectomy. I think I did ~35 last year (first year out in practice, both peds and adult tonsils).
 
The OP's scenario seems on the extreme side... but I do not treat tonsoliths. I would be interested in the Oto folks comments if such a protracted course of recurrence and self "treatment" would push them more to tonsilectomy....In the OP case, years of smelling, recurrent liths, ~permanent sinus tracts, that is being self treated with paperclip, I image you would not regard as "routinely"? Would you, in such scenario, recommend tonsilectomy?

Yes. It would be completely elective and I would make the patient very aware of all of the rare but serious potential complications. A handful of people die every year in this country having their tonsils out. **** happens during "routine" surgery and you can't ever forget that.
 
The OP's scenario seems on the extreme side... but I do not treat tonsoliths. I would be interested in the Oto folks comments if such a protracted course of recurrence and self "treatment" would push them more to tonsilectomy....In the OP case, years of smelling, recurrent liths, ~permanent sinus tracts, that is being self treated with paperclip, I image you would not regard as "routinely"? Would you, in such scenario, recommend tonsilectomy?
Yes. It would be completely elective and I would make the patient very aware of all of the rare but serious potential complications. A handful of people die every year in this country having their tonsils out. **** happens during "routine" surgery and you can't ever forget that.
Thank you for your reply. I am completely with you that routine surgery does not mean without risk.

I know there are routine/elective procedures I do. My question is just in the degrees. There are some patients I may counsel more heavily and question more readily the desire to proceed with a particular procedure. Others, seeking the same procedure, I may not counsel as heavily in a manner to discourage. I tell the risks and benefits to all. But, some patients have more symptomology that makes the choice far more reasonable. Again, under such circumstances would you recommend or discourage as seem to suggest is norm for adult tonsilectomy?

So, I appreciate that tonsoliths may be a soft indication, etc... I am just wondering if in a scenario as described, is it still so soft. I have never treated this. I don't and have not had tonsoliths. But, it sounds like a benign, but chronic disease to this degree is not the garden variety??? Thus, it seems more reasonable curative therapy.
...That being said, I try to talk most adults out of tonsillectomy...
I guess same question... is the described scenario more extreme then average? Under such a scenario would you still try to talk the patient out of procedure?
 
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Thank you for your reply. I am completely with you that routine surgery does not mean without risk.

I know there are routine/elective procedures I do. My question is just in the degrees. There are some patients I may counsel more heavily and question more readily the desire to proceed with a particular procedure. Others, seeking the same procedure, I may not counsel as heavily in a manner to discourage. I tell the risks and benefits to all. But, some patients have more symptomology that makes the choice far more reasonable. Again, under such circumstances would you recommend or discourage as seem to suggest is norm for adult tonsilectomy?

So, I appreciate that tonsoliths may be a soft indication, etc... I am just wondering if in a scenario as described, is it still so soft. I have never treated this. I don't and have not had tonsoliths. But, it sounds like a benign, but chronic disease to this degree is not the garden variety??? Thus, it seems more reasonable curative therapy.I guess same question... is the described scenario more extreme then average? Under such a scenario would you still try to talk the patient out of procedure?

The original post is just way too long for me to read. I'll have to take your word for it that this person has an unusually extreme case of tonsiliths. In that case, I would recommend tonsillectomy. I would then go into my usual pre-op spiel on tonsillectomy. If they are willing to accept the risks and the 2 weeks of utter misery and extraordinary pain in exchange for never having another tonsilith, then I start sharpening the tonsillotome:

http://www.phisick.com/images/ent/tonsillotome-reynders-101.jpg
 
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Thanks for the replies. I do have a few non-advice-seeking questions that I hope someone will weigh in on at the end of this post.

JackADeli wrote, "But, it is my guess that after years of stones, and extraction, and ~permanent sinus development, these crypts & tracts have scar tissue, etc... and tonsils will never be normal."

Other than the episode where there were quite a few 'liths self-extracted from one crypt over a period of several months, ten years ago, culminating with the long tubular one produced via a coughing fit, I rarely get them... maybe one, once or twice a year. And they've never been nearly as big as during that episode.

I didn't write the original post because they are still a frequent occurrance, rather because I noticed a small one that evening for the first time in quite a while, removed it, checked to see if there were more packed in behind it (because of that past experience), but found no additional ones waiting in line, and then got the urge to go online and research them.

You'd be amazed at the number of videos people have posted on Youtube where they self-treat their 'liths. You'd think they had better things to do than videotape that... I'd rather go to an online medical forum to discuss them.

I have lived in several cities and thus had several physicians and get regular exams and usually mention the occasional 'liths on the right tonsil to them and have the physicians look at my tonsils and I've never had my physicians suggest that my tonsils needed removal. I've also never mentioned the paper clip to them.

There's never been any bleeding when I removed a 'lith (the paperclip is U-shaped, not linear) and I'm not aware of any scar tissue. Also, the tonsil on the right looks the same as the one on the left, including the size and placement of the only visible crypt opening, but I've never had a 'lith on the left.

resxn wrote, "I very much doubt any unusual anatomy, but I'll never say never."

BOOURNS wrote, "These crypts are indeed random appearing, much like holes in swiss cheese or a kitchen sponge. Perhaps you have some that connect into a tube of sorts."

On the anatomy...

Every physician who has examined my tonsils has commented on their size. What I've heard, in paraphrase, has been a consistent, "Wow... they're huge... but they seem healthy enough... I don't see any problem with them..."

When my youngest son's pediatrician looked at his throat years ago, she commented on the size of his tonsils and I said he probably got them from me. She asked to look at mine and after doing so, she agreed.

When I did have what I would now describe as a single crypt impacted with 'liths, and wondered how many more were forthcoming, I illuminated the tonsil with a flashlight reflected in the mirror, said "Aaaah," inserted the U of the paperclip about a quarter inch, and pushed sideways.

The crypt opened up and I was startled to see how deep it was. I have installed cabinets for a couple decades and fractions of an inch are a big deal to me. Taking countless fine, detailed measurements has given me the ability to look at an object across a room and, for example, tell you whether it is 4" or 4.25" inches across. It's a neat party trick.

In my professional opinion, I could see a full inch into the tonsil. The crypt got wider, not narrower, as it went in and I didn't see a back to the crypt, rather just pitch black at the limit of illumination (if I had shined the flashlight straight into it, I would have just seen the flashlight in the mirror, so it was at a slight angle).

Out of curiosity, I checked the left tonsil and it is the same, but again, I've never noticed a 'lith in that one.

When I looked up tonsilloliths on Wikipedia, the pathophysiology portion of the article has a diagram of a tonsil and the accompanying text, "...Many lymph cells pass from the nodules toward the surface and will eventually mix with the saliva as salivary corpuscles."

If anyone will indulge me...

If the tonsils are passing lymph cells through crypts regularly, could a colony of microbes be subsisting off these cells? In my case, since I only get 'liths on the right side, that would discount the food I eat as being the source of the tonsilloliths, wouldn't it?

Since, as BOOURNS wrote, tonsils are quite porous and spongelike, what if someone whose tonsils had a "main crypt" (as mine appear to have) had that crypt blocked with tonsilloliths but didn't notice early on? As more 'liths contined to form behind the blockage, and the crypt became impacted, wouldn't the 'liths migrate outward through the sponge-like tissue and eventually appear as 'liths on the surface of the tonsil?

In other words, what if a tonsil laden with tonsilloliths (as some severe cases appear in online photos) wasn't necessarily the result of food residue building up in the crypts from the outside, but rather the result of a colony of microbes deep inside the tonsil feeding on lymph cells and creating 'liths that clogged crypts and migrated out and eventually filled the porous structure of the tonsil?

As they reach the surface and are dislodged by eating, might they leave behind a swiss-cheese-looking surface that traps food and causes additional problems and leaves physicians looking at the resulting situation thinking that the food accumulation was the cause of the problem when it was actually a later issue?

Various literature mentions lasering the surface of the tonsil to smooth it out so food residue is less likely to accumulate in the crypts. Has anyone reading this tried that enough times to get an idea of how often that succeeds in resolving the problem? Do a lot of those patients still suffer 'liths and eventually need to have their tonsils removed in the end, anyway?

If I'm right about what was causing my own 'liths, and if I hadn't got lucky and caught it early on and used the paperclip to go deep and clear out most of the impacted crypt instead of just dealing with the 'liths as they surfaced, and got luckier when I aspirated a bit of pool water and hacked out the really deep tubular portion, which seemed to resolve the problem for me, I suppose I might have ended up with a tonsil heavily impacted with 'liths to the point where I needed my tonsils removed, as opposed to one that various physicians have told me is not in need of removal.
 
The original post is just way too long for me to read. I'll have to take your word for it that this person has an unusually extreme case of tonsiliths. In that case, I would recommend tonsillectomy. I would then go into my usual pre-op spiel on tonsillectomy. If they are willing to accept the risks and the 2 weeks of utter misery and extraordinary pain in exchange for never having another tonsilith, then I start sharpening the tonsillotome:

http://www.phisick.com/images/ent/tonsillotome-reynders-101.jpg
Thank you again. I am with you. I don't take "routine" for granted. I just asked out of curiousity as I do not deal with this disease process.
 
If they are willing to accept the risks and the 2 weeks of utter misery and extraordinary pain

I had mine out at 23 (as mentioned above) and I didn't have extraordinary pain (didn't need any narcs post-op), and was only mildly bothered (not so much as to skip a conference in Pittsburgh) for about 4 days (had them out on Friday, was well on Wednesday).
 
I had mine out at 23 (as mentioned above) and I didn't have extraordinary pain (didn't need any narcs post-op), and was only mildly bothered (not so much as to skip a conference in Pittsburgh) for about 4 days (had them out on Friday, was well on Wednesday).
I guess that raises an interesting but nagging question I have had in the back of my thoughts. I know numerous adults that have had their tonsils out and their experiences have seemed more akin to the description above (i.e. 4-5 day recovery, sore throat, minimal pain meds) as opposed to what some are warning (i.e. 2 weeks of utter misery and extraordinary pain).

I agree there is risk to surgery. I know people die every year from routine groin hernias or routine lap appies or routine tonsilectomies or even routine root canals. But, I have not heard of tonsilectomy being such a difficult post-op course... until this thread. I have also not seen the Otolaryngologists use the instrument displayed above. They usually use some energy source device. Do tonsilectomy for tonsoliths require those tonsilotomes???

http://www.utmb.edu/otoref/grnds/Tonsillectomy-2005-0427/Tonsillectomy-050427.htm

http://www.medicalnewstoday.com/articles/52636.php
 
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Adult tonsillectomy is rough by most accounts. Many patients seem to have 7-10 days of pretty rough pain - we encourage all patients to take narcotics, even waking up in the night the first few days. We get a disproportionate number of calls from post-op tonsil patients (though generally pedi tonsillectomy).

There are about as many ways to take out tonsils as there are surgeons doing the procedure. Each attending where I am training has a slightly different instrument or approach. Everyone thinks their way is less painful post op and leads to fewer tonsil bleeds. The data isn't overwhelming in any direction.
 
Adult tonsillectomy is rough by most accounts. Many patients seem to have 7-10 days of pretty rough pain - we encourage all patients to take narcotics, even waking up in the night the first few days. We get a disproportionate number of calls from post-op tonsil patients (though generally pedi tonsillectomy).

There are about as many ways to take out tonsils as there are surgeons doing the procedure. Each attending where I am training has a slightly different instrument or approach. Everyone thinks their way is less painful post op and leads to fewer tonsil bleeds. The data isn't overwhelming in any direction.
Thank you, that's interesting. I fortunately have no tonsoliths & very little tonsils left by ~natural involution/atrophy. I am just always interested in common procedures I don't do or have much direct involvement in....
 
I have also not seen the Otolaryngologists use the instrument displayed above. They usually use some energy source device. Do tonsilectomy for tonsoliths require those tonsilotomes???

I hope you never see someone using a tonsillotome. It is a very old instrument and I was joking about using it.
 
First, tonsillectomy for tonsilloliths is a relative indication. Absolute indications are only for suspected/confirmed malignancy, Strep infections (7 in 1 year, 5/yr x2 yrs, or 3/yr x3+ yrs), 2+ Peritonsillar abscess, or OSA. Everything else (including tonsilloliths) are relative indications. I took about 90 patients to the OR in 2010 for tonsillectomy, about 60% were for absolute indications, 40 for relative. Of the relative, probably 30% were for tonsilloliths. I encourage avoidance of surgery for this condition, but tonsillectomy is curative. Tonsillotomy is less assured to be curative, but certainly can be.

If anyone will indulge me...

If the tonsils are passing lymph cells through crypts regularly, could a colony of microbes be subsisting off these cells? In my case, since I only get 'liths on the right side, that would discount the food I eat as being the source of the tonsilloliths, wouldn't it?
Lymph cells? I think we need to define these more appropriately. If we're talking about lymphocytes (literally, lymph cell) they are specifically created by the body to kill microbes, not to be preyed upon by them. I very much doubt the idea that there are microbes subsisting on the ingestion of lymphocytes in tonsil crypts.

No, only getting a lith on one side does not discount the food you eat as the source. Certainly, many patients have multiple diverticuli in their colon but only get diverticulitis in specific ones.

Since, as BOOURNS wrote, tonsils are quite porous and spongelike, what if someone whose tonsils had a "main crypt" (as mine appear to have) had that crypt blocked with tonsilloliths but didn't notice early on? As more 'liths contined to form behind the blockage, and the crypt became impacted, wouldn't the 'liths migrate outward through the sponge-like tissue and eventually appear as 'liths on the surface of the tonsil?
yes, this is certainly possible

In other words, what if a tonsil laden with tonsilloliths (as some severe cases appear in online photos) wasn't necessarily the result of food residue building up in the crypts from the outside, but rather the result of a colony of microbes deep inside the tonsil feeding on lymph cells and creating 'liths that clogged crypts and migrated out and eventually filled the porous structure of the tonsil?
Again, highly unlikely for the reasons above. Additionally, if this were the case, you would expect that we would see tonsilloliths form in the adenoid crypts and in hypertrophic lingual tonsils, which we don't. We would also then expect to see tonsilliths form in lymph nodes (doesn't happen) or a similar process occur in sinuses.

As they reach the surface and are dislodged by eating, might they leave behind a swiss-cheese-looking surface that traps food and causes additional problems and leaves physicians looking at the resulting situation thinking that the food accumulation was the cause of the problem when it was actually a later issue?
Chicken vs Egg. Sounds like you're positing that tonsilloliths create crypts that creates a cycle that can then trap food and create other problems such as more liths? Possible. What difference would it make? How would it affect treatment?

Various literature mentions lasering the surface of the tonsil to smooth it out so food residue is less likely to accumulate in the crypts. Has anyone reading this tried that enough times to get an idea of how often that succeeds in resolving the problem? Do a lot of those patients still suffer 'liths and eventually need to have their tonsils removed in the end, anyway?
Depends on the method of tonsillotomy. In its most conservative form (cryptolysis) you simply smooth the rim of the crypt so that there is no cave wherein food may be trapped. This is effective 70% of the time on a first pass. On a 2nd attempt, the effectiveness improves to about 85%. If doing a near total tonsillotomy by aggressively removing tonsil just shy of the capsule, this is more uncomfortable but more effective to the tune of about 90-95%.

More detail than anyone probably wants:

quoting from the below article "Tonsilloliths act as a localized
concentration of aerobic and anaerobic bacteria, they calcify
over time, progressing from soft gels to hard "stones"


Otolaryngol Head Neck Surg. 2009 Sep;141(3):316-21.
Tonsillolith: not just a stone but a living biofilm.
Stoodley P, Debeer D, Longwell M, Nistico L, Hall-Stoodley L, Wenig B, Krespi YP.
Center for Genomic Science, Allegheny-Singer Research Institute, Pittsburgh, PA, USA.
Abstract
OBJECTIVE: To study the morphology and activity of tonsilloliths, demonstrating oxygen respiration, denitrification, and acidification on exposure to sucrose.
STUDY DESIGN: Tonsilloliths were extracted in atraumatic conditions during tonsillectomy from 16 adults and sent to two different laboratories for histological, bacteriological, and biofilm studies under sterile conditions.
SETTING: Multicenter laboratory study.
SUBJECTS AND METHODS: Multiple tonsilloliths from two patients examined by confocal microscopy and microelectrodes were used to measure aerobic/anaerobic respiration and acid production (dissolved oxygen, nitrous oxide, pH) when exposed to saliva following addition of sucrose and fluoride.
RESULTS: Morphologically, tonsilloliths were similar to dental biofilms, containing corncob structures, filaments, and cocci. Microelectrodes showed that the microorganisms respired oxygen and nitrate. The oxygen concentration in the center of the tonsillolith was depleted to approximately one-tenth of that of the overlying fluid. The addition of sucrose resulted in acid production within the tonsillolith, dropping the pH from 7.3 to 5.8. The data showed stratification with oxygen respiration at the outer layer of tonsillolith, denitrification toward the middle, and acidification toward the bottom. The depletion of oxygen and acid production following addition of sucrose may allow the proliferation of anaerobic/acidophilic bacteria. Fluoride suppressed acid production in the presence of sucrose.
CONCLUSIONS: Tonsilloliths exhibit biofilm structure and the formation of chemical gradients through physiological activity. Although tonsillectomy is an option for treating cryptic infections, understanding the morphology and biofilm characteristics of tonsilloliths may stimulate scientists to use limited or targeted remedies in the future.
 
I am not trained in medicine other than honors anatomy and phsyiology in high school.

I was wondering if anyone here has the bad habit of picking their nose? Maybe there is a high correlation between picking the nose and the appearance of tonsilloliths? Don't microorganisms from the finger pass through the mucous membranes of the nose and up into the sinuses? Maybe the tonsillolith formation process happens as such foreign microrganisms move through the sinuses and end up being discharged through the tonsils. The body builds the layers to cover the microrganisms the same way a virus would infect a cell and use a protein coat to mask its presence. That way, the layered microrganisms can be expelled from the body or discharged from the tonsil, swallowed, and pass through the body without causing any problems.

Also, does anyone scratch inside of their ears, perhaps too aggressively? Maybe that can also introduce foreign organisms into the sinuses and lead to tonsilloliths.

Lastly, I always wondered if tonsilloliths are a relatively recent phenomenon. Maybe they have "coincidentally" appeared in people at the same time we started to use new technologies such as mouthwash and toothpaste. Wouldn't that be the ultimate irony that the toothpaste we use to prevent bad breath actually ends up increasing the likelihood of tonsil stones and causing bad breath? Just curious, how long after you guys eat do you typically wait before brushing your teeth? Maybe if we did an informal trial of brushing our teeth immediately after meals, we would find that tonsil stones stopped appearing? Because if you wait too long after you eat before brushing, then bacteria accumulates and then when you rinse your mouth and gargle, maybe those bacteria end up being introduced into the tonsils. Maybe it has something to do with the toothpaste.
 
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I often wonder, since there is 100x more bacterial DNA in the human body, if tonisiliths are also a bank of bacteria important for digestion. Tonsiliths, once free form the crypt, could be swallowed, protected from gastric juices by the hard outer shell, travel the GI tract in order to re-colonize the small intestines with microbial species for digestion.
I definitely don't think it is just food stuck in the back of the mouth; it seems so silly to me more research has not been done to out rule this lazy theory.
 
What if these tonisiliths are formed as a way for the body to recolonize the gut with microbes important for digestion? After swallowed, they would be protected from gastric juices by the hard outer shell to survive the stomach in order to reach the small intestines.
 
First, tonsillectomy for tonsilloliths is a relative indication. Absolute indications are only for suspected/confirmed malignancy, Strep infections (7 in 1 year, 5/yr x2 yrs, or 3/yr x3+ yrs), 2+ Peritonsillar abscess, or OSA. Everything else (including tonsilloliths) are relative indications. I took about 90 patients to the OR in 2010 for tonsillectomy, about 60% were for absolute indications, 40 for relative. Of the relative, probably 30% were for tonsilloliths. I encourage avoidance of surgery for this condition, but tonsillectomy is curative. Tonsillotomy is less assured to be curative, but certainly can be.

Lymph cells? I think we need to define these more appropriately. If we're talking about lymphocytes (literally, lymph cell) they are specifically created by the body to kill microbes, not to be preyed upon by them. I very much doubt the idea that there are microbes subsisting on the ingestion of lymphocytes in tonsil crypts.

No, only getting a lith on one side does not discount the food you eat as the source. Certainly, many patients have multiple diverticuli in their colon but only get diverticulitis in specific ones.

yes, this is certainly possible


Again, highly unlikely for the reasons above. Additionally, if this were the case, you would expect that we would see tonsilloliths form in the adenoid crypts and in hypertrophic lingual tonsils, which we don't. We would also then expect to see tonsilliths form in lymph nodes (doesn't happen) or a similar process occur in sinuses.

Chicken vs Egg. Sounds like you're positing that tonsilloliths create crypts that creates a cycle that can then trap food and create other problems such as more liths? Possible. What difference would it make? How would it affect treatment?

Depends on the method of tonsillotomy. In its most conservative form (cryptolysis) you simply smooth the rim of the crypt so that there is no cave wherein food may be trapped. This is effective 70% of the time on a first pass. On a 2nd attempt, the effectiveness improves to about 85%. If doing a near total tonsillotomy by aggressively removing tonsil just shy of the capsule, this is more uncomfortable but more effective to the tune of about 90-95%.

More detail than anyone probably wants:

quoting from the below article "Tonsilloliths act as a localized
concentration of aerobic and anaerobic bacteria, they calcify
over time, progressing from soft gels to hard "stones"


Otolaryngol Head Neck Surg. 2009 Sep;141(3):316-21.
Tonsillolith: not just a stone but a living biofilm.
Stoodley P, Debeer D, Longwell M, Nistico L, Hall-Stoodley L, Wenig B, Krespi YP.
Center for Genomic Science, Allegheny-Singer Research Institute, Pittsburgh, PA, USA.
Abstract
OBJECTIVE: To study the morphology and activity of tonsilloliths, demonstrating oxygen respiration, denitrification, and acidification on exposure to sucrose.
STUDY DESIGN: Tonsilloliths were extracted in atraumatic conditions during tonsillectomy from 16 adults and sent to two different laboratories for histological, bacteriological, and biofilm studies under sterile conditions.
SETTING: Multicenter laboratory study.
SUBJECTS AND METHODS: Multiple tonsilloliths from two patients examined by confocal microscopy and microelectrodes were used to measure aerobic/anaerobic respiration and acid production (dissolved oxygen, nitrous oxide, pH) when exposed to saliva following addition of sucrose and fluoride.
RESULTS: Morphologically, tonsilloliths were similar to dental biofilms, containing corncob structures, filaments, and cocci. Microelectrodes showed that the microorganisms respired oxygen and nitrate. The oxygen concentration in the center of the tonsillolith was depleted to approximately one-tenth of that of the overlying fluid. The addition of sucrose resulted in acid production within the tonsillolith, dropping the pH from 7.3 to 5.8. The data showed stratification with oxygen respiration at the outer layer of tonsillolith, denitrification toward the middle, and acidification toward the bottom. The depletion of oxygen and acid production following addition of sucrose may allow the proliferation of anaerobic/acidophilic bacteria. Fluoride suppressed acid production in the presence of sucrose.
CONCLUSIONS: Tonsilloliths exhibit biofilm structure and the formation of chemical gradients through physiological activity. Although tonsillectomy is an option for treating cryptic infections, understanding the morphology and biofilm characteristics of tonsilloliths may stimulate scientists to use limited or targeted remedies in the future.
It matters, because more than likely, the tonsils are more complex than they seem. I don't think it is dumb to bring up lymphocytes as maybe they are involved with the microbial balance.
Please use your brain creatively and think outside the box to shed light on the purpose of tonsiliths. also watch this before you do:
http://www.ted.com/talks/bonnie_bassler_on_how_bacteria_communicate.html
It wouldn't hurt to brush up on micro, please let me know what references I can read for background on lymphocytes and tonsil tissue. Thanks
 
It matters, because more than likely, the tonsils are more complex than they seem. I don't think it is dumb to bring up lymphocytes as maybe they are involved with the microbial balance.
Please use your brain creatively and think outside the box to shed light on the purpose of tonsiliths. also watch this before you do:
http://www.ted.com/talks/bonnie_bassler_on_how_bacteria_communicate.html
It wouldn't hurt to brush up on micro, please let me know what references I can read for background on lymphocytes and tonsil tissue. Thanks

Thank you, LuLuAndJaffa, for your recommendations. My limited brain power and non-pre-veterinarian MD boxed in thinking has prevented me from seeing the benefits of broader thought processes. I'm going to propose a few other ways to use my "brain creatively" and perhaps with your more enlightened mind, we may be able to through more sophisticated cognitive functioning prove the Higgs Boson too.

Some creative thinking for you to explore:
1 - Cataracts are designed to prevent retinal melanoma
2 - Cavities are present to sensitize and enhance our immune response to changes in gut flora that perhaps are dangerous. More cavities may mean less diarrhea.
3 - Ingrown toenails occur to push skin toward the ground, creating more surface area and therefore better traction on the ground to escape predators during evasive maneuvering.
4 - Thyroglossal duct cysts develop to provide us with secondary stores of much needed colloid.
5 - preveterinary trolls post on ENT boards in order to promote higher level reasoning.


Then again, sometimes crap just happens because it happens and there is no grand reward for it (in a boxed in, cro magnon, IQ lower than my GPA, sort of thinking way).

I'm out.
 
Not sure I understand any of this...

Sent via Tapatalk.
 
I didn't mean to cause offense, but was seriously commenting that you sound smart and I would be interested in other theories you could come up with if you allowed yourself and others to think creatively about other possibilities. It doesn't hurt to imagine, so please don't discourage others from doing so.
Goodluck in vet school.
 
Some creative thinking for you to explore:
1 - Cataracts are designed to prevent retinal melanoma
2 - Cavities are present to sensitize and enhance our immune response to changes in gut flora that perhaps are dangerous. More cavities may mean less diarrhea.
3 - Ingrown toenails occur to push skin toward the ground, creating more surface area and therefore better traction on the ground to escape predators during evasive maneuvering.
4 - Thyroglossal duct cysts develop to provide us with secondary stores of much needed colloid.
5 - preveterinary trolls post on ENT boards in order to promote higher level reasoning.

6 - Insulinomas as an evolutionary mechanism to reduce the risks of developing diabetes mellitus.
7 - Melanomas develop as a natural marker of hyper-vitaminosis D.
8 - Reproductive organ cancer as a regulator of population dynamics.
9 - Acute Myocardial Infarctions causes increased myocyte loss so the elderly would not require as much nutrition to drive a metabolically demanding organ allowing preservation of other organs leading to decreased rates of osteoporosis and skin laxity.
10 - Ectopic pregnancy as a natural indication for becoming a nun.

[YOUTUBE]http://www.youtube.com/watch?v=8cT_Ulmcrys[/YOUTUBE]
 
Thank you, LuLuAndJaffa, for your recommendations. My limited brain power and non-pre-veterinarian MD boxed in thinking has prevented me from seeing the benefits of broader thought processes. I'm going to propose a few other ways to use my "brain creatively" and perhaps with your more enlightened mind, we may be able to through more sophisticated cognitive functioning prove the Higgs Boson too.

Some creative thinking for you to explore:
1 - Cataracts are designed to prevent retinal melanoma
2 - Cavities are present to sensitize and enhance our immune response to changes in gut flora that perhaps are dangerous. More cavities may mean less diarrhea.
3 - Ingrown toenails occur to push skin toward the ground, creating more surface area and therefore better traction on the ground to escape predators during evasive maneuvering.
4 - Thyroglossal duct cysts develop to provide us with secondary stores of much needed colloid.
5 - preveterinary trolls post on ENT boards in order to promote higher level reasoning.


Then again, sometimes crap just happens because it happens and there is no grand reward for it (in a boxed in, cro magnon, IQ lower than my GPA, sort of thinking way).

I'm out.

Lol
 
I didn't mean to cause offense,

Then don't troll with requests to "think creatively" as though those who engaged in an academic discussion hadn't tried to do so in a cognitively rigorous sort of way.

but was seriously commenting that you sound smart and I would be interested in other theories you could come up with if you allowed yourself and others to think creatively about other possibilities.

I think you just said something to the effect that "I didn't mean to offend you when I said you didn't think creatively before, but I think you're stupid for not thinking creatively and you stifle others."

How could I possibly be offended, troll.

You couldn't let it go. You had to throw your sophomoric little jab where you could. Well, now, sit back and enjoy another diatribe.

It doesn't hurt to imagine, so please don't discourage others from doing so.


You know what hurts to imagine? "Gee I know that mass in your neck has all evidence pointing to squamous cell carcinoma and because it's cystic I suspect the lesion is in your tonsil, but I'm going to think creatively in lieu of all acquired evidence to the contrary. Perhaps that mass is meant to enhance your immune system to stave off the met in your lung. I think we should hold off on any treatment to make sure your immune system is on its highest level of activity before going after it."

You see, there is a time and a place for imagination. Let me offer this to your little theory. Where the hell have you seen a tonsilith with a "hard outer shell" one that is hard enough to withstand a pH of 4? Let's assume your creative mind isn't aware of biofilms and that's what you meant by "hard outer shell." Well, Copernicus, now you're on to something. Oh no, wait, biofilms are not protective of acidic solutions (well at least the anaerobic biofilms that are found in tonsillar crypts). Never mind.

On one thing you're partially correct, no one should ever stifle imagination, but you forgot a key caveat (at least for physicians)--unless it puts others at harm. Ignoring treating a pt suffering from severe social phobia due to the halitosis secondary to their cryptic tonsillitis is indeed harmful. They shouldn't be told to suck it up because their tonsiliths are great for their gut flora.

BTW, it can hurt to imagine--Osama Bin Laden had quite the imagination and was a creative thinker. It's how you imagine that counts. Be productive. Use reason. Stand on the shoulders of the giants before you. By all means, if you want to reinvent the wheel with your creative thinking, more power to you. Just don't be upset by all the missed opportunities to help people on the way when you spend so much time recognizing that round was right after all.

Goodluck in vet school.
And good luck to you, although I'm saddened to see you no longer list yourself as "pre-verterinarian." I hope your goal wasn't a figment of your imagination.

You caught me on a bad week, troll, I mean LuLu. My rebukes may have simply been left in my imagination (if I had one) had you not insulted me. . .twice.
 
I have a theory! Stop playing with the back of your throat.
 
Great information about tonsils stones given by all participants. I'm also suffering from tonsils stones but till doesn't know the main cause of tonsils stones. However I have read about many different root causes of tonsils stones ranging from environmental to personal problems. You can also read causes of tonsils stones.
Thanks to all Members
 
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