tonsilloliths are white or yellowish calcified structures of bacteria and organic debris that commonly develop in enlarged tonsillar crypts
tonsilloliths exhibit a biofilm structure in which aerobic and anaerobic bacteria colonise an epithelial or mucosal surface in the presence of an extracellular matrix that envelopes the bacteria .
tonsilloliths act as a localised concentration of bacteria that ultimately calcifies by progressing from a soft gel to hard concretions ( 2 ) .
tonsilloliths are composed of calcium hydroxyapatite and calcium carbonate with other minerals including phosphorus , ammonia and magnesium ( 1 ) .
alternative mechanisms have been proposed that include ectopic tonsillar tissue , minor salivary gland duct stasis leading to formation of calculi or peritonsillar abscess calcification ( 3 ) .
a 17-year - old female presented with a two - year history recurrent tonsillitis of three episodes per year . over a two - year period between episodes there remained a persistent left sided oral cavity swelling that increased in size .
this swelling caused dysphagia , foreign body sensation and  hot potato  speech with progressively worsening dysphagia over the preceding two months prior to clinical review .
there is no allergy history and the medications included terbutaline inhaler ( 500mcg ) and budesonide inhaler ( 200mcg ) .
the patient is a non - smoker . clinical examination revealed a very large solid left tonsillar mass protruding at the level of the soft palate .
the lesion appeared as a white mass with overlying erythematous mucosa and a small ulcerated area superiorly in the left palatoglossal fold ( figure 1a & 1b ) .
computer tomography ( ct ) scan of the neck was performed to exclude any underlying parapharyngeal space mass .
ct scan reported the presence of a large lobulated , well - defined , calcified left tonsillar mass measuring 1.8 x 2.4 x 2.6 cm ( figure 2 ) .
computer tomography image of the left radiopaque tonsillolith and its relationship to the parapharyngeal space .
pathological analysis confirmed the presence of a chronically inflamed tonsil and a large tonsillolith ( figure 3 ) .
the earliest known recorded description of oropharyngeal concretions is 1560 ( 1 ) . small concretions are common however larger tonsilloliths relatively infrequent with a low incidence ( 4 ) . the age range has been documented from 20 to 68 years with no gender predilection ( 1,5 ) .
tonsilloliths act as localised concentration of bacteria , which calcify progressively from a soft gel to hard calculi .
they appear to have characteristics in common with biofilms ( 2 ) , which are colonies of bacteria enveloped by an extracellular matrix .
bacteria in biofilms are difficult to treat with antibiotic chemotherapy because they are localised and act as a nidus for acute infection ( 4 ) .
this is associated with a high recurrence rate and chronicity of otorhinolaryngology infections ( 6 ) .
thus as in this patient case report , tonsilloliths are associated with recurrent inflammation i.e. tonsillitis .
this explanation offers an alternate aetiopathogenesis to tonsillolith formation by salivary stasis in accessory salivary glands secondary to mechanical obstruction by post tonsillectomy scarring or chronic inflammation or lithogenic diathesis ( 5 ) .
tonsilloliths can be asymptomatic , even when large ( 1 ) , and can be found incidentally on dental or soft tissue radiography . however , if large they usually present symptomatically .
symptoms include dysphagia , recurrent sore throat , foreign body sensation , or referred otalgia .
halitosis is thought to be due to anaerobic bacterial metabolic release of sulphur containing compounds .
these radio - opaque masses need to be distinguished from other anatomical structures or pathological calcifications .
anatomical structures include a prominent pterygoid hamulus , large maxillary tuberosity , displaced third molar tooth or an elongated styloid process due to calcification of the stylohyoid ligament ( eagle s syndrome ) ( 3 ) .
pathological radio - opaque calcifications simulating tonsilloliths are of vasculature ( atherosclerosis or phleboliths ) , lymph node calcification , calcified peritonsillar abscess , salivary gland sialolith or an intraosseous abnormality within the mandibular ramus .
as in this case , computer tomography is the investigation of choice as it allows assessment of any anatomical aberration or to establish the location and extent of a pathological lesion , which in this case was the exclusion of any parapharyngeal masses .
small tonsilloliths within tonsillar crypts may require nothing more than patient reassurance and may be manually expressed from the tonsil crypt .
giant tonsilloliths as in this case report patient or large calculi associated with recurrent tonsillitis , or if there is a suspicion of malignancy , requires surgical excision and tonsillectomy .
 tonsilloliths are calcified concretions that originate within the palatal tonsil crypts . moreover , 
 development of these concretions into giant tonsilloliths is exceptionally uncommon . 
 we present a 17-year - old female with a two - year history of increasing dysphagia , persistent oral cavity swelling and speech alteration . 
 clinical examination of the oral cavity revealed a large solid left tonsil with no obvious neck masses . 
 computer tomography demonstrated a well - defined , large calcified left tonsillar fossa mass of uncertain underlying cause . 
 this patient subsequently underwent surgical excision for histology . 
INTRODUCTION
CASE REPORT
DISCUSSION