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Giant tonsillolith causing odynophagia in a child: a rare case report
Jagdeep S Thakur*1, Ravinder S Minhas1, Anamika Thakur2, Dev R Sharma1
and Narinder K Mohindroo1
Address: 1Department of Otolaryngology-Head Neck Surgery, I. G. Medical College, Shimla, HP, 171001, India and 2Dept of Pharmacology, I G
Medical College, Shimla, HP, 171001, India
Email: Jagdeep S Thakur* - email@example.com; Ravinder S Minhas - firstname.lastname@example.org;
Anamika Thakur - email@example.com; Dev R Sharma - firstname.lastname@example.org; Narinder K Mohindroo - email@example.com
* Corresponding author
Giant tonsillolith is a rare clinical entity. Commonly, it occurs between 20–77 years of age. We had
a twelve years old female patient, who had odynophagia due to a giant tonsillolith. The stone was
removed and tonsillectomy was performed. We reviewed the literature on this rare clinical entity
and found that this is the fourth case of giant tonsillolith in a child and largest ever tonsillolith to
be reported in English literature.
Giant tonsillolith is a rare entity  although small con-
cretions in the palatine tonsil are a common clinical find-
ing in adults . These patients usually present with bad
breath odor, pain during swallowing or foreign body sen-
sation in the throat. In English literature, there are many
reports on tonsillolith in adults but we found ('Medline'
and 'Scopus' search) only three reports on tonsillolith in
children [3-5]. We report a case of giant tonsillolith and
review the literature on this rare clinical finding.
A 12 years female child presented with pain during swal-
lowing for last one year. The pain was mild-moderate and
non-radiating. Patient had recurrent episodes of sore
throat for last six years and used to recover after medica-
tion. There were no other associated symptoms. The med-
ical and family histories were insignificant.
On examination, both tonsils were enlarged but with
massive enlargement of left tonsil. There were no other
significant findings on examination of oral cavity,
oropharynx or larynx. The provisional diagnosis of recur-
rent tonsillitis was made and patient was advised tonsil-
lectomy under general anesthesia.
After three weeks at the time of admission, patient had
large chalky white patch on the left tonsil which was hard
and could not be removed (Fig 1). The tonsil was tender
on touch. Patient underwent radiological examination
and X-ray and CT scan (Fig 2) showed large 3.9 × 3.4 cm
radio opaque shadow in left tonsillar area. This mass had
no relation to styloid process or any bone. The provisional
diagnosis of giant tonsillolith was made and surgical
removal of stone with tonsillectomy was done under gen-
eral anesthesia. The stone (Fig 3) was hard, yellowish-
white with 4.2 × 3.6 × 2.1 cm in size and was made of cal-
cium carbonate and oxalate. Postoperative period was
uneventful and patient recovered well. Patient had com-
plete relief in odynophagia with follow up lasting for one
Published: 18 July 2008
Cases Journal 2008, 1:50doi:10.1186/1757-1626-1-50
Received: 8 July 2008
Accepted: 18 July 2008
This article is available from: http://www.casesjournal.com/content/1/1/50
© 2008 Thakur et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Cases Journal 2008, 1:50http://www.casesjournal.com/content/1/1/50
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The tonsilloliths are white or yellow colored stones com-
posed of calcium salts such as hydroxyapatite or calcium
carbonate apatite, oxalates and other magnesium salts or
containing ammonium radicals . The exact pathogene-
sis of these stones is unknown although there are many
hypotheses on the formation of these calculi. It has been
stated that they originate as a result repeated tonsillitis
which lead to fibrosis of ducts of crypts and retention of
epithelial debris thereof. This epithelial debris forms the
ideal media for the growth of bacterial, actinomyces 
and fungi such as Leptothrix buccalis . Finally dystrophic
calcification occurs as a result of deposition of above
stated inorganic salts from the saliva secreted in the
mouth by major and minor salivary glands.
Calculi have been reported in the peritonsillar region 
and lateral pharyngeal wall ; and were explained by
calcification of peritonsillar abscess, presence of ectopic
tonsillar tissue and calcification of saliva in blocked secre-
tory ducts of minor salivary glands [11,12].
We did 'Medline' and 'Scopus' search with keywords:
'Tonsillectomy'; Tonsillolith'; 'Child'; 'Pediatrics' and
found only three reports [3-5] on tonsillolith in pediatric
age group. Tonsilloliths are rare in pediatric age group as
they occur between 20 and 77 years of age [10,13-15]. The
stone may be asymptomatic or can cause variety of symp-
toms i.e. bad breath odor, foreign body sensation in
throat, odynophagia or dysphagia. These stones are usu-
ally found in X-ray or CT scan done for other reason .
X ray shows single or multiple radio opaque shadows
which can be mistaken for foreign body, calcified lymph
node, unerupted tooth, calcified stylohyoid ligament or
prominent tuber of maxilla or elongated styloid process
. Computed tomography (CT) is found to diagnostic
by obtaining multiple axial sections . We also found
the stone by chance as calculus was extruding out from
tonsil and it was only CT scan which confirmed the diag-
It has been advocated to remove the stone surgically or
perform tonsillectomy if stone is large or impacted within
Photograph of removed stone
Photograph of removed stone.
CT scan showing stone in oral cavity
CT scan showing stone in oral cavity.
Large stone visible on intra oral examination
Large stone visible on intra oral examination.
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Cases Journal 2008, 1:50 http://www.casesjournal.com/content/1/1/50
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tonsil . In our case although stone was quite large and
was removed as whole but tonsillectomy was also per-
formed as tonsils were hypertrophied.
In this case study and review of literature we concluded
1. The hypothesis of recurrent tonsillitis leading to fibrosis
of ducts and formation of tonsillolith appeared to be rea-
son for the tonsillolith in our case as patient had recurrent
tonsillitis for last six years.
2. All the pediatric or adult patients presenting with for-
eign body sensation in throat, dysphagia or odynophagia
should have thorough tonsillar examination including
digital palpation to rule out any concretion or stone in
tonsil as a cause of above mentioned symptoms and CT
scan should be done to confirm this rare diagnosis.
The written informed consent of the guardian of the
patient has been obtained for the publication of this case
report and accompanied images.
The authors declare that they have no competing interest.
JST has designed and written the article and is the princi-
pal contributor, RSM was involved with the management
of the patient, conception, design and review of the arti-
cle, AT was involved in acquisition of the data, review of
the literature and critical review of the article, DRS was
involved in the management of the patient, conception
and critical review of the article, NKM was also involved
in the management of the patient, conception and critical
review of the article. All the authors have read and given
final approval for this article.
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