In Tonsils, a Problem the Size of a Pea
As a child, Meghan Swann had suffered several bouts of strep throat, and when she was a teenager, she thought she felt another one coming on. The main symptom was familiar — a dull sore-throat pain.
But this time something was different; there seemed to be a foreign object stuck in the back of her throat, something she couldn’t quite swallow. “So I pushed on my tonsil, and something popped out,” Ms. Swann said. The yellowish object was about the size of a piece of gravel and had the sulfurous odor of bad breath. “I thought it was a piece of food or something,” she said.
From then on, Ms. Swann, now 25 and living in the St. Louis area, engaged in a secret ritual: popping the mushrooming bits of debris out of her tonsils with a cotton swab whenever they got big enough to cause discomfort.
One day, she mentioned her problem to her mother — and was surprised at the knowing response. Those squishy little things were tonsil stones, her mother explained, and she sometimes got them too. This year, when Ms. Swann posted a blog entry about her stones, readers came out of the woodwork to tell her they also had the problem. “Wow,” she remembers thinking, “there’s a lot of people out there with this.”
Formally known as tonsilloliths, the stones consist of mucus, dead cells and other debris that collect in the deep pockets of the tonsils and gradually condense into small, light-colored globs. Bacteria feed on this accumulated matter, giving rise to the odor. Most commonly, the stones are no bigger than a pencil eraser, although doctors have reported individual cases of patients with stones more than an inch wide.
In recent years, tonsil stones have become a frequent topic of discussion on the Internet. Lively message-board threads on sites like wrongdiagnosis.com draw dozens of anonymous sufferers looking for advice, sympathy and possible remedies. “All these years I’ve suffered in silence,” one typical post reads. “Good to know I’m not some weirdo after all!”
Indeed, tonsil stones appear to be a widespread affliction. In a 2007 study, French researchers found that in a sample of 515 CT scans, 31 subjects — about 6 percent — showed evidence of calcified matter in their nasopharyngeal tonsils, better known as adenoids.
No comparable data is available for the United States, but Dr. Harold Katz, a dentist in Los Angeles and author of “The Bad Breath Bible,” says he suspects that a sizable percentage of Americans suffer from tonsilloliths.
“I travel around the country a lot,” he said, “and one of the No. 1 questions I get is, ‘What are those things growing in my tonsils?’ ”
Dr. Katz speculates that the stones are prevalent nowadays for a number of reasons. “As people get fewer and fewer tonsillectomies, the potential for tonsil stones grows,” he said. “Also, many prescription medications have dry mouth as a side effect, which causes anaerobic bacteria to go into overdrive.”
While tonsil stones are relatively common, they remain little understood among many ear, nose and throat specialists. Sufferers are used to hearing from doctors that there’s nothing wrong with them or that the particles trapped in their tonsils are simply the dregs of last night’s dinner.
“My daughter used to cough them up,” Dr. Katz said. “I went to U.C.L.A. to have it checked out, but no one ever told us what a tonsil stone was.” He took her to a friend who was an ear, nose and throat specialist and was told, “It’s just a piece of food.”
Perhaps because tonsil stones are not typically considered a pathological condition, few research reports have been published about them. Nevertheless, the stones can cause an array of uncomfortable side effects, including sore throat and ear pain, not to mention the maddening sensation of a foreign body in the throat. In a 2008 case report from India, doctors described removing a giant tonsillolith that was making it painful for a young patient to swallow.
Some research suggests that tonsilloliths also have the potential to take a toll on sufferers’ social lives. In a 2007 study at the State University of Campinas in Brazil, doctors found that tonsilloliths were present in 75 percent of tonsillitis patients who had bad breath and in only 6 percent with normal breath.
But Dr. Toshihiro Ansai, an associate professor at Kyushu Dental College in Japan who has studied the link between tonsil stones and bad breath, does not think all stone sufferers need to be concerned. “Most halitosis is caused by periodontal diseases and tongue coat,” he said. “Tonsillolith would be a minor cause.”
While having tonsils surgically removed is the only solution likely to banish tonsil stones for good, Dr. Lee A. Zimmer, an otolaryngologist at the University of Cincinnati, hesitates to recommend tonsillectomy to stone sufferers right off the bat. (In some patients, tonsil removal results in complications and excess bleeding.)
Instead, Dr. Zimmer offers an arsenal of less drastic remedies. “Gargle with a non-alcohol-based mouthwash, and use a Waterpik — literally blast the tonsils to see if you can force the stones out,” he said. “Try that for a month or so and see how it goes.”
Dr. Katz offers another alternative to surgery: oxygenating mouthwashes and sinus sprays he sells on his Web site, therabreath.com, which he claims neutralize the anaerobic bacteria responsible for stone formation.
For Ms. Swann, noninvasive remedies have not helped much. For the time being, she is continuing her tried-and-true maintenance routine of dislodging the stones as soon as they get big enough to annoy her.
“I don’t mess with them until I feel my tonsils starting to hurt,” she said, “and then I go to the bathroom for 10 or 15 minutes and push on my tonsils until they start popping out.”
She views her problem as manageable, but savors the thought of doing away with her tonsil-plumbing sessions forever. “I’m on the fence about surgery,” she said, “but maybe I should just pull the trigger and go for it.”
A version of this article appeared in print on September 1, 2009, on page D5 of the New York edition.