Transoral Sonographic Diagnosis ofTonsillolithsReport of 3 Cases

onsilloliths have been diagnosed from simple inspection,panoramic or lateral pharyngeal radiography, computedtomography (CT), and magnetic resonance imaging

(MRI).1 Superimposed hard and soft tissue structures on radi-ographs are common in this anatomic region and create challengesin interpretation. A prominent hamulus and elongated styloidprocess, calcification of the stylohyoid ligament, and unusual promi-nence of the maxillary tuberosity and mandibular ramus may sim-ulate tonsillar calculi.1 This difficulty may be overcome by the use ofCT or MRI; however, CT has potential side effects such as radiationexposure, and MRI is expensive. Office-based head-and-neck sonog-raphy allows for an effective physical examination that improvesdiagnostic accuracy and often removes the need for additional tests,studies, and procedures that are often more invasive or expensive.2We diagnosed 3 cases of previously undiagnosed tonsilloliths byconventional methods with the use of an intraoral transducer(Figure 1; 3–12 MHz, linear array, 18-mm footprint; Alpinion,Seoul, Korea) designed for transoral sonography. Transoral sonog-raphy can be performed in an office-based setting without additionalpreparation such as local anesthesia (except for patients who havea moderate gag reflex symptom). To the best of our knowledge, theuse of transoral sonography for imaging tonsilloliths has not beenreported previously in the literature.

Woojin Cho, MD, Hachoon Park, MD

Received March 18, 2013, from the Thyroid,Head, and Neck Ultrasound Center, Dain Ear-Nose-Throat Hospital, Incheon, Korea. Revisionrequested April 3, 2013. Revised manuscriptaccepted for publication April 6, 2013.

Address correspondence to Woojin Cho,MD, Withsim Clinic, 203-2 Sienne Building,88 Seohyeon-dong, Bundang-gu, Seongnam-si,Gyeonggi-do 463-821, Korea.

E-mail : withdrcho@gmail.com

AbbreviationsCT, computed tomography; MRI, magneticresonance imaging

T

©2013 by the American Institute of Ultrasound in Medicine | J Ultrasound Med 2013; 32:2037–2042 | 0278-4297 | www.aium.org

CASE SERIES

doi:10.7863/ultra.32.11.2037

Tonsilloliths are calcified concretions that develop in tonsillar crypts. They areusually asymptomatic; however, they may cause problems such as halitosis, dys-phagia, a globus sensation, and otalgia. Tonsilloliths may be diagnosed by a sim-ple inspection or palpation of tonsillar crypts, which can be confirmed bypanoramic radiography, computed tomography, or magnetic resonance imag-ing. We report 3 cases of tonsilloliths diagnosed by transoral sonography thatwas performed easily and comfortably in an office-based setting.Key Words—diagnosis; sonography; tonsillolith

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Case Descriptions

Case 1A 32-year-old male patient presented to our institutionwith a several-year history of a sore throat and right-sideotalgia that was aggravated by opening his mouth or yawn-ing. He was examined at another general hospital, whichfailed to diagnose the cause of the pain; subsequently, hewas referred to our institution for further evaluation andtreatment. A clinical intraoral examination (includinginspection and palpation) did not show any abnormalfindings other than palatine tonsillar hypertrophy (Fig-ure 2A). Direct laryngoscopic findings were normal. Plainlateral neck radiography and CT of the neck did notreveal the presence of a mass or lesion in the pharynx orlarynx, such as Eagle syndrome (Figure 2B). Transoralsonography with the intraoral transducer revealed a 0.5-cm hyper echoic calcified ovoid lesion, which did notshow posterior acoustic shadowing in the left tonsillar

parenchyma (Figure 2C). A tonsillectomy was performedunder general anesthesia. The specimens were removedfrom both tonsillar fossae, and then a meticulous exami-nation with micro forceps revealed soft and yellowish whitemultiple tonsilloliths in the right tonsillar crypt (Figure2D). Postoperative recovery was uneventful, and thesymptoms subsided.

Case 2A 17-year-old female patient came to our institution witha several-year history of tiny yellowish material in herthroat. She had a foreign body sensation and halitosis. An oral examination showed no dental caries, and her peri-odontal tissue condition was good. The bilateral palatinetonsils were hypertrophied with multiple large crypts; how-ever, direct laryngoscopy did not reveal tonsilloliths in thetonsillar crypts (Figure 3A). On her first visit to the outpa-tient clinic, transoral sonography was performed with theintraoral transducer, which revealed multiple hypere-choic foci in the parenchyma of both tonsils (Figure 3B).Both tonsils were removed under general anesthesia.The specimen had tonsilloliths in multiple crypts (Figure3C). The patient recovered without complications and hadno complaints on subsequent follow-ups.

Cho and Park—Transoral Sonography of Tonsilloliths

J Ultrasound Med 2013; 32:2037–20422038

Figure 1. Transoral use of the intraoral transducer. A, Hand grip appear-

ance. B, Transoral sonography in an office-based setting. C, Transoral

scanning of the right tonsil.

A

B C

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Case 3A 22-year-old male patient presented with periodicthroat discomfort on his left side. His medical history wasuneventful except for having received intermittent anal-gesics such as nonsteroidal anti-inflammatory drugs. Sys-temic examination findings were normal. An intraoralexamination including palpation and direct laryngoscopydid not reveal any lesions such as masses or inflammation

(Figure 4A). Plain lateral neck radiography showed nor-mal findings. Transoral sonography revealed a 0.3-cmhyperechoic lesion in the left tonsillar parenchyma (Fig-ure 4B). A tonsillectomy was performed under generalanesthesia. The lesion found on sonography was con-firmed as a tonsillolith (Figure 4C). There were no com-plications in the postoperative period, and the patient hadno complaints on subsequent follow-ups.

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Cho and Park—Transoral Sonography of Tonsilloliths

Figure 2. Images from a 32-year-old male patient with right-side otalgia.

A, Oral examination showing bilateral hypertrophied tonsils with redun-

dant peritonsillar mucosa. B, Axial CT scan showing no abnormal find-

ings in the right tonsillar parenchyma (arrowhead). C, Transoral

sonogram showing a 0.5-cm hyperechoic calcified ovoid lesion (arrow)

in the right tonsillar parenchyma. D, Soft and yellowish white multiple

tonsilloliths in the right tonsillar crypt.

A

B

C

D

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Discussion

The earliest known description of concretions in theoropharynx is thought to have been recorded in 1560.3The exact etiology and pathogenesis are unknown.4 Thecalcifications develop within a mass of desquamated epithe-lium, serum, food debris, and bacterial colonies. Recurrenttonsillar inflammation may promote the development of ton-s illar concretions.5 Consequently, they occur most com-monly in young adults with long histories of recurrent sorethroats.3 They occur twice as often in male than in femalepatients and predominantly affect the right tonsil.6

Many patients have small and noncalcified tonsil-loliths. Tonsilloliths may be diagnosed by simple inspec-tion of both tonsillar crypts and can be confirmed bypanoramic radiography or CT without contrast.7

Small and noncalcified tonsilloliths located in embedded

tonsillar crypts are difficult to diagnosis by conventionalmethods. Most cases reported in the literature wererelated to symptomatic patients with large or moderatelycalcified tonsilloliths diagnosed by radiography or CT;however, tonsilloliths seldom occur as radiopaque objectson panoramic radiographs.8

Applications of sonography in the oral cavity ororopharynx have been performed with existing transducers(transvaginal and hockey stick types); however, they havesome limitations, such as handling, patient discomfort, andlow image quality. The new type of intraoral transducerdesigned for transoral sonography enabled us to overcomethe previous limitations. Transoral sonography can be per-formed in an office-based setting when a visual inspectionfails to locate tonsilloliths in a suspected patient. Noncal-cified tonsilloliths can be diagnosed with transoral sonog-raphy, which enables a physician to explain the status of a

Cho and Park—Transoral Sonography of Tonsilloliths

J Ultrasound Med 2013; 32:2037–20422040

A

B

C

Figure 3. Images from a 17-year-old female patient with a several-year

history of tiny yellowish material from the throat. A, Oral examination

showing hypertrophied tonsils with multiple large crypts but no visible

tonsilloliths. B, Transoral sonogram showing multiple hyperechoic foci

(arrows) in the parenchyma of both tonsils. C, Specimen after tonsillec-

tomy showing tonsilloliths in multiple crypts.

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patient with a real-time image. Unlike radiography and CT,transoral sonography has no risk of exposure to radiation.In the diagnosis of calcified tonsilloliths with radiographyor CT, it is sometimes difficult to determine whether thelesions are within the tonsil or the surrounding anatomicstructures of the pharyngeal region, such as a prominenthamulus of the pterygoid, an elongated styloid process, ora large maxillary tuberosity, or pathologic calcifications ofarteries, lymph nodes, and salivary glands.9 Transoralsonography can display the tonsil itself and enable theexaminer to distinguish a lesion from the peritonsillarstructures; in addition, its manipulation is similar to anendoscopic examination performed by ear, nose, andthroat physicians. The 3 cases described above indicatethat it could even detect lesions of deep crypts in the ton-sillar parenchyma and embedded tonsils with redundantsurrounding mucosa.

Small and asymptomatic tonsilloliths require no treat-ment.7 However, the above cases show that even small ton-silloliths create problems that can be treated after a properdiagnosis. In this situation, transoral sonography might beone diagnostic option. Transoral sonography can detecttonsilloliths that are not diagnosed by visual inspection andconventional radiologic methods.

In conclusion, transoral sonography using an intraoraltransducer can be easily performed in outpatient clinics.Physicians can detect small or invisible lesions that are oth-erwise difficult to diagnose by a physical examination orconventional radiologic methods. In the diagnosis of ton-silloliths, transoral sonography represents a new diagnos-tic option that should be further evaluated in clinicalstudies.

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Cho and Park—Transoral Sonography of Tonsilloliths

A

B

C

Figure 4. Images from a 22-year-old male patient with periodic throat

discomfort on the left side. A, Oral examination showing no specific find-

ings. B, Transoral sonogram showing a 0.3-cm hyperechoic lesion

(arrow) in the left tonsillar parenchyma. C, Meticulous examination of

the specimen after tonsillectomy showing tonsilloliths in the left tonsil.

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References

1. Sezer B, Tugsel Z, Bilgen C. An usual tonsillolith. Oral Surg Oral Med OralPathol Oral Radiol Endod 2003; 95:471–473.

2. Sniezek JC, Sofferman RA. Preface: head and neck ultrasound. OtolaryngolClin North Am 2010; 43:ix–x.

3. Cooper MM, Steinberg JJ, Lastra M, Antopol S. Tonsillar calculi: reportof a case and review of the literature. Oral Surg Oral Med Oral Pathol 1983;55:239–243.

4. Hadi UM, Samara MS. Giant tonsillolith. Ear Nose Throat J 1985;64:507–508.

5. Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and MaxillofacialPathology. Philadelphia, PA: WB Saunders Co; 2002.

6. Ram S, Siar CH, Ismail SM, Prepageran N. Pseudo bilateral tonsilloliths:a case report and review of the literature. Oral Surg Oral Med Oral PatholOral Radiol Endod 2004; 98:110–114.

7. de Moura MD, Madureira DF, Noman-Ferreira LC, Abdo EN, de AguiarEG, Freire AR. Tonsillolith: a report of three clinical cases. Med Oral PatolOral Cir Bucal 2007; 12:e130–e133.

8. Neshat K, Penna KJ, Shah D. Tonsillolith: a case report. J Oral MaxillofacSurg 2001; 59:692–693.

9. Revel MP, Beley N, Laccourreye O, Naudo P, Hartl D, Brasnu D. Gianttonsillolith. Ann Otol Rhinol Laryngol 1998; 107:262–263.

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