Tonsilloliths a common finding in pediatric patients

Halitosis and the Tonsils

Objective

Halitosis secondary to pathology of the palatine tonsils is considered airway (type 2) halitosis in the etiologic classification. Reports differ as to the proportion of objective halitosis complaints that have tonsillar etiology, with some giving this figure as 3%. Due to their immunologic role, even healthy tonsils usually possess some subclinical inflammation. The tonsil crypt system is also the most ideal environment for anaerobic bacterial activity in the upper respiratory tract. Tonsillar halitosis is thought to occur mainly because of chronic caseous tonsillitis and tonsillolithiasis (tonsil stones). Tonsillectomy and various cryptolysis techniques are reported to improve halitosis in such cases. In this article, diagnostic methods and evidence for interventions are reviewed.

Data Source

Medline search.

Review Methods

Studies reporting the efficacy of any intervention (medical or surgical) on tonsillar halitosis were included, whether halitosis was the focus or one of several measures.

Conclusions

There are insufficient high-quality studies on this topic. Improved methodology, for example, use of control groups and utilization of more accurate halitosis detection/quantification techniques, are required.

Implications for Practice

Lack of evidence currently prevents firm conclusions, but the following is recommended: (1) Use reliable methods for halitosis diagnosis and confirmation of tonsillar etiology. Initial treatment such as tongue scraping is useful to rule out oral halitosis. (2) Tonsillar procedures are contraindicated in: subjective halitosis, non-tonsillar etiology, or if medical management resolves halitosis. (3) Where indicated and where facilities permit, less invasive techniques such as laser cryptolysis may be preferable to tonsillectomy in adults, potentially avoiding general anesthetic and the higher risk associated with tonsillectomy in this group.

Halitosis: could it be more than mere bad breath?

Halitosis is a generic term used to describe unpleasant odor emanating from the mouth air and breath, independent of the source where the odor substances originate. It affects between 50 and 65% of the population, but despite its frequency, this problem is often unaccepted and declared as taboo. Ninety percent of patients suffering from halitosis have oral causes: a small, but important percentage, of oral malodor cases have an extra-oral etiology, very often falling into the category of "blood-borne halitosis". Several systemic diseases have been found to provoke malodor or to be a cofactor; bad breath may be an early sign of a serious local or systemic condition. A psychogenic halitosis also exists including the variant "pseudo-halitosis", when the oral malodor does not exist, but the patient believes he or she is suffering severely from it, and the halitophobia, when, instead, there is an exaggerated fear of having halitosis. The aims of this paper are to review both oral and extra-oral causes of halitosis, especially those related to underlying systemic diseases, and to provide the primary care clinician a helpful means for its diagnosis and management. In fact, it is important to determine quickly whether the odor comes from an oral cause or not: if so, it requires referral to a dentist; if not (extra-oral origin alone or combined), its management requires the treatment of the underlying causes. Extra-oral disorders can be the cause in up to 15% of cases.

Tonsillolith: not just a stone but a living biofilm

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.