John is a 10 year-old patient of mine who was brought to the office for “possible strep throat”.

 

His mom said that she noticed that he had bad breath recently and when she asked him if he had a sore throat or felt warm, he said that he felt just fine, but did have a bit of a sore throat. She took his temperature and he did not have a fever but when she looked in his throat she was shocked to see that there were multiple white “pus pockets” that studded his tonsils. She was concerned because he had his second bout of strep throat about 2 months ago.

 

When I saw John, he did not have a fever, nor did he have the typical symptoms of strep throat such as fever, headache, or stomach ache.

 

If one has strep throat with a fever and a sandpapery red rash, this would be scarlet fever. On exam, his ears were clear, he did not have any swollen lymph nodes in his neck, his throat was not red or inflamed but his tonsils were truly studded with what looked like whitish/yellow stones that could be mistaken for pus pockets. I told mom that I thought these were tonsil stones and not indicative of an infection. To be on the safe side, I did a step test and it was negative. I then talked to John and his mom about tonsil stones.
 

Tonsil stones are common and are not dangerous or concerning.

 

The tonsils are round fleshy oval structures that sit in the back of the throat on the right and left side with the uvula in the middle. The tonsils are part of the lymphatic system that helps the body fight infection or disease that enter the body through our mouth or nose. They act like lymph nodes to filter germs or other pathogens. Some people have small tonsils that can barely be seen, and others may have large “golf-ball-like” tonsils. Large tonsils may have little pocketed dents that create crypts or crevices. When one chews their food before swallowing, some food particles can get trapped in these little pockets. The saliva which contains certain enzymes to break down the food, bathes the tonsils and the enzymes may blanche the food particles giving it a whitish appearance that can look like pus pockets. Some people with multiple tonsil stones have tonsils that appear to be studded with these tiny pebbles. The stones consist of food debris, hardened minerals such as calcium from food products and bacteria.

 

Tonsil stones are not dangerous or serious.

 

They may cause bad breath or in some cases may cause a sore throat, but they are not an infection. The bad breath is caused by the mouth bacteria that can get trapped in the cryptic tonsil along with old food particles. While this can possibly lead to a case of tonsillitis, it is not very likely. If one has a propensity to get tonsil stones, the best way to prevent them from occurring is to brush your teeth and floss regularly, gargle with warm salt water after eating and to keep well hydrated. Stones can be removed by gargling with warm salt water, vigorous coughing to dislodge the stone, the use of a dental water pic, or gently dislodging them with a Q-tip (never use anything that is sharp).
 

After discussing this with John and his mom, we elected to treat this conservatively and to use the preventive measures we discussed.

 

If it continued to be a problem with sore throat, ear pain or persistent halitosis (bad breath) then I would gladly refer him to an ear-nose and throat specialist for possible tonsillectomy, but I assured mom that in 40 years of private practice, I have never had to do this…John was pleased to hear this.