Development of tonsil stones during pregnancy

Introduction

The palatine tonsils are lymphoid tissue found bilaterally in the lateral oropharynx as part of Waldeyer's ring. They function as a first-line defense in the oral cavity against ingested or inhaled pathogens. ¹ The exterior surface of tonsils includes numerous small pockets called crypts, in which retained cellular debris, food, and bacterial growth may combine and calcify, forming tonsil stones. These white or yellow concretions, also known as tonsilloliths, are often asymptomatic but can be malodorous and cause halitosis, foreign body sensation, or throat irritation.^2,3 Ear pain, or otalgia, is an additional common presenting symptom as the tonsillar fossa is innervated by the glossopharyngeal nerve, and pain or pressure is often referred to the ipsilateral ear through a branch of the glossopharyngeal nerve known as the tympanic branch or Jacobson's nerve. ⁴ Diagnosis of tonsil stones is typically clinical, based on symptoms and direct visualization during the examination, although their radiopaque nature may also be seen on imaging. ⁵ Unfortunately, there is limited published data on patient demographics regarding tonsil stones, although they appear to be slightly more common in males and younger patients. ⁶ However, to our knowledge, no association between pregnancy and tonsil stones has been published in literature. As such, women and their providers in the past have turned to internet pregnancy forums and numerous complaints about these stones can be found online. ^{7 – 9} Here we present three such cases, pregnant women with new incidence or worsening of existing tonsil stones, in order to help obstetricians recognize and manage this condition.

Case 1

A 32-year-old female in her third pregnancy presented to an otolaryngology clinic during her second trimester with nausea and tonsil stones that started around the eighth week of pregnancy. She reported a foreign body and gagging sensation due to a visible tonsil stone, increased salivation, and mild referred right ear pain. She used saltwater gargles and attempted a water pick to remove the tonsil stone but was not successful. As nausea subsided, the foreign body sensation improved but the patient could still visualize two stones in the right tonsil. She denied dysphagia, voice changes, fever, or sore throat. The patient had never experienced tonsil stones prior to this episode, including during her previous pregnancies. She had a past history of strep tococcal throat infections but none recently. On physical exam, the tonsils were size 1+ bilaterally and symmetric (on a common tonsil grading scale from 0 to 4+, with 0 indicating absent tonsils and increasing incrementally to 4+ tonsils that touch in the midline). A small tonsil stone was present in the right tonsil. A tonsillectomy was not offered and her otolaryngologist recommended a trial of apple cider vinegar gargles twice per day for 3 months. She reported alleviated symptoms as the pregnancy progressed. The patient was induced at 36 weeks due to fetal hydrocephalus. Following the completion of her pregnancy, she has not experienced any recurrence of tonsil stones.

Case 2

A 23-year-old female in her first pregnancy presented to an otolaryngology clinic during her second trimester with ear pain. A focused otologic history was obtained and the patient revealed that she had experienced tonsil stones in the past but noticed an increased frequency during this pregnancy. In addition to the ear pain, she also experienced halitosis and throat pain. She denied dysphagia, voice changes, or fever. On physical exam, the tonsils were 1+ bilaterally and symmetric with a small tonsil stone present in the right tonsil. Surgery was not offered and her otolaryngologist recommended she utilize a home dental water pick device or water flosser to attempt to displace the stone, which she chose to forgo. A healthy baby was delivered at 40 weeks. Following the completion of her pregnancy in June 2022, the frequency of her tonsil stones has decreased back to pre-pregnancy levels.

Case 3

A 26-year-old female in her third pregnancy presented to an otolaryngology clinic during her second trimester with worsening tonsil stones. The patient has a 5-year history of persistently bothersome tonsil stones but the number of stones, size of stones, and pain associated with her stones increased during her pregnancy. She also noted halitosis but denied recurrent tonsillitis or ear pain. She had attempted to use Q-tips and a toothbrush to remove stones but was unable due to a strong gag reflex. On physical exam, tonsil size was noted to be 1+ bilaterally with tonsil stones present bilaterally. Medical and surgical management were discussed and future postpartum bilateral tonsillectomy was offered due to the severity of her symptoms. The patient opted to trial increasing hydration and starting a chlorhexidine antibacterial mouthwash. She did not notice a clinical improvement with this regimen. A healthy baby was delivered at 39 weeks. Following the completion of her pregnancy, her frequency and size of tonsil stones have improved back to her baseline. She is planning to have her tonsil surgically removed in the coming months.

Discussion and management

These three cases show various presentations of tonsil stones during pregnancy—primary incidence of tonsil stones during a woman's third pregnancy that resolved after delivery; worsening of existing tonsil stones during a woman's first pregnancy that improved after partum; and worsening of existing stones during a woman's third pregnancy that returned to baseline after the pregnancy. While these empirical observations cannot establish whether the pregnancy is a true inciting factor for tonsil stone formation, explanations for the correlation are reasonable. Studies have shown that oral bacteria may increase in number and unusual oral microorganisms maybe become more prominent during pregnancy.^10,11 Excessive saliva, also frequently associated with pregnancy, or ptyalism gravidarum, ^{12 – 14} could be an additional contributing factor to increased tonsil stone formation. Furthermore, increases in other calcified body calculi, such as renal calculi or kidney stones, have also been shown to increase during pregnancy. ¹⁵

For pregnant patients complaining of chronic throat pain, ear pain, halitosis, difficulty swallowing, cough, or feeling of something stuck in the throat, obstetricians should have a high level of suspicion for tonsil stones. A quick glance into the mouth with a penlight and a tongue depressor may reveal small white or yellow concretions within the tonsils that would confirm the diagnosis. Additionally, gently pressing on the palatine tonsils with a tongue depressor may express tonsil stones that are located deep within the crypts. With a confirmed diagnosis, obstetricians could recommend basic medical management. Various treatments have been suggested but no treatment has been shown to be highly effective for the elimination of tonsil stones. Typical first-line recommendations include improved oral hygiene, throat gargles (using salt water, antibiotic rinse, or apple cider vinegar), and manual removal with a water pick device. Although tonsil stones are often associated with biofilms, antibiotics are not effective in eliminating or reducing the frequency of stones and are thus not indicated in the absence of a clear bacterial tonsil infection. ¹⁶ The gold standard of treatment for tonsil stones is a tonsillectomy, although this is reserved as a final option for patients who have failed medical management. Other surgical options which have been explored include laser cryptolysis and radiofrequency ablation of the tonsillar crypts.^17,18 However, any form of surgical removal of the tonsils to address tonsil stones is not an urgent matter and should be delayed to the postpartum period in most cases. While no preventative strategies are known, proper oral hygiene is recommended. If at any point the patient notes worsening unilateral pain, weight loss or appetite changes, difficulty swallowing, asymmetrical growth of one tonsil, or desires further workup, an otolaryngology referral could be recommended by the obstetrician.

For the cases presented here, different treatments were recommended by three distinct academic otolaryngologists and included gargling apple cider vinegar or antimicrobial rinse, removal with a home water pick device, and increasing hydration. While the effectiveness of these treatments was unfortunately minimal, these three cases suggest that tonsil stones may resolve or improve following the completion of pregnancy. While the precise mechanism is unknown, the postpartum return to baseline levels of the aforementioned oral bacteria, salivary rates, or other hormonal changes likely drives this symptomatic improvement.

Future investigation should focus on establishing an incidence of tonsil stones during pregnancy across varying populations. Long-term follow-up including any recurrence in subsequent pregnancies would be beneficial. In addition, an in-depth focus on mechanisms of tonsil stone formation may reveal answers to why pregnant women may be at an increased risk of stone development.

Conclusion

While literature has yet to identify pregnancy as a risk factor for tonsil stone formation, three such cases are presented here. Obstetricians should be aware of common presenting symptoms, including throat pain or discomfort, otalgia, halitosis, dysphagia, cough, or globus sensation. Although there is limited evidence regarding an effective medical treatment for tonsil stones, treatment options the obstetrician could recommend include adequate hydration, improved oral hygiene, throat gargles, manual removal with a water pick device or cotton swab, or antibacterial mouthwashes. Surgical intervention to remove tonsils should be delayed until the postpartum period and is only used as a last resort. If the patient or provider desires further workup or assistance, an otolaryngology consultation would be recommended.