My daughter has very large tonsils with deep crevices. She has large numbers of small, hard lumps that she scrapes out. Her doctor said they were food particles that had gotten stuck. I find this hard to believe. Could there be other reasons for the lumps?
Alice Bradford – Carrollton, Texas
Dr. Greene’s Answer:
The tonsils are sentinels, standing guard at the back of the throat to protect the delicate tissues of our lungs and intestines from foreign invaders. They are part of a ring of defenders, Waldeyer’s Ring (which includes the tonsils, adenoids, and other lymphoid tissue), encircling the back of the throat as an important line of defense. The tonsils and adenoids are largest during childhood; they are front-line guardians while the body’s more sophisticated internal immune system learns and develops.
The situation you describe, Alice, is a very common one. The tonsils usually appear like small, dimpled golf balls set on either side of the back of the throat. Children with large tonsils and deep crypts often do get food particles trapped in there. Because saliva contains digestive enzymes, trapped food begins to break down. Particularly, the starch or carbohydrate part of the food melts away, leaving firmer, harder remains of food in the tonsils. This does not look like the food that went into the mouth.
As you suspect, however, there is more to these hard lumps than just food. The tonsils also trap other mouth debris such as bacteria and old cells from the surface of the mouth’s lining. Some of these cells contain small amounts of keratin, the same substance found in fingernails and rhinoceros horns. Whatever the nature of the debris, it is then attacked by white blood cells. The aftermath of this battle leaves the crevices of the tonsil strewn with hardened remains.
Most people swallow this material without ever noticing it, while it is still tiny. In those whose tonsils are large, however, the particles can lodge in the deep crypts, where they continue to grow. The enlarging lumps are called calculi of the tonsil, or tonsilloliths (tonsil stones). These stones are most common during adolescence.
Microscopic studies of these tonsilloliths have shown them to contain a combination of food particles, bacteria, oral debris, and white blood cells in a concentrically laminated pattern — rather like a pearl. Usually they are small gritty particles found in the center of soft, cheesy flecks. Sometimes, however, they become quite large, appearing as rough, yellow or gray, round stones. At times they reach an extraordinary size. Affected people usually have a history of repeated attacks of tonsillitis in earlier years.
Most people with calculi of the tonsils have no associated symptoms. In that case nothing need be done, except perhaps for brushing or scraping them out, as your daughter does. Gargling, refraining from eating during the 30 minutes before falling asleep, and careful oral hygiene may help minimize their formation.
For some people, however, the calculi can be quite bothersome, causing a constant foreign-body sensation, a chronic low-grade sore throat, recurrent episodes of tonsillitis persisting beyond childhood, or chronic bad breath.
Surgical treatment is almost never necessary for this condition, but when needed, treatment consists of either removing the tonsils or removing the calculi. Troublesome large calculi that are not easily dislodged may need an ear, nose, and throat doctor to remove them.
Not too long ago, tonsils were routinely removed for the sole crime of being swollen and inflamed. We didn’t understand, then, that the tonsils purposely accept the infections to prevent the organisms from traveling deeper, and to show the invaders to the developing immune system to train it for the future. The tonsils are selfless protectors. As a child becomes an adult, the tonsils usually begin to shrink; the watchful guardians of childhood are no longer much-needed.
Tonsils are a bit like parents: looming large early in life, diminishing over time, ever-protecting, ever-teaching, but sometimes with rough or hard spots when we let things build up ;^)
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