Large tonsillolith associated with the accessory duct of the ipsilateral submandibular gland: support for saliva stasis hypothesis

Abstract

Tonsillolith is a calcified mass in the tonsil and/or its surrounding tissue, which is considered to be caused by chronic tonsillitis. However, here we hypothesized that a tonsillolith can also be formed by chronic saliva stasis in the tonsillar tissue, without any signs of chronic inflammation. We present the case of a 32-year-old male patient with a large tonsillolith. We reviewed his medical files, pre-operative imaging and intraoperative findings. During a standard tonsillectomy, we encountered a large tonsillolith measuring 3.1 3 2.6 cm. Additionally, a careful dissection of the lower pole of the remaining tonsillar tissue revealed a large fistulous tract filled with saliva. Post-operative examination of the pre-operative CT scan found a hypodense fistulous tract extending from the lower tonsillar pole towards the left submandibular gland, measuring 36 mm in length, which was diagnosed as an accessory duct of the submandibular gland. To our knowledge, this is the first case of a large tonsillolith associated with the accessory duct of the ipsilateral major salivary gland. Furthermore, from the aetiopathological view, this finding supports the saliva stasis hypothesis for formation of the tonsillolith. However, larger studies, including a detailed radiological analysis as in our case, are needed to further investigate this possible aetiology of tonsilloliths.

Chronic sialadenitis with sialolithiasis associated with parapharyngeal fistula and tonsillolith

“…This process has not previously been attributed to inflammatory sialadenitis. Pirkl et al [14] recount the case of a symptomatic tonsillolith that required a tonsillectomy, during which a salivary “fistula” was identified as a discrete entity in the inferior pole of the tonsillar fossa. The authors posit that the fistula was in fact a large accessory SMG duct, a congenital phenomenon that is also uncommonly described in the literature, and that the tonsillolith was salivary in origin.…”