"I have a throat infection," announced the patient when asked the reason for her visit, through the interpreter.
I couldn't elicit much on history: no pain, no fever, no cough. Her only complaint was recurrent "white stuff" in her throat for months.
Strep throat? Thrush?
She sat on the exam table and I shone a light onto her pink, uninflamed, exudate-free pharynx. The rest of the exam was similarly unremarkable.
"Do you ever spit out pieces of the white stuff?" I asked. "And is it particularly foul-smelling?"
Yet another diagnosis of tonsilloliths, more aptly christened 'throat poo' by one of my friends. I refrained from sharing that phrase with the patient, being quite certain that something would be lost in translation and the patient would be very, very alarmed. Instead, I gave my tonsillolith spiel.
Tonsilloliths, also called tonsil stones or calculi, are white or yellow foul-smelling concretions that form in the tonsillar crypts, the deep crevices in the tonsils. They consist of a calcified accumulation of food matter, bacteria and white blood cells. The stones gradually increase in size until they are expelled from the tonsil, at which point they are swallowed or spit out.
* Not my photo or tonsilloliths. Image from Answers.com
Tonsilloliths are typically smaller than a pea, although there are case reports of calculi reaching several centimetres in diameter.
The stones are usually asymptomatic, but may cause sore throat, a chronic cough, a foreign body sensation in the pharynx or bad breath.
I can tell you from my work at the refugee clinic that tonsillolithiasis is a global problem.
If you are unwilling to wait for the stone to fly its tonsillar nest, some removal methods I've heard from patients include sucking it out with a medicine dropper, milking it out with a q-tip or directing a stream of water at it.
(Disclaimer: This does not constitute medical advice. I do not advocate any of the above methods, which can result in tonsillar injury or infection. Present your pharynx to your own physician and get her opinion.)
A physician may remove a tonsillolith by curettage, or by excision it if it is extraordinarily large. Rarely, a tonsillectomy may be performed.
I confess I suffer from this affliction. I suffered in shame until a friend raised the issue one evening at a party and it turned out roughly half the attendees had the same condition. I can't find any statistics on the incidence of throat poo, but anecdotally I'm going to put it at 35%.
Maybe we can hold an informal poll in the comments. Are you a tonsillolith former, or not? I won't blame you if you comment anonymously.