Dentomaxillofacial Radiology (2015) 44, 20150090

ª 2015 The Authors. Published by the British Institute of Radiology

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CASE REPORT
Large tonsillolith associated with the accessory duct of the
ipsilateral submandibular gland: support for saliva
stasis hypothesis
1
I Pirkl, 1B Filipović, 2T Goranović and 1B Šimunjak
1
Department of Otorhinolaryngology—Head and Neck Surgery, University Hospital “Sveti Duh”, Zagreb, Croatia; 2Department
of Anesthesiology and Intensive Care Medicine, University Hospital “Sveti Duh”, Zagreb, Croatia

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.
Dentomaxillofacial Radiology (2015) 44, 20150090. doi: 10.1259/dmfr.20150090

Cite this article as: Pirkl I, Filipović B, Goranović T, Šimunjak B. Large tonsillolith associated
with the accessory duct of the ipsilateral submandibular gland: support for saliva stasis hy-
pothesis. Dentomaxillofac Radiol 2015; 44: 20150090.

Keywords: palatine tonsil; salivary duct; saliva

Introduction

Tonsilloliths or tonsil stones are singular or multiple
calculi found in tonsillar crypts that are located unilat-
erally or bilaterally. A review report determined the
exact location of the tonsillolith, showing that in 69.7%
of cases they are located in the tonsillar tissue, 21.2% in
the tonsillar fossa and 9% in the soft palate.1 Tonsillo-
lith prevalence in population ranging from 10 to 77
years is up to 16%.2 Stones are composed of calcium
salts such as hydroxyapatite or calcium carbonate ap-
atite, oxalates and other magnesium salts.3 They can
vary in size, measuring from microscopic to a few
Correspondence to: Dr Boris Filipović. E-mail: boris.filipovic@hotmail.com
Received 16 March 2015; revised 7 May 2015; accepted 19 May 2015
centimetres in diameter.4 A histological study of excised
tonsils found microscopic size in 8% of specimens, while
intermediate size (up to 7 mm) was found in 2%.4 Small
tonsilloliths are usually asymptomatic and have small
clinical importance. Large tonsilloliths are extremely
rare, measuring several centimetres in diameter.3,5,6
They result in clinical symptoms such as dysphagia,
otalgia, chronic halitosis and foreign body sensations.7,8
Differential diagnosis of the large tonsillolith includes
phleboliths, lymph node calcifications, tuberculosis and
other chronic granulomatous diseases, elongated styloid
process, prominent hamular process, foreign bodies,
displaced tooth, peritonsillar abscess and neoplasm.1
Today, a detailed clinical ear, nose and throat (ENT)
 Tonsillolith and accessory duct of the salivary gland
2 of 4 I Pirkl et al

examination and a CT scan are sufficient for a proper
diagnosis. Treatment is linked to the size and clinical
symptoms and usually involves removal of the stone by
curettage or tonsillectomy under general anaesthesia.7
A large majority of published articles regarding tonsil-
loliths are focused on size of the particular stone, but
only a few discuss the pathogenesis of stone formation.
Most authors believe that chronic tonsillitis is a suffi-
cient factor for localized salt precipitation and forma-
tion of a tonsillolith.3,5,7 However, some authors
alternatively suggest that the tonsilloliths form as a re-
sult of saliva stasis in the efferent ducts of the small
accessory salivary glands located in the oral cavity.9
Up to now, we have found only a few reports refer-
encing an accessory duct of the submandibular
gland.10–13 This anomaly is defined as a duplication of
the main Wharton’s duct and usually running parallel to
it. Its opening can be at the orifice of the gland together
with the main duct or separate in the floor of the oral
cavity.13
tract is an accessory duct of the submandibular gland
and therefore inspected the sublingual region and pro-
bed the left orifice of Wharton’s duct. As they appeared
normal, we placed a suture around the duct at the lower
pole of the tonsil bed. We found no abnormal adhesions
between the tonsillar capsule and the superior con-
strictor muscle. The rest of the surgery and post-
operative period were uneventful, and the patient
recovered well. There was no post-operative swelling in
the left submandibular region. The stone was hard,
yellowish-white, measuring 3.1 3 2.6 cm, the weight was
6.99 g (Figure 3).
Additionally, a detailed analysis of the pre-operative
CT scan showed a well-defined, hypodense fistulous
tract measuring 6 mm in width and 36 mm in length,
extending from the lower tonsillar pole towards the left
submandibular gland (Figure 4). It was then diagnosed
as an accessory duct of the submandibular gland
extending to the tonsil associated with a large
tonsillolith.

Case report Discussion

A 32-year-old male patient was referred to our ENT Up to now, case reports with large giant tonsilloliths
department by his general practitioner under suspicion were mainly focused on the particular size of the stones,
of left peritonsillar abscess. His main symptoms were localization and clinical presentation.3,5,6 However,
slight dysphagia and foreign body sensation, which aetiopathogenesis of tonsilloliths is still unknown. Most
lasted for 1 year. He had no medical history of chronic authors believe tonsilloliths are formed in cases of
tonsillitis, peritonsillar abscess or any other diseases. chronic tonsillitis; as a result of organic debris, epithelial
ENT examination revealed an intraoral, submucosal, tissue and dead bacteria collections in tonsillar crypts
hard and well-delineated mass protruding from the soft which are a nidus for salt precipitation from the saliva
palate and tonsillar fossa of the left side, measuring secreted in the mouth by major and minor salivary
30 3 20 mm. Overlying mucosa was slightly erythema-
tous but with neither oedema nor displacement of the
uvula. There was no sign of trismus. The rest of the
head and neck examination findings were within normal
limits with no palpable neck lymphadenopathy. Labo-
ratory blood test parameters were normal. CT of the
head and neck showed a large hyperdense oval mass in
the left tonsillar fossa between the palatoglossus and
palatopharyngeus muscles, measuring approximately
30 3 20 mm (Figure 1). In order to exclude a possible
lithiasis in other regions of the body, we performed
ultrasounds of salivary glands, kidney and gallbladder,
and results were within normal values. The diagnosis of
a large left tonsillolith was made and, owing to the size
of the stone, we decided to perform a left tonsillectomy
under general anaesthesia. During surgery, upon ma-
nipulating to release the upper pole, we noticed a flow
of blocked saliva around the stone. Progressing from
the upper to the lower pole of the tonsillar bed, at the
level of lower pole, we opened a fistulous tract filled
with saliva. It was approximately 5 mm in width and 30
mm long (Figure 2), running from the lower pole of the
left tonsil, medial to the mandibular bone and towards
the left submandibular gland. The lumen of the fistula
was wide enough to accommodate the endoscope Figure 1 Coronal CT scan showing hyperdense mass (T) in the left
(Supplementary Video 1). We suspected that this fistula peritonsillar region. It measures approximately 30 3 20 mm (D1 3 D2).

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 Tonsillolith and accessory duct of the salivary gland
I Pirkl et al 3 of 4

abscess or tonsillectomy. Laboratory findings were all

in normal range. Lithogenic diathesis was excluded
based on normal ultrasound findings of the salivary
gland, kidneys and gallbladder. During the standard
tonsillectomy surgery and removal of the stone, we
found a flow of blocked saliva and, more surprisingly,
a large accessory salivary duct (Figure 2). Although we
performed the routine pre-operative CT scans, no ac-
cessory duct or fistula formation was reported by the
radiologist. However, after the surgery and intra-
operative visualization of the duct, we collaborated with
radiologists and analysed the pre-operative CT scan in
detail. We found a well-defined, hypodense fistulous
tract measuring 6 mm in width and 36 mm in length,
extending from the lower tonsillar pole towards the left
submandibular gland. This was defined as a large ac-
cessory duct of the left submandibular gland with a di-
rect opening at the lower level of the tonsillar pole
(Figure 4). The inability to diagnose this pre-operatively
can be attributed to the fact that a similar case did not
present itself before, and therefore its possibility was not
Figure 2 Intraoperative intraoral picture showing the opening of the
accessory salivary duct (SD) of the left submandibular gland at the
taken into account. Furthermore, there was a possibility
level of the lower tonsillar pole and tonsillolith (T) in the left tonsil. that the duct observed intraoperatively was not the ac-
cessory but rather the main duct of the submandibular
gland, in which case a submandibulectomy would have
glands.1,4,6 The second theory similarly explains the to be performed. Intraoperative probing of the left or-
mechanism by which these stones are formed by cal- ifice of the submandibular gland was normal, so we
cification of peritonsillar abscess.3,5 However, a dif- decided to leave the submandibular gland intact and
ferent theory was presented by Mishenkin and Shtil9 closely monitor the patient in the post-operative period
hypothesizing that tonsilloliths are a part of the pa- for signs of possible submandibular swelling and/or
thology of salivary glands. They performed a histo-
logical examination of the adjacent tissue of
a tonsillolith and found small salivary gland lobuli
with efferent ducts surrounded by lymphoid tissue.
Their conclusion was that stone formation results
from stasis of saliva in the efferent ducts of the small
accessory salivary glands in the oral cavity, owing to
their mechanical obstruction caused by post-
tonsillectomy scar or chronic inflammation. In our
case, a tonsillolith was formed only by the saliva from
the accessory duct of the large salivary gland. In-
flammation was excluded as an aetiological factor as
the patient was without any inflammation of the
tonsils. This finding put emphasis on saliva stasis and
accessory ducts of salivary glands as a possible cause
of tonsillolith as hypothesized by Mishenkin and
Shtil.9 It is important to note that probably, in most
cases, the minor salivary glands are the aetiological
cause of a tonsillolith and not the major glands, which
can be diagnosed with a comprehensive radiological
assessment (CT, MRI).
The accessory duct of the submandibular gland was
reported in only a few cases up to now.10–13 This anom-
aly was described in most cases as a duplication of the
main Wharton’s duct, with the uniform opening at the
orifice or as a separate opening in the oral cavity.13
Gaur et al11 even reported three ducts with each open-
ing separately at the floor of the mouth. Our patient had Figure 3 A calcified mass (tonsillolith) is removed after tonsillec-
no medical history of chronic tonsillitis, peritonsillar tomy, measuring 31 mm in length.

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 Tonsillolith and accessory duct of the salivary gland
4 of 4 I Pirkl et al
Figure 4 (a) Axial CT scan showing the hypodense fistulous tract of the left side (white arrow), starting at the lower pole of the tonsil, measuring
6 mm in width (A–B). (b, c) Coronal and sagittal CT scans showing the calcified mass, tonsillolith (T) (dark arrow), at the level of the left
peritonsillar region with a hypodense fistulous tract (white arrows) extending from the lower tonsillar pole (A) towards the left submandibular
gland (B), measuring 36 mm in length (A–B).
inflammation. Our patient had an uneventful post-
operative period and recovered fully.
We found only a few reports presenting patients with
a combination of pathology of salivary glands and
tonsilloliths.14,15 However, a direct link between those
two conditions, as in our case, was never documented.
Giudice et al14 reported the case of a patient who was
diagnosed with a left tonsillolith and 2 years prior with
lithiasis of the left Wharton’s duct. They found no an-
atomical connection between the left tonsil and the left
submandibular gland. However, the reason for that
could be that, similar to our case, the radiologist did not
actively look for the possibility of an accessory salivary
duct and, furthermore, the duct remained unobserved
during surgery.
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To our knowledge, this is the first report of a large
tonsillolith associated with the accessory duct of the
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