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Pathology · patient case with 3 questions

Young man with a white 'stone' in his throat

Patient: Male, 21 years old

Chief complaint: “I have this white stone in my mouth that doesn't want to come out.”

Background: Had influenza 3 weeks ago. Oral hygiene is normal.

Current findings: White, calculus-like concretion visible in the oropharynx.

Question 1

What is this white concretion in the oropharynx?

  1. A sialolith
  2. A tonsillolith (tonsil stone)
  3. A peritonsillar abscess
  4. A parulis
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Correct answer: B. A tonsillolith (tonsil stone)

  • A. A sialolith forms within a salivary duct, most often Wharton duct of the submandibular gland, and causes mealtime swelling and pain — not a visible oropharyngeal stone.
  • B. CORRECT. TONSILLOLITHS form when food debris, desquamated cells and bacteria become trapped and calcify within the tonsillar crypts. They follow episodes of tonsillitis, present as white or yellowish concretions, and characteristically cause halitosis and a foreign-body sensation.
  • C. A peritonsillar abscess is an acutely painful, fluctuant swelling displacing the tonsil and uvula, with trismus and a muffled voice — a very different clinical picture.
  • D. A parulis is the soft tissue swelling at the opening of a sinus tract from an odontogenic abscess, on the alveolar mucosa.

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Question 2

Which muscle forms the fold immediately ANTERIOR to the palatine tonsil?

  1. Palatoglossus
  2. Superior constrictor
  3. Palatopharyngeus
  4. Styloglossus
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Correct answer: A. Palatoglossus

  • A. CORRECT. The palatine tonsil sits in the tonsillar fossa between two folds. The ANTERIOR fold, the palatoglossal arch, is raised by PALATOGLOSSUS. It is worth noting that palatoglossus is classified as a muscle of the soft palate rather than of the tongue, despite its name and its action of elevating the tongue base.
  • B. The superior constrictor forms the lateral pharyngeal wall deep to the tonsillar bed, not the anterior fold.
  • C. Palatopharyngeus raises the POSTERIOR fold (palatopharyngeal arch), behind the tonsil.
  • D. Styloglossus retracts and elevates the tongue; it does not form the tonsillar arches.

Note: Anterior = palatoGLOSSal arch; posterior = palatoPHARYNGeal arch. Among soft palate muscles, tensor veli palatini is the odd one out — supplied by V3, all others by the pharyngeal plexus.

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Question 3

What is the appropriate first-line management?

  1. Surgical excision of the tonsillar crypt
  2. A course of systemic antifungals
  3. Immediate tonsillectomy
  4. Gargle and rinse
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Correct answer: D. Gargle and rinse

  • A. Cryptolysis exists as a procedure for recurrent cases but is not first-line.
  • B. These are bacterial and debris concretions, not fungal.
  • C. Tonsillectomy is reserved for recurrent tonsillitis or severe, persistent, refractory symptoms — far beyond a single stone.
  • D. CORRECT. Tonsilloliths are benign. First-line management is conservative: gargling and rinsing with salt water, gentle dislodgement, and attention to hydration and hygiene. Most resolve without intervention.

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