Bilateral Tonsillar White Patches in Young Adult
Case at a Glance
A 23-year-old female presented with bilateral white patches on her tonsils, initially noticed while investigating a sensation of tonsil stone on the left side. Patient reported no systemic symptoms and was currently undergoing orthodontic treatment with clear aligners.
Patient's Story
The patient awoke with a sensation of something lodging in her left tonsil, which she identified as likely being a tonsil stone based on the familiar feeling. Upon self-examination of her throat, she discovered bilateral white patches on both tonsils. She attempted salt water gargling and gentle manual pressure, which successfully expelled one tonsil stone from the left side but did not affect the white patches on either tonsil. The patient noted that the left tonsil appeared to have typical pebbly tonsil stone formations, while the right tonsil showed more diffuse, splotchy white areas. She reported mild discomfort on the right tonsil following her self-examination attempts but denied fever, sore throat, difficulty swallowing, or other systemic symptoms.
Initial Assessment
Physical examination revealed bilateral tonsillar white patches with apparent mild tonsillar enlargement. The left tonsil showed characteristic appearance of tonsil stones (tonsilloliths) with successful manual extraction of one stone. The right tonsil displayed more diffuse white patches with a splotchy rather than pebbly appearance. Patient appeared well with no signs of systemic illness.
The Diagnostic Journey
Differential diagnosis included tonsilloliths (tonsil stones), bacterial tonsillitis (particularly streptococcal), viral tonsillitis, oral thrush (candidiasis), or tonsillar exudate from other infectious causes. The absence of fever, sore throat, and systemic symptoms made bacterial infection less likely. The asymmetric presentation with different morphology between tonsils suggested possible mixed etiology.
Final Diagnosis
Bilateral tonsilloliths with asymmetric presentation - left tonsil showing typical tonsil stone formation, right tonsil showing atypical white patches requiring further evaluation to rule out concurrent infection or other pathology.
Treatment Plan
Patient advised to continue warm salt water gargles twice daily. Recommended professional medical evaluation for definitive diagnosis and to rule out bacterial infection. If tonsil stones confirmed bilaterally, patient education provided on prevention strategies including improved oral hygiene, regular gargling, and consideration of tonsil cryptolysis if recurrent.
Outcome and Follow-up
Patient scheduled for urgent care evaluation given the asymmetric presentation and need to exclude infectious etiology. Follow-up planned based on clinical findings and any necessary diagnostic testing including rapid strep test or throat culture if indicated.