What is the significance of a small white spot, approximately the size of a grain of rice, on the right tonsil?

White Spot on Tonsil: Clinical Significance and Management

A small white spot on the tonsil, approximately the size of a grain of rice, most commonly represents either a tonsillolith (tonsil stone) or tonsillar exudate from acute tonsillitis, and the distinction is made by assessing for accompanying symptoms of infection.

Differential Diagnosis

The two primary considerations for a white spot on the tonsil are:

Tonsillolith (Tonsil Stone)

• Tonsilloliths are calcified accumulations of cellular debris and microorganisms within tonsillar crypts and are common clinical findings 1, 2
• They typically present as small, white or yellowish deposits and are a known cause of halitosis 2
• Patients with tonsilloliths usually lack systemic symptoms such as fever, severe throat pain, or cervical adenopathy 1
• The cryptic and reticulated epithelium of the tonsils creates channels where debris can accumulate 3

Tonsillar Exudate from Acute Tonsillitis

• Tonsillitis causes inflammation of the tonsils and is viral in 70-95% of cases, but bacterial infection with group A beta-hemolytic streptococcus occurs in 15-30% of children aged 5-15 years 1
• White exudate on the tonsil accompanied by fever ≥38.3°C (101°F), cervical adenopathy, or severe throat pain suggests bacterial tonsillitis 3, 4
• The presence of tonsillar exudate alone is insufficient for diagnosis without additional clinical features 1

Clinical Assessment Algorithm

Step 1: Assess for Infectious Symptoms

• Check for fever (temperature ≥38.3°C), sore throat, cervical lymphadenopathy, and difficulty swallowing 3, 4
• Evaluate for systemic symptoms including malaise, headache, or referred otalgia 3
• Document any history of recurrent throat infections 3

Step 2: Examine for Red Flags

• Unilateral tonsillar findings require heightened vigilance for malignancy, particularly tonsil asymmetry or mass 3
• Assess for suspicious features including ulceration, firm consistency on palpation, or progressive enlargement 3
• In adults with persistent unilateral tonsillar abnormalities, referral to otolaryngology is warranted to exclude neoplasm 3

Step 3: Determine Management Based on Clinical Picture

If asymptomatic or minimal symptoms (likely tonsillolith):

• Expectant management is appropriate for small tonsilloliths, as they commonly pass spontaneously 1
• Patients can attempt gentle removal with cotton swab or water irrigation 1
• Surgical intervention is rarely required unless tonsilloliths become too large to pass 1

If symptomatic with infectious features (likely acute tonsillitis):

• Use validated scoring systems (Centor score) to assess probability of bacterial infection 1
• Perform rapid antigen detection testing or throat culture if bacterial infection is suspected 1
• If group A beta-hemolytic streptococcus is identified, penicillin should be used as first-line antibiotic 1
• Provide supportive care with analgesia and adequate hydration for viral or bacterial tonsillitis 1, 5

Important Clinical Pitfalls

• Do not assume all white spots represent infection requiring antibiotics—tonsilloliths are benign and common 1, 2
• Avoid prescribing antibiotics without appropriate testing, as viral tonsillitis (70-95% of cases) does not benefit from antimicrobial therapy 1
• Unilateral findings warrant closer scrutiny and possible specialist referral to exclude malignancy, particularly in adults or with persistent symptoms 3
• Recurrent tonsillitis requires documentation of frequency and severity before considering tonsillectomy; watchful waiting is strongly recommended if <7 episodes in past year, <5 episodes/year for 2 years, or <3 episodes/year for 3 years 3, 4, 1

When to Refer

• Persistent unilateral tonsillar abnormality without clear infectious etiology 3
• Recurrent tonsillitis meeting criteria for surgical consideration (≥7 episodes in past year, ≥5 episodes/year for 2 years, or ≥3 episodes/year for 3 years with documented fever, adenopathy, exudate, or positive streptococcal testing) 3, 4
• Large tonsilloliths causing significant symptoms or unable to pass spontaneously 1, 2
• Any concern for neoplasm based on examination findings 3