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A Rare Cause of Tonsillitis
Dr. Stanley Voigt, Dr. Peter Rappo, & Dr. Mark A Vecchiotti
Tufts Medical Center
Figure 1.
Abstract
We present a unique Case of a 10 year-old boy with
Trichotillomania who presented to Tufts Medical Center
Floating Hospital for Children Pediatric Otolaryngology
clinic upon referral from his primary care physician for
noted hair within his tonsils & halitosis. Trichotillomania is
an impulse control disorder that involves strong urges to
pull out one’s own hair and in some cases eat it. The
patient had been pulling out his hair for 2 years and
ingesting the hair with development of bilateral tonsilloliths.
These hairs were partially removed in the clinic setting and
the patient required eventual operative management in the
form of bilateral tonsillectomy. A review of trichotillomania
as well as our management of this unique condition is
discussed.
Right Tonsil
Tonsilloliths
Left Tonsil
Figure 2.
Trichotillomania
Trichotillomania (ICD9-code 312.39, ICD10F63.3) is a
medical/psychiatric condition characterized by the
compulsive need to pull or twirl hair, usually from the scalp,
but potentially also from the eyelashes, eyebrows, or pubic
area. [10]. Patients with Trichotillomania exhibit hair loss of
different lengths. This is distinctively different from those
patients who have Alopecia, where the hair loss is even
and to the scalp line, or fungal infection, where the scalp is
rough and scaly. Anxiety and depression are also
commonly associated with Trichotillomania. Patients report
that pulling of hair leads to pleasure, satisfaction, or relief
of stress. During childhood, boys and girls have an equal
incidence of Trichotillomania. Negative stressors can also
cause an increase in hair pulling. [11]
Treatment options are varied but the efficacy of such
treatment and results are mixed. Habit reversal training
(HRT) has had the highest rate of success in
treating Trichotillomania. [12, 13] The individual is trained to
recognize the impulses that lead to hair pulling along with
teaching to redirect the impulse. Biofeedback and
Cognitive Behavioral Therapy have also been employed.
[12] Since Trichotillomania is associated with both
obsessive compulsive disorder and anxiety, selective
serotonin re-uptake inhibitors (SSRI's) have been
employed, but with limited success. As in the case of
ADHD, combination of dual therapy with both medication
and behavioral therapy would appear to be a logical
combination. Other holistic approaches such as yoga,
relaxation therapy, homeopathy, naturopathy and herbal
medications have been employed, but without convincing
scientific validation.
Contact
Stanley Voigt
Tufts Medical Center
Email: [email protected]
Phone: 617-636-7878
Photo of hair lodged within right tonsillar
crypt after in-office removal
Figure 3.
Given the cryptic nature of the palatine tonsils, they tend to
be prone to retention of foreign body or exfoliated epithelial
cells within the tonsil termed tonsilloliths. [5] This creates the
optimal environment for the activity of anaerobic bacteria in
the upper airway and patients therefore may develop what is
termed Chronic Caseous Tonsillitis. Tonsilloliths are rare in
the pediatric population and are more commonly seen in the
20-77 age group [7]
The exact pathogenesis of tonsilloliths is unknown however
potential etiologies have been proposed. Examination of
tonsilloliths frequently reveal carbonates and phosphates of
calcium and magnesium.[6] This is thought to be a result of
chronic inflammation of the tonsils leading to scarring and
fibrosis of the tonsillar ducts and crypts. This then leads to
retention of epithelial debris and further bacterial invasion
and colonization of the tonsils. Calcification results from the
deposition of inorganic salts secreted by the salivary glands.
[7] Tonsilloliths are usually managed conservatively with salt
water gargles or expression by the patient. With larger
tonsilloliths attempts can be made to remove them in the
office setting. Pulsating water jet can be used in a
cooperative patient to clean the pockets of debris
mechanically. [8,9]
Tonsilloliths that cause symptoms such as foreign body
sensation, otalgia or halitosis refractory to medical
management or in our unique case where the patient was at
risk for recurrence of his tonsilloliths and resultant tonsillitis,
the patient should be offered surgical management in the
form of tonsillectomy. [9] He underwent bilateral
tonsillectomy without issue and future therapeutic
interventions for management of his trichotillomania will
include behavioral therapy and the use of an SSRI
medication to reduce anxiety. A behavioral approach called
symptom substitution in which the patient will substitute one
neuromotor activity for another (squeezing a soft rubber ball
with his hand rather than twirling his hair) will also be
recommended. (Kaplan 2012). Finally, counseling for the
mother around her own personal anxiety and resistance to
medical follow-up will be pursued.
References
1.
Dal Rio et al. Relationship between the presence of tonsilloliths and halitosis in patients with chronic caseous tonsillitis. British Dental Journal. 2008; 26;204(2):E4.
2.
Abbey K, Kawabata I. Computerized three-dimensional reconstruction of the crypt system of the palatine tonsil. Acta Otolaryngol 1988; 454: 39-42.
3.
Ansai T & Takehara T. Tonsillolith as a halitosis-inducing factor. British Dental Journal. 2005; 198(5): 263-4.
4.
Stoodley P et al. Tonsillolith: Not just a stone but a living biofilm. Otolaryngology-Head and Neck Surgery. 2009; 141: 316-321.
5.
Parsek MR, Singh PK. Bacterial biofilms: an emerging link to disease pathogenesis. Annu Rev Microbiol 2003;57:677–701.
6.
Thirunavukkarasu, AB et al. Persistent Earache Due to Tonsillolith. Indian pediatrics. 2012; 49: 144-5.
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Thakur JS et al. Giant Tonsillolith causing odynophphagia in a child: a rare case report. Cases Journal. 2008; 1: 50.
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Pruet CW, Duplan DA: Tonsil concretions and tonsilloliths. Otolaryngol Clin North Am 1987; 20:305.
9.
Flint PW et al. Pharyngitis and Adenotonsillar Disease in Cummings Otolaryngology. Fifth Edition. Philadelphia: Elsavier. 2010.
10. Harrison JP & Franklin ME. Pediatric Trichotillomania. Curr Psychiatry Rep. 2012; 14(3): 188-196.
11. Stemberger RMT, Thomas AM, Mansueto CS, Carter JG. Personal toll of trichotillomania: behavioral and interpersonal sequelae. J Anxiety Disord. 2000; 14:97–
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12. Franklin ME, Flessner CA, Woods DW, et al. The Child and Adolescent Trichotillomania Impact Project: descriptive psychopathology, comorbidity, functional
impairment, and treatment utilization. J Dev Behav Pediatr. 2008; 29:493–500
13. Gupta, S & Gargi PD. Habit Reversal Training for Trichotillomania. International Journal of Trichology. 2012; 4(1): 39-41.
Adolescent with severe trichotillomania
Title: Trichotillomania. 29 September 2003
via Wikimedia Commons
14. Trichotillomania. 29 September 2003. Created by Robodoc (original uploader) (de.wiki) [Public domain], via Wikimedia Commons
http://commons.wikimedia.org/wiki/File%3ATrichotillomania_1.jpg
15. Mahajan, P & Johnson, LD. Foresee Your Next Patient: Trichobezoars. Consultant for Pediatricians, May 2012. pp. 148-149.
16. Kaplan, A. Update on Trichotillomania. Psychiatric Times, May 14, 2012.