AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y H EA D A N D N E CK ME D I CI NE AN D SUR G E RY XX ( 2 0 13 ) XXX XXX

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Laser tonsil cryptolysis: In-office 500 cases review,,

Yosef P. Krespi, MD a , Victor Kizhner, MD b,
a
b

New York Head & Neck Institute and Lenox Hill Hospital, New York, NY, USA
St. Luke's-Roosevelt Hospital, New York, NY, USA

ARTI CLE I NFO

A BS TRACT

Article history:

Objectives: Tonsilloliths, proven to be tonsillar biofilms cause symptoms of halitosis, foreign

Received 8 February 2013

body sensation and recurrent sore throats. Laser Tonsil Cryptolysis (LTC) performed in the
office may represent an alternative to tonsillectomy in selected cases of persistent
tonsilloliths with cryptic infections.
Study Design: A retrospective chart analysis using CPT codes.
Setting: Office and hospital.
Methods: A retrospective complications review consisting of bleeding, the need for an
additional procedure, patient satisfaction and conversion rate to complete tonsillectomy
was documented.
Results: Five hundred consecutive LTCs performed in the office under local anesthesia with
a CO2 or diode laser were identified. Energy delivery was in continuous mode with power
settings of 18W and 10W respectively. Bleeding occurred in 6 patients requiring
unscheduled return office visit for evaluation. Eighty patients required a second
procedure, comprising total of 1.16 procedures per patient. Eighteen (3.6%) patients
underwent complete tonsillectomy. Patient satisfaction was high with an overall
incidence of 02 days of work absence. Follow-up was 18 years.
Conclusions: With a small tonsil size, controllable gag reflex and cooperative adult patient LTC
allows several advantages compared to conventional tonsillectomy. Benefits of LTC include
avoidance of general anesthesia and limited ablation of cryptic pockets, resulting in reduced
post-operative pain, bleeding, shorter recovery time and the convenience and cost advantage
of an office procedure. With 1.16 sessions required per patient, low conversion rate to standard
tonsillectomy and minimal complication rate LTC can be considered an alternative option to a
patient suffering from recurrent cryptic tonsillitis with or without tonsilloliths.
2013 Elsevier Inc. All rights reserved.

1.

Introduction

Tonsilloliths may contain calcium deposits, and some have

suggested that they result from infection. Samant and Gupta
[1] concluded in 1975 that they represent incomplete evacuation of pus with the dead bacteria and the inflammatory cells
providing the nidus for their formation. Most of the ensuing

reports regarding tonsilloliths have focused on the tonsillolith size (up to 44 gram reported) and symptoms derived from
it [2]. Evidence of tonsilloliths being responsible for chronic
silent infection came with Stoodley et al [3], confirming that
tonsilloliths are similar in architecture and physiologically
behaving as dental biofilms. This fact coincides with preferential formation of biofilms forming in grooves, depressions

Presented at the Triological society meeting, April 2012, San-Diego.

Financial support: none, conflict of interest: Y. Krespi is a consultant for Lumenis and Valam board of directors.

Level of evidence: level II-3.

Corresponding author. 10th Floor 425 West 59 Street, New York, NY 10019. Tel.: +1 212 523 7791.
E-mail address: vkizhner@chpnet.org (V. Kizhner).

0196-0709/$ see front matter 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.amjoto.2013.03.006

Please cite this article as: Krespi YP, Kizhner V, Laser tonsil cryptolysis: In-office 500 cases review, Am J OtolaryngolHead and
Neck Med and Surg (2013), http://dx.doi.org/10.1016/j.amjoto.2013.03.006

AM ER IC AN JOURNAL OF OTOLARYNGO LOGY H EAD AN D N E CK ME D I CI NE AN D SUR GE RY XX ( 2 0 13 ) XXXX XX

and cryptic pockets rather than on the tonsil surface. Biofilms

are mixture of dormant bacteria within a matrix in a low
energetic form capable of reversing their hibernation under
environmental changes. Typically tonsillar biofilms are
formed by anaerobic gram negative bacteria. Oxygen poor
environments can be detected at the center of the tonsilloliths, with depletion of sugar at the surface. This state is
reversible with the addition of fluoride in experimental
models. Thus Stoodley and collaborators postulated that
tonsilloliths exhibit typical behavior quite similar to dental
biofilms [3].
Despite inadequate understanding regarding the cause of
tonsilloliths, the signs and symptoms of foreign body sensation, metallic taste, throat closing or tightening, coughing,
choking and halitosis are well documented. Rio et al [4]
performed halitometry in patients suffering from recurrent
tonsilloliths, finding a tenfold increase in the risk of halitosis
when tonsilloliths were present. Conversely, all patients
without tonsilloliths had normal halitometry. Tonsilloliths
form within the tonsillar crypts. The external face of the tonsil
is covered by stratified squamous epithelium, which invaginates toward the inside of the tonsillar parenchyma, forming
the crypts. Each adult palatine tonsil has an average of 1020
crypts [5], which resemble fissure apertures on the tonsil
surface and become an anaerobic environment for certain
bacteria to accumulate to form biofilms. As the biofilm
matures and enlarges the crypt dilates to accommodate the
tonsillolith causing inflammation at crypts. According to Dal
Rio et al [6] CO2 laser ablation of the tonsil crypts opens the
crypt ostium, thus avoiding bacterial retention and allows easy
clearing the cryptic pocket. The stretching and tension of scar
tissue around the crypt with the resultant superficial coagulation and contraction are similar to that observed in laser skin
resurfacing. The tissue vaporization leading to consequent
reduction of tonsillar parenchyma results in crypt's opening
directed outward thus forcing the crypt to remain widely open.
Halitometry was performed before the treatment and following LTC. A histological exam following LTC showed that
procedure was safe and halitometry showed reduction of
volatile sulphur compounds by 30% with disappearance of
halitosis [6]. Finkelstein et al [7] presented a series of 53
patients with the tonsils as a source of halitosis to assess the
efficacy of CO2 laser for its treatment. Finkelstein's tonsil
smelling evaluation consisted of massaging the tonsils with a
gloved index finger and smelling the squeezed discharge. The
authors performed Laser Cryptolysis as an office procedure
under topical anesthesia and concluded that LTC appeared as
an effective, safe, and well-tolerated procedure. Although
simple smelling of the gloved finger may not represent an
objective measurement of the reduction of halitosis.
Passos et al [8] introduced LTC as treatment for chronic
tonsillitis. The CO2 laser was used with biopsies of the tonsil
and histological evaluation focusing on germinal centers,
lymphoid tissue, sub-epithelial fibrosis, and parenchyma
fibrosis documented. The biopsies showed that the laser,
used at a specific energy density, could relieve the symptoms
without increase of the fibrotic content, nor decrease of the
lymphoid structure. The laser action caused only epithelial
coagulation, thus only weakening the tension forces in the
crypt borders resulting in their marsupialization and exteri-

orization. The large or deeper crypts required additional

vaporization creating a large furrow.
The current study is a compilation of the above mentioned
indications for LTC, i.e. halitosis, tonsilloliths formation and
chronic cryptic tonsillitis. The study focuses on safety,
effectiveness and complications of LTC by reviewing a large
series of office procedures performed. Additionally, an alternative method of examining the tonsils and tonsilloliths is
suggested in indentifying imbedded tonsilloliths. Patient
satisfaction and grading of halitosis were performed on
some patients with the Halitosis Associated Life-quality Test
(HALT) questionnaire, which was recently introduced by
Kizhner et al [9].

2.

Methods

Following IRB approval using CPT codes five hundred consecutive cases of LTC going from 2003 to 2011 were analyzed. End
results included: number of total procedures, complications
and number of patients that needed completion tonsillectomy
under general anesthesia.
The indications for office LTC are a cooperative patient,
tonsil size <+2, controllable gag reflex and the ability to
adequately visualize and explore the oropharynx. The exclusion criteria are large tonsils with tonsillar tissue extending
beyond the posterior pillar, hyperactive uncontrolled gag
reflex and an uncooperative patient. Patients with significant
tonsil hypertrophy were not considered candidates.
Patients were excluded if the tonsils expanded medial to
the posterior pillar, obstructing the view of the palatopharyngeal fold. Assessment of the gag reflex, during the
initial examination consisted of palpation of the anterior
pillars after spraying with Benzocaine aerosol 20% spray.
Patients gagging after topical spray were excluded. Prior to the
procedure, only local anesthesia is used avoiding intravenous
agents. Lidocaine 2% with1:100,000 epinephrine is injected
with a 27 gauge needle. Approximately 1 cc. injected in each
tonsil site Local anesthesia was infiltrated along the
anterior pillar and into the posterior pillar. When tonsilloliths
are suspected a two hand technique using two wooden tongue
blades is used. One hand gently depresses the tongue, while
the other tongue depressor will press the upper border of the
anterior pillar (palato-glossal fold) vertically and laterally
pushing the tonsil medially and gently squeezing its contents.
The tonsilloliths are hidden from view, particularly at the
upper pole behind the anterior pillar. The caseous tonsilloliths
material is examined with an offensive smell confirming the
source of halitosis.
Since 2010 fifty patients also completed the HALT questioner before and after LTC. Additionally, mapping of the
location of the tonsilloliths was performed.
As the general technique for LTC is covered elsewhere [10]
some key points are worth mentioning. Ablation of the upper
corner of the anterior pillar to expose the superior pole of the
tonsil enables complete identification of new crypts filled with
tonsilloliths (Fig. 1).
Then the tonsil lymphoid tissue is ablated with CO2 laser
with a rapidly rotating 2 mm scanning device to evaporate the
tonsil surface layer by layer (Fig. 2), similar to peeling the

Please cite this article as: Krespi YP, Kizhner V, Laser tonsil cryptolysis: In-office 500 cases review, Am J OtolaryngolHead and
Neck Med and Surg (2013), http://dx.doi.org/10.1016/j.amjoto.2013.03.006

AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y H EA D A N D N E CK ME D I CI NE AN D SUR G E RY XX ( 2 0 13 ) XXX XXX

Fig. 1 Tonsil cryptic infection with tonsillolith (biofilm).

layers of an onion. The laser action with scanner causes charfree epithelial coagulation. Contraction of mucosa at the
ablation site weakens the crypt borders resulting in their
marsupialization. The mucosal tension and forces end up
pulling the edges apart resulting in thus opening the crypts.
The tissue characteristics of the tissue after ablation resemble
those after laser skin resurfacing. Eventually exteriorization of
the cryptic pocket with complete evacuation occurs as the
laser energy reaches close to the bottom of the crypt (Fig. 3).
The large or deeper crypts require additional vaporization
creating a large furrow. The procedure is continued until the
bottom of the crypts are identified and coagulated to avoid
reformation of biofilm. Post procedure patient instructions
include analgesic medications, topical anesthetics in the form
of a gargling solution and antibiotics.

3.

Results

Five hundred patients who underwent LTC in the office

during the past 8 years were identified. The age range was 11
73 years, with a female predominance of 62%. All patients had
follow up appointment scheduled within 49 days following

Fig. 2 Laser Tonsil Cryptolysis (LTC). Note the tissue

retraction at the crypt surface caused by CO2 laser ablation
with scanner.

the procedure. The length of the procedure was less than 30

minutes. The lasers in use were CO2 laser (Lumenis, Santa
Clara, CA) with scanner set at 2 mm and Kamami pharyngeal
hand piece at 18 W under continuous mode for the vast
majority of the cases. Diode laser, 980 nm (ARC lasers,
Nuremberg Germany) with 300 micron fiber and curved tip
surgical hand piece with a power setting of 10 W in
continuous mode was used where ablation of only of single
crypt was needed.
Post operative bleeding necessitating bleeding control
under local anesthesia in the office occurred in 1 patient.
Additionally five patients reported minor bleeding which
resolved spontaneously with intake of ice cold water. No
hospital admissions or emergency department visits were
recorded in this series. Eighty patients required a repeat
procedure due to persistence symptoms and tonsilloliths,
comprising 1.16 procedures per patient. A total of 18 patients
(3.6%) patients required complete conventional tonsillectomy
under general anesthesia. Patient satisfaction was high
overall with limited disability and 02 work days lost. Patient
follow-up was 18 years.
Over the last three years in 50 patients we had documented
and recorded: stone visualization and HALT scores before and
after the LTC procedure. In almost 40% of these patients the
tonsilloliths were not visible and were hidden behind the
anterior pillars, only careful pillar retraction could reveal
them, usually in the upper tonsil pole. Improvement on the
self reported HALT questionnaire was 46% (P < 0.05). There
appeared to be no connection between tonsil size and tonsil
stone production with patients with small to medium size
tonsils producing large tonsilloliths once the tonsils were
pushed medially following lateralization of the anterior pillar.
This can be easily performed using topical anesthetic even
with patient with strong gag reflex.

4.

Discussion

Since the advent of LTC part of the search focused revealing

the presence and depth of tonsillar crypts with tonsilloliths.

Fig. 3 Marsupialization of tonsil crypt and evacuation of the

tonsillolith are the end result of LTC.

Please cite this article as: Krespi YP, Kizhner V, Laser tonsil cryptolysis: In-office 500 cases review, Am J OtolaryngolHead and
Neck Med and Surg (2013), http://dx.doi.org/10.1016/j.amjoto.2013.03.006

AM ER IC AN JOURNAL OF OTOLARYNGO LOGY H EAD AN D N E CK ME D I CI NE AN D SUR GE RY XX ( 2 0 13 ) XXXX XX

Fig. 4 Retraction of left anterior pillar and exposure of upper tonsillar pole. Arrows show the enhanced tonsil tissue exposure
between A & B.

As crypts become loaded with tonsilloliths they dilate,

resulting in clinical of inflammation and a foreign body
sensation. Occasionally, part of the tonsilloliths will break
off and present in the anterior oral cavity causing oral malodor
and social embarrassment. Since tonsilloliths are biofilms, the
only permanent intervention is mechanical disruption and
ablation of the base of the crypt with laser or total surgical
resection. Therefore, a careful tonsillar exam is a search for
tonsilloliths specifically addressed with two hand pillar
retraction described here and introduced by the senior author.
Advantages of carefully examining tonsil pockets over
previously described tonsil assessment include several factors. From the patient's perspective much less gagging is
produced and direct visualization allowing the identification
and partial extraction of tonsilloliths. While Finkelstein's
palpation and tonsillar massage test is performed blindly and
can initiate severe gagging. The elevation of the anterior pillar
laterally and pushing the tonsil medially allow a clear
visualization of the tonsil, which allows the surgeon a clearer
plan for the procedure. Moreover, while a tonsillar massage

will push the tonsilloliths deeper into the crypts, this method
will do quite the opposite, by exteriorizing the crypts and
revealing hidden biofilm loaded crypts resulting with better
identification of areas needed to be treated. This method also
discloses the tonsils that on a regular one hand oropharyngeal
exam with tongue depression most tonsilloliths will be
missed (Fig. 4A & B). By comparison of the same tonsil in
Fig. 4 (as the depth of the picture is different we compared the
tonsil to itself) and comparing the height to width measurement with this exposure method the ratio of height to width
was 60/30 (2) while without was 10/3 (3.33). Assuming the
same anterior posterior ratio we gain over 250% additional
tonsil tissue exposure. Our observation indicated that some of
the stones are completely embedded within the crypts, with
the location of caseous material varying from upper pole to
mid pole and rarely at lower pole, thus obliging us to seek for
the tonsilloliths aggressively. This method used for evaluation
of tonsil crypts will answer that need precisely by localizing
tonsilloliths and the exact location and the depth of tonsil
crypts (Fig. 5A & B). This method allows mapping of the

Fig. 5 Right tonsil with anterior pillar retraction (A) exposing previously undetected tonsilloliths (circled) (B).
Please cite this article as: Krespi YP, Kizhner V, Laser tonsil cryptolysis: In-office 500 cases review, Am J OtolaryngolHead and
Neck Med and Surg (2013), http://dx.doi.org/10.1016/j.amjoto.2013.03.006

AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y H EA D A N D N E CK ME D I CI NE AN D SUR G E RY XX ( 2 0 13 ) XXX XXX

tonsillar site for more accurate and complete crypt vaporization with the laser, thus causing less tissue damage and
potentially minimal post operative pain.

4.1.

only in some of the patients (50), our results showed clearly a

significant reduction of 46% in HALT scores completed prior
and following LTC.

Laser choice

5.
While the choice of a CO2 laser with a scanner is perhaps more
accurate and effective for a quicker ablation, a CO2 laser for
the office is a higher fiscal burden. A small diode laser may be
an alternative device for limited use in treating one or two
cryptic areas. Sedlmaier et al [11] compared the CO2 laser
versus a diode laser in a group of 183 pediatric tonsillotomies
with results showing similar pain scores at both group,
without post-operative complications such as bleeding or
significant pain. Furthermore, laser tonsillectomy potentially
offers an advantage over standard tonsillectomy when pain,
intra-operative hemostasis, re-bleeding and post-operative
inflammatory reaction are considered as suggested by the
Jiang et al [12] study. Another confirmation for minimal
complication arises from Eisfeld et al's [13] study who
observed 181 partial tonsillotomies performed with CO2
laser. In his observation post operative bleeding was 0%,
repeated infection was 3% with a follow-up period of six years.
Our results comprise a large series of LTC procedures
performed for chronic cryptic tonsillitis with or without
tonsilloliths. Although LTC is not as definite or complete as
conventional tonsillectomy, it is definitely counterbalanced
by a negligible complication rate, postoperative pain, loss of
productive time or post operative bleeding as was pointed out
by the aforementioned series. Note the ablation of anterior
pillar exposing the upper pole of tonsil.

4.2.

Patient satisfaction

As LTC is performed under local anesthesia it offers greater

patient comfort and minimal recovery time. In cases with
superficial exposure of crypts one can perform LTC even with
topical anesthesia. It is well known that the tonsil lymphoid
structure has minimal sensory innervations and by not
injuring the pillars one may be able to avoid even injections
of local anesthetics. Intra operative or post operative bleeding
was negligible due to absence of large blood vessels at the
surface of tonsils far away from the tonsil capsule and
pharyngeal muscles. The amount of second procedures
required (planned or unplanned) was 1.16 per patient
comparing to 1.42 in Finkelstein's series. This number
possibly reflects a natural learning curve as well as accurate
identification and mapping of loaded and inflamed crypts
prior to LTC. As with all tonsillotomies performed with various
surgical devices post operative pain is in general much less
intense than a complete tonsillectomy, as pointed out in
previous studies. The estimated work loss was usually zero
but no more than two days, a factor leading to major patient
satisfaction since the vast majority of LTC patients were
working adults. The HALT questionnaire allowed us to score
patient satisfaction in reduction of halitosis, albeit recorded

Conclusions

Laser Tonsil Cryptolysis (LTC) performed for cryptic tonsillitis

with tonsilloliths in selected patients with small tonsils, a
controllable gag reflex, and cooperative permits numerous
advantages over conventional tonsillectomy. Most important
are a brief recovery time and avoidance of general anesthesia
with LTC. The proper examination of tonsils explained in detail
above is essential in selecting the patients. With 1.16 sessions
required per patient, a low conversion rate to conventional
tonsillectomy and no incidence of serious post operative
complications, LTC should be considered as an alternative
option for the properly selected and appropriate adult patient.

REFERENCES

[1] Samant HC, Gupta OP. Peritonsillolith. Oral Surg Oral Med
Oral Pathol 1975;40(1):5660.
[2] Pruet CW, Duplan DA. Tonsil concretions and tonsilloliths.
Otolaryngol Clin North Am 1987;20(2):3059.
[3] Stoodley P, Debeer D, Longwell M, et al. Tonsillolith: not just a
stone but a living biofilm. Otolaryngol Head Neck Surg
2009;141(3):31621.
[4] Rio AC, Franchi-Teixeira AR, Nicola EM. Relationship between
the presence of tonsilloliths and halitosis in patients with
chronic caseous tonsillitis. Br Dent J 2008;204(2).
[5] Perry ME, Jones MM, Mustafa Y. Structure of the crypt
epithelium in human palatine tonsils. Acta Otolaryngol
1988;454:539.
[6] Dal Rio AC, Passos CA, Nicola JH, et al. CO2 laser cryptolysis by
coagulation for the treatment of halitosis. Photomed Laser
Surg 2006;24(5):6306.
[7] Finkelstein Y, Talmi YP, Ophir D, et al. Laser cryptolysis for
the treatment of halitosis. Otolaryngol Head Neck Surg
2004;131(4):3727.
[8] Passos CA, Altemani A, Nicola JH, et al. Histopathological
evaluation in biopsies of palatine tonsils submitted to
cryptolysis by coagulation with CO2 laser for treatment of
chronic caseous tonsillitis. Photomed Laser Surg 2004;22(3):
2119.
[9] Kizhner V, Xu D, Krespi YP. A new tool measuring oral
malodor quality of life. Eur Arch Otorhinolaryngol 2011;268(8):
122732.
[10] Krespi YP. Tonsil cryptolysis using CO2 swift laser. Operative
techniques in otolaryngology. Head Neck Surg 1994;5:2947.
[11] Sedlmaier B, Bohlmann P, Jakob O, et al. Outpatient diode
laser tonsillotomy in children with tonsillar hyperplasia.
Clinical results. HNO 2010;58(3):24454.
[12] Jiang Z, Wang J, Dong C, et al. Clinical study of carbon dioxide
laser tonsillectomy. Lin Chung Er Bi Yan Hou Tou Jing Wai Ke
Za Zhi 2010;24(3):11921.
[13] Eisfeld W, Amler S, Deitmer T. Long-term results following
tonsillotomy in children.Laryngorhinootologie 2010;89(8):
46672 [Epub 2010 Apr 12].

Please cite this article as: Krespi YP, Kizhner V, Laser tonsil cryptolysis: In-office 500 cases review, Am J OtolaryngolHead and
Neck Med and Surg (2013), http://dx.doi.org/10.1016/j.amjoto.2013.03.006