# Which of the following clinical presentations is the most frequent chief complaint for patients diagnosed with tonsilloliths?
a) Acute, severe throat pain radiating to the ear (otalgia).
b) Chronic, severe unilateral tonsillar swelling with fever.
c) Hemoptysis (coughing up blood) associated with tonsillar irritation.
d) Halitosis (fetor oris) refractory to oral hygiene measures.
The correct answer is D. Halitosis (fetor oris) refractory to oral hygiene measures.
Halitosis is the most frequent chief complaint for tonsilloliths (tonsil stones), reported in up to 75% of symptomatic cases, due to anaerobic bacterial overgrowth in the crypts producing volatile sulfur compounds like hydrogen sulfide. This bad breath persists despite routine oral hygiene, distinguishing it from other causes. Studies and clinical reviews (e.g., from Cleveland Clinic and Mayo Clinic) consistently identify it as the primary symptom, far outpacing others: acute otalgia (a) occurs in <20% and ties to inflammation; chronic swelling with fever (b) suggests peritonsillar abscess, not stones; and hemoptysis (c) is exceedingly rare, linked to vascular erosion in giant stones only.
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