From the Guidelines
Tonsil stones are primarily managed through conservative approaches and good oral hygiene, with surgery reserved for cases that significantly impact quality of life. For diagnosis, a thorough oral examination is typically sufficient, with visualization of white or yellowish calcified deposits in the tonsillar crypts, as noted in the guidelines for tonsillectomy in children and adolescents 1. No special imaging is usually required unless complications are suspected. Management begins with regular oral hygiene practices including:
- Brushing twice daily
- Flossing
- Using an alcohol-free mouthwash Gentle removal of visible stones can be attempted at home using a cotton swab, water flosser, or oral irrigator. Gargling with salt water (1/2 teaspoon salt in 8 ounces warm water) several times daily can help dislodge stones and reduce inflammation, as suggested by the clinical practice guideline for tonsillectomy in children 1. For persistent bad breath associated with tonsil stones, chlorhexidine mouthwash may be used twice daily for 7-14 days. If stones recur frequently or cause significant symptoms like persistent sore throat, difficulty swallowing, or ear pain, medical evaluation is warranted. In severe cases, otolaryngology referral may be considered for procedures such as coblation cryptolysis, laser cryptolysis, or tonsillectomy, though surgery is reserved for cases that significantly impact quality of life, as emphasized by the guidelines 1. Tonsil stones form when food debris, bacteria, and dead cells become trapped in tonsillar crypts and calcify, so addressing the underlying causes through proper oral hygiene is the cornerstone of management.
From the Research
Tonsil Stones: Workup and Management
- Tonsillitis is caused by a viral infection in 70% to 95% of cases, while bacterial infections caused by group A beta-hemolytic streptococcus account for tonsillitis in 5% to 15% of adults and 15% to 30% of patients five to 15 years of age 2
- Diagnostic tools for tonsillitis include symptom-based validated scoring systems, such as the Centor score, and oropharyngeal and serum laboratory testing 2
- Treatment for tonsillitis is focused on supportive care, and if group A beta-hemolytic streptococcus is identified, penicillin should be used as the first-line antibiotic 2
- In cases of recurrent tonsillitis, watchful waiting is strongly recommended if there have been less than seven episodes in the past year, less than five episodes per year for the past two years, or less than three episodes per year for the past three years 2
- Tonsilloliths, or tonsil stones, are managed expectantly, and small tonsilloliths are common clinical findings 2
- Rarely, surgical intervention is required if tonsilloliths become too large to pass on their own 2
- Clindamycin therapy has been shown to be effective in eradicating group A beta-hemolytic streptococci and beta-lactamase-producing bacteria in recurrent tonsillitis, especially in persons aged 12 years old and younger 3, 4
- Treatment with clindamycin may prevent recurrence of acute tonsillitis and eliminate the need for tonsillectomy 4