What is the treatment for tonsillar stones?

Treatment of Tonsillar Stones

For most patients with tonsillar stones, conservative management with self-care measures should be the first-line approach, reserving tonsillectomy for cases with severe symptoms or recurrent tonsillitis meeting specific frequency criteria. 1

Conservative Management Options

• Hydration: Adequate fluid intake helps naturally flush debris from tonsillar crypts 2
• Gargling with salt water: Regular gargling can help dislodge small tonsil stones and reduce bacterial load 1
• Manual removal: For visible stones, gentle removal using a cotton swab, water irrigator, or soft toothbrush can be effective 1
• Ice popsicles/lollies: Can provide temporary relief from discomfort associated with tonsil stones 2
• Honey: Can be used as an adjunctive therapy due to its antimicrobial properties and ability to soothe the throat 2

When to Consider Tonsillectomy

Tonsillectomy should be considered in patients with:

• Recurrent throat infections meeting the Paradise criteria: 3, 2

  • ≥7 episodes in the past year, OR
  • ≥5 episodes per year for 2 years, OR
  • ≥3 episodes per year for 3 years

• Modifying factors that may lower the threshold for surgery: 2

  • Multiple antibiotic allergies/intolerance
  • History of peritonsillar abscess
  • Very large tonsil stones causing significant symptoms 4

Surgical Considerations

• Observation period: A 12-month period of observation is usually recommended prior to consideration of tonsillectomy 3
• Surgical techniques: Several options exist with varying outcomes:
  • Cold dissection (traditional approach)
  • Electrocautery
  • Coblation (shows slightly less postoperative pain during first day) 3
  • Laser tonsillotomy (less time-consuming, less bleeding, but higher recurrence rate of tonsillitis) 3

Pain Management After Procedures

For patients undergoing tonsillectomy or other procedures:

• Multimodal analgesia is recommended: 2

  • Scheduled paracetamol (acetaminophen) combined with NSAIDs as baseline therapy
  • A single intraoperative dose of IV dexamethasone (reduces pain and postoperative nausea/vomiting) 3
  • Opioids should be reserved only as rescue medication 2

• Avoid codeine in children younger than 12 years 3

Important Caveats and Pitfalls

• Spontaneous improvement: Many cases of recurrent tonsillitis improve with time, making observation a reasonable approach 3
• Surgical risks: Tonsillectomy carries risks including bleeding (0.1-3%), pain, dehydration, and rarely, more serious complications 3
• Limited evidence: There is limited high-quality evidence specifically for managing tonsil stones, with most recommendations derived from tonsillitis management guidelines 1
• Large stones: While most tonsil stones are small and manageable with conservative measures, rarely they can become large enough to require surgical intervention 4

Follow-up Recommendations

• Monitor for adequate pain control after any procedure to prevent poor oral intake and dehydration 2
• For patients with recurrent tonsil stones who don't meet surgical criteria, regular follow-up to assess symptom progression is recommended 1