Treatment of Tonsil Stones
For symptomatic tonsil stones, conservative management with hydration and manual removal is first-line, reserving tonsillectomy only for patients meeting strict recurrence criteria (≥7 episodes in past year, ≥5 episodes/year for 2 years, or ≥3 episodes/year for 3 years) or those with large stones that cannot pass spontaneously. 1, 2, 3
Conservative Management (First-Line)
Most tonsil stones are small, asymptomatic, and require only expectant management. 3
Supportive measures include:
- Adequate hydration to promote natural flushing of debris from tonsillar crypts 2
- Manual removal for accessible stones causing symptoms 3
- Honey as an adjunctive therapy due to antimicrobial properties and throat-soothing effects 2
- Ice popsicles/lollies for temporary relief from discomfort 2
The vast majority of tonsilloliths can be managed expectantly, as they are common clinical findings that typically pass on their own. 3
When to Consider Surgical Intervention
Tonsillectomy should be considered only when:
- Patients meet the Paradise criteria for recurrent tonsillitis: ≥7 documented episodes in the past year, OR ≥5 episodes per year for the past 2 years, OR ≥3 episodes per year for the past 3 years 1, 2, 3
- Modifying factors are present, such as multiple antibiotic allergies/intolerance or history of peritonsillar abscess 2
- Stones become too large to pass spontaneously (rare cases) 3
Important caveat: Watchful waiting is strongly recommended if patients do not meet these frequency criteria. 1, 3 The threshold exists because tonsillectomy carries significant morbidity including postoperative pain, bleeding risk (0.2-3% hemorrhage rate), and potential complications. 4
Alternative Minimally Invasive Options
For patients with recurrent symptomatic tonsilloliths who do not meet criteria for full tonsillectomy:
Coblation tonsil cryptolysis can be performed under local anesthesia in adults, offering:
- Significant decrease or elimination of tonsil stones after a single session 5
- Recovery within 1 week (versus several weeks for tonsillectomy) 5
- Avoidance of laser-related complications (airway fire risk, retinal damage, high equipment costs) 5
This technique obliterates the crypts where stones form while preserving tonsil tissue. 5
Post-Procedure Pain Management (If Surgery Required)
Multimodal analgesia is essential:
- Scheduled paracetamol (acetaminophen) started pre/intra-operatively, continued postoperatively 6, 2
- NSAIDs (ibuprofen) combined with paracetamol for superior analgesia 6, 2
- Single dose IV dexamethasone intraoperatively for analgesic and anti-emetic effects 6, 2
- Opioids reserved as rescue medication only when other measures insufficient 6, 2
Previous concerns about NSAIDs increasing bleeding risk have not been substantiated in recent studies. 6
Critical Pitfalls to Avoid
- Do not perform tonsillectomy for tonsil stones alone unless strict recurrence criteria are met or stones are exceptionally large 1, 3
- Do not restrict diet to liquids/cold foods only post-operatively—patients should maintain adequate hydration and nutrition as tolerated 6
- Monitor for inadequate pain control post-operatively, which may lead to poor oral intake and dehydration 6, 2
- Any post-tonsillectomy bleeding, even minor, requires proper evaluation as it can precede life-threatening hemorrhage 7