What is the best treatment for ear pain caused by tonsil stones and swollen tonsils?

Treatment of Ear Pain from Tonsil Stones and Swollen Tonsils

For ear pain caused by tonsil stones and swollen tonsils, start with scheduled (not as-needed) acetaminophen and ibuprofen together, maintain aggressive hydration, and manually remove visible tonsil stones if accessible—reserving tonsillectomy for recurrent cases meeting specific frequency criteria. 1, 2

Immediate Pain Management

The cornerstone of treatment is multimodal analgesia using non-opioid medications on a fixed schedule:

• Acetaminophen (paracetamol) should be given at weight-based dosing on a scheduled basis every 4-6 hours, not as-needed. 1, 2
• Ibuprofen (or another NSAID) should be combined with acetaminophen unless contraindicated, as this combination provides superior pain relief compared to either alone. 1
• The combination of acetaminophen plus ibuprofen is more effective than acetaminophen with codeine and causes less nausea. 3
• Avoid opioids as first-line therapy—reserve them only for severe breakthrough pain uncontrolled by the above regimen. 1, 2

Why This Matters for Referred Ear Pain

The ear pain you're experiencing is referred pain from the tonsillar inflammation transmitted through shared nerve pathways (glossopharyngeal nerve). 4 Controlling the source inflammation with NSAIDs directly addresses both throat and ear pain simultaneously. 1

Hydration is Critical

• Aggressive oral hydration is essential and directly reduces pain intensity—dehydration worsens throat pain and referred ear pain. 1, 2
• Aim for frequent small sips of fluids throughout the day rather than large amounts at once. 2
• Ice popsicles can provide temporary additional relief in the immediate period. 2
• Morning pain is typically worse due to overnight dehydration, making consistent fluid intake before bed important. 1

Tonsil Stone Management

For the tonsil stones themselves:

• Manual removal of visible tonsilloliths can be attempted at home using a cotton swab or water irrigator if stones are accessible and causing symptoms. 4
• Most small tonsil stones pass spontaneously and require only expectant management. 4
• Large stones (>2-3 cm) that cannot be removed manually may require surgical extraction. 5
• Tonsil stones alone rarely require tonsillectomy unless they are recurrent and causing persistent symptoms. 4

When to Consider Tonsillectomy

Tonsillectomy should be considered only if you meet specific recurrence criteria for tonsillitis:

• 7 or more episodes in the past year, OR
• 5 or more episodes per year for the past 2 years, OR
• 3 or more episodes per year for the past 3 years 1, 4

If you don't meet these thresholds, watchful waiting is strongly recommended as most cases resolve with conservative management. 4

Additional Supportive Measures

• Honey (1-2 teaspoons) can be used as an adjunctive analgesic with no side effects—it has anti-inflammatory properties. 1, 2
• Maintain adequate nutrition as tolerated; there's no benefit to restricting diet to only liquids or cold foods. 2
• If fever is present, the same acetaminophen/ibuprofen regimen treats both pain and fever. 2

Important Pitfalls to Avoid

• Don't use PRN (as-needed) dosing for the first several days—scheduled dosing is more effective at preventing pain than treating it after it occurs. 1, 2
• Don't avoid NSAIDs due to bleeding concerns—recent meta-analyses involving over 6,000 patients confirm ibuprofen does not increase bleeding risk in tonsil-related conditions. 1, 2, 3
• Don't assume antibiotics are needed—70-95% of tonsillitis is viral, and antibiotics are only indicated if Group A Streptococcus is confirmed. 4
• Don't use topical anesthetic sprays (like benzocaine)—they provide minimal benefit and are not FDA-approved for safety or effectiveness in this indication. 1

When to Seek Further Care

Contact your clinician if:

• Pain is not controlled with the above regimen after 48 hours 1, 2
• You develop difficulty swallowing saliva or breathing 4
• You notice signs of dehydration (decreased urination, dizziness) 2
• Fever persists beyond 3-4 days despite treatment 4
• You develop severe unilateral throat pain suggesting peritonsillar abscess 4