Can Tonsil Stones Become Infected?
Yes, tonsil stones (tonsilloliths) can become infected, though they themselves are already products of bacterial accumulation and chronic inflammation in tonsillar crypts. 1, 2
Understanding Tonsilloliths and Infection Risk
Tonsil stones are calcified accumulations of cellular debris and microorganisms that form in the crypts of palatine tonsils. 1 These stones are composed of polymicrobial bacterial aggregates surrounded by inflammatory cells, indicating an ongoing inflammatory process. 3
Key Clinical Considerations:
The distinction between tonsilloliths and active infection is important:
- Tonsilloliths themselves represent chronic bacterial colonization with calcified debris, not necessarily acute infection 1, 2
- Acute tonsillitis can develop in patients with existing tonsilloliths, particularly when group A beta-hemolytic streptococcus (GABHS) or other pathogens cause superimposed infection 2
- Chronic focal infection in tonsils with stones can persist and potentially trigger systemic inflammatory conditions 4
When to Suspect Acute Infection
Look for these specific clinical features that indicate progression from simple tonsilloliths to acute tonsillitis:
- Temperature ≥38.3°C (101°F) 5
- Tonsillar exudate (beyond the stone itself) 5
- Tender, enlarged anterior cervical lymphadenopathy 5
- Severe sore throat with pain on swallowing 5
- Positive rapid antigen detection test or throat culture for GABHS 5, 2
Management Algorithm
For patients with tonsilloliths alone (no acute infection):
- Expectant management is appropriate for small stones 2
- Manual removal or irrigation for symptomatic stones causing halitosis 1, 2
- Surgical intervention only if stones become too large to pass spontaneously 2
For patients with tonsilloliths AND acute tonsillitis:
- Obtain throat culture or rapid antigen detection test to confirm GABHS 5
- If GABHS positive: prescribe penicillin as first-line antibiotic 2
- Provide supportive care for viral etiologies 2
- Consider tonsillectomy only if meeting Paradise criteria (≥7 episodes in past year, ≥5 episodes/year for 2 years, or ≥3 episodes/year for 3 years with proper documentation) 5
Important Pitfalls to Avoid
Do not confuse chronic tonsilloliths with acute infection. The presence of stones alone does not mandate antibiotic therapy unless clinical features of acute bacterial tonsillitis are present. 2
Do not rush to tonsillectomy. Watchful waiting is strongly recommended for recurrent infections not meeting Paradise criteria, as spontaneous resolution rates are high. 5
Consider adenoid involvement. Similar stones ("adenoliths") can form in adenoid tissue and may be a source of recurrent upper respiratory infections when tonsilloliths are present. 3