What is the diagnosis and recommended treatment for a patient with a visible tonsil stone, tonsillar pain, and odynophagia (pain when swallowing) after a recent cold, with failed attempts at removal?

Diagnosis and Management of Tonsillolith with Odynophagia

Diagnosis

The diagnosis is tonsillolith (tonsil stone) causing localized tonsillar pain and odynophagia. 1, 2

• Tonsilloliths are calcified accumulations of cellular debris and microorganisms that form in tonsillar crypts 3
• Small tonsilloliths are typically asymptomatic, but larger stones commonly cause recurrent sore throat and painful swallowing (odynophagia) 2
• The absence of fever, systemic symptoms, and bilateral tonsillar involvement makes acute bacterial tonsillitis (Group A Streptococcus) unlikely 4, 5
• The recent viral upper respiratory infection may have contributed to inflammation that promoted stone formation or retention 1

Immediate Management Recommendations

Conservative management with attempted removal at home should continue, supplemented with symptomatic treatment and close monitoring. 1

First-Line Approach:

• Continue gentle self-removal attempts using cotton swabs, water irrigation (oral irrigator on low setting), or gargling with warm salt water to dislodge the stone 1
• Provide symptomatic pain relief with NSAIDs (ibuprofen) or acetaminophen for odynophagia 5, 6
• Warm salt water gargles several times daily to reduce inflammation and potentially help mobilize the stone 6

When to Escalate Care:

Refer to ENT or primary care for removal if:

• The stone cannot be dislodged within 3-5 days of home attempts 1
• Pain worsens or becomes severe 2
• New systemic symptoms develop (fever, difficulty swallowing liquids, trismus) suggesting peritonsillar abscess 1
• The stone appears very large (>1 cm) on visual inspection 3, 7

Office-Based Removal Options

If home removal fails, a clinician can perform:

• Manual extraction using forceps or curette under direct visualization 1
• Irrigation with saline under pressure 1
• Local anesthesia may be needed for patient comfort during removal 1

Surgical Consideration

Tonsillectomy is reserved only for recurrent symptomatic tonsilloliths that significantly impact quality of life despite conservative management. 1

• Watchful waiting is strongly recommended unless there are recurrent episodes requiring frequent intervention 1
• The threshold for tonsillectomy due to tonsilloliths alone is high, as most cases resolve with conservative measures 1
• Giant tonsilloliths (>2 cm) that cannot be removed conservatively may require surgical extraction with or without tonsillectomy 3, 7

Important Pitfalls to Avoid

• Do not prescribe antibiotics - this is not bacterial tonsillitis requiring antibiotic treatment, as there are no systemic symptoms and the stone itself is the mechanical cause of pain 4, 5, 1
• Do not confuse with acute bacterial tonsillitis - the unilateral presentation, visible stone, absence of fever, and lack of systemic symptoms distinguish this from GAS pharyngitis 4, 6
• Avoid aggressive removal attempts that could cause bleeding or trauma to the tonsillar tissue 1
• Do not ignore worsening symptoms - development of fever, severe dysphagia, or trismus requires urgent evaluation for complications like peritonsillar abscess 1