What is the treatment for a tonsil stone with additional white patches on the tonsil, suspected to be bacterial or fungal in origin?

Management of Tonsil Stone with White Patches on Tonsil

You should obtain a rapid antigen detection test (RADT) or throat culture to confirm Group A Streptococcus (GAS) infection before initiating antibiotic therapy, as white patches on tonsils can represent bacterial tonsillitis requiring treatment, while tonsil stones themselves are benign calcified debris. 1, 2

Diagnostic Approach

The presence of white patches alongside a tonsil stone requires differentiation between:

• Bacterial tonsillitis (GAS): Characterized by sudden onset sore throat, fever >38°C, tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough 1, 2
• Viral tonsillitis: Typically presents without high fever, tonsillar exudate, and cervical lymphadenopathy 1
• Fungal infection (oral candidiasis): White patches that can be scraped off, leaving red base, more common in immunocompromised patients 1
• Tonsilloliths alone: Benign calcified accumulations of cellular debris and microorganisms in tonsillar crypts that do not require treatment unless symptomatic 3, 4

Perform RADT and/or throat culture before prescribing antibiotics to confirm bacterial infection, as antibiotics should only be used for confirmed GAS cases. 5, 1, 2

First-Line Treatment for Confirmed Bacterial Tonsillitis

If GAS is confirmed:

• Penicillin V oral: Children 250 mg twice or three times daily; adolescents/adults 250 mg four times daily or 500 mg twice daily for 10 days 5, 1
• Alternative: Amoxicillin 50 mg/kg once daily (max 1000 mg) or 25 mg/kg twice daily (max 500 mg per dose) for 10 days 5, 1

The full 10-day course is essential to maximize bacterial eradication and prevent complications including acute rheumatic fever and suppurative complications. 5, 1, 6, 2 Short courses of 5 days are less effective for GAS eradication and should be avoided. 1, 6

Treatment for Penicillin-Allergic Patients

For non-anaphylactic penicillin allergy:

• Cephalexin 20 mg/kg/dose twice daily (max 500 mg/dose) for 10 days 5
• Cefadroxil 30 mg/kg once daily (max 1 g) for 10 days 5

For anaphylactic penicillin allergy:

• Clindamycin 7 mg/kg/dose three times daily (max 300 mg/dose) for 10 days 5, 1
• Azithromycin 12 mg/kg once daily (max 500 mg) for 5 days 5, 7
• Clarithromycin 7.5 mg/kg/dose twice daily (max 250 mg/dose) for 10 days 5

Note that resistance of GAS to macrolides (azithromycin, clarithromycin) varies geographically and temporally. 5

Symptomatic Management

Regardless of antibiotic use:

• Ibuprofen or acetaminophen for pain and fever relief 5, 1
• Warm salt water gargles for patients old enough to perform them 1
• Adequate hydration 8

Management of Tonsil Stones

• Tonsilloliths alone do not require treatment unless they become symptomatic or excessively large 3, 4
• Small tonsilloliths are common clinical findings and managed expectantly 4
• Rarely, surgical intervention is required if stones become too large to pass spontaneously 4
• The tonsil stone itself is not an indication for antibiotics 3, 4

When to Consider Fungal Infection

If white patches persist after appropriate antibiotic therapy for confirmed GAS, or if the clinical presentation suggests oral candidiasis (immunocompromised patient, recent antibiotic use, patches that scrape off):

• Fluconazole is recommended for confirmed fungal infection 5
• Consult with infectious disease provider for persistent or atypical presentations 5

Follow-Up Recommendations

• Do not perform follow-up throat cultures for asymptomatic patients who have completed appropriate antibiotic therapy 5, 1, 6, 2
• If symptoms persist despite appropriate therapy, consider medication compliance issues or possibility of chronic GAS carriage with intercurrent viral infections 1, 6, 2
• For recurrent documented GAS tonsillitis shortly after completing therapy, consider alternative regimens such as clindamycin, amoxicillin-clavulanate, or penicillin with rifampin 5, 1, 6

Common Pitfalls to Avoid

• Initiating antibiotic therapy without confirming GAS infection through testing, as most tonsillitis is viral and does not benefit from antibiotics 1, 2
• Assuming all white patches are tonsil stones when they may represent bacterial or fungal infection requiring specific treatment 1, 2
• Using broad-spectrum antibiotics when narrow-spectrum penicillins are effective for confirmed GAS 2
• Inadequate duration of antibiotic therapy (less than 10 days) for GAS tonsillitis, which increases risk of treatment failure and complications 1, 6, 2
• Treating asymptomatic GAS carriers, as they are unlikely to spread infection or develop complications and do not require antimicrobial therapy 5

Consideration for Tonsillectomy

Tonsillectomy is not recommended solely to reduce frequency of GAS pharyngitis or to manage tonsilloliths. 5 Consider tonsillectomy only for recurrent throat infections meeting Paradise criteria: 7 or more well-documented episodes in the preceding year, or 5 or more episodes per year for 2 consecutive years, or 3 or more episodes per year for 3 consecutive years, with all episodes being disabling and adequately treated. 5, 2, 4, 9