Unilateral Tonsil Pain with Tonsil Stones Without URI Symptoms
Tonsil stones (tonsilloliths) themselves cause localized inflammation and irritation in the tonsillar crypts where they form, producing unilateral pain even without active infection. 1
Mechanism of Pain from Tonsilloliths
Tonsil stones are calcified accumulations of cellular debris and microorganisms that lodge in the crypts of the palatine tonsils. 2 The pain mechanism involves:
- Direct mechanical irritation from the stone pressing against tonsillar tissue and nerve endings 1
- Local inflammatory response to the trapped debris and bacterial colonization within the crypt, independent of systemic infection 1
- Chronic low-grade inflammation that persists as long as the stone remains lodged in the crypt 2
Why This Differs from Infectious Tonsillitis
The key distinction is that tonsilloliths cause localized mechanical and chemical irritation rather than acute infectious inflammation:
- Viral tonsillitis (70-95% of acute tonsillitis cases) presents with systemic URI symptoms including fever, constitutional symptoms, and typically bilateral involvement 1, 3
- Bacterial tonsillitis from Group A Streptococcus (15-30% in children, 5-15% in adults) similarly presents with fever, bilateral tonsillar inflammation, and systemic symptoms 1, 3
- Tonsilloliths are common clinical findings that cause halitosis and localized discomfort without requiring active infection 1, 2
Clinical Presentation Pattern
Your patient's presentation is entirely consistent with symptomatic tonsilloliths:
- Unilateral involvement is typical since stones form in individual crypts 2
- Absence of fever or constitutional symptoms distinguishes this from acute infectious tonsillitis 1, 3
- Localized pain reflects the mechanical irritation and chronic inflammation at the stone site 1
- History of recurrent sore throat is common in patients who develop large tonsilloliths 2
Important Caveat About Unilateral Tonsillar Findings
While tonsilloliths are the likely explanation, any unilateral tonsillar enlargement with suspicious appearance or cervical lymphadenopathy requires tonsillectomy to rule out malignancy (20% malignancy rate when these features present). 4, 5 However, unilateral tonsillar enlargement alone without other concerning features has zero to very low malignancy risk and can be managed with watchful waiting. 5
Management Approach
- Small tonsilloliths are managed expectantly as they typically pass spontaneously 1
- Surgical intervention is rarely required unless stones become too large to pass on their own 1
- If the stone is visible and causing significant symptoms, manual removal can be attempted 2
- Tonsillectomy is reserved for recurrent symptomatic tonsilloliths or when malignancy cannot be excluded based on clinical features 1, 4