Treatment for Tonsil Stones
For tonsil stones (tonsilloliths), expectant management with watchful waiting is the recommended approach, as small tonsil stones are common clinical findings that typically pass on their own without intervention. 1
Conservative Management (First-Line)
Expectant management is appropriate for most cases of tonsilloliths:
- Small tonsil stones are common and rarely require intervention 1
- Most stones will pass spontaneously without treatment 1
- Symptomatic relief can be achieved through gentle oral hygiene and gargling 1
When to Consider Surgical Intervention
Tonsillectomy should only be considered in rare circumstances when stones become too large to pass on their own or meet specific criteria for recurrent tonsillitis: 1
Surgical Criteria (Based on AAO-HNS Guidelines)
Tonsillectomy may be appropriate if you have documented recurrent tonsillitis meeting the Paradise criteria: 2
- Seven or more documented episodes in the past year, OR
- Five or more documented episodes per year for the past two years, OR
- Three or more documented episodes per year for the past three years 3, 1
If you do not meet these frequency thresholds, watchful waiting is strongly recommended before considering surgical intervention. 3, 1
Important Caveat About Surgery
- Surgical morbidity for tonsillectomy includes bleeding (0.2-3%), pain, dehydration, and anesthetic risks 4
- At least 12 months of observation is recommended before considering tonsillectomy in patients without modifying factors 2
- Giant tonsilloliths (>3 cm) represent rare exceptions where elective stone removal with tonsillectomy may be warranted 5
What NOT to Do
Antibiotics are NOT indicated for tonsil stones alone:
- Perioperative antibiotics should not be routinely used, as they provide no benefit for reducing postoperative morbidity and carry risks of rash, allergy, gastrointestinal upset, and bacterial resistance 2
- Antibiotics are only appropriate if you have concurrent bacterial pharyngitis with group A beta-hemolytic streptococcus infection 2, 1
Documentation Requirements
If considering tonsillectomy, proper documentation of throat infections should include: 2
- Sore throat plus objective findings (fever >100.9°F, cervical adenopathy, tonsillar exudate, or positive strep culture)
- Absences from school or work
- Spread of infection within the family