Treatment of Tonsil Stones
Start with conservative management including adequate hydration and manual removal for symptomatic tonsil stones, reserving tonsillectomy only for patients meeting strict Paradise criteria for recurrent infections. 1
Conservative Management (First-Line Approach)
Most tonsil stones can be managed expectantly without surgical intervention. 2
- Adequate fluid intake is the cornerstone of conservative therapy, helping to naturally flush debris from tonsillar crypts and providing relief from associated discomfort 1
- Honey can serve as adjunctive therapy due to its antimicrobial properties and throat-soothing effects 1
- Manual removal of visible stones can be performed by the patient or clinician for symptomatic relief 2
- Small tonsilloliths are common clinical findings and typically pass spontaneously without intervention 2
When to Consider Surgical Intervention
Tonsillectomy should only be considered when patients meet the Paradise criteria for recurrent throat infections, not simply for the presence of tonsil stones alone 1. The specific thresholds are:
- ≥7 episodes of tonsillitis in the past year, OR
- ≥5 episodes per year for 2 consecutive years, OR
- ≥3 episodes per year for 3 consecutive years 1
Modifying Factors That Lower the Surgical Threshold
- Multiple antibiotic allergies or intolerance 1
- History of peritonsillar abscess 1
- Giant tonsilloliths (>3 cm) that cannot pass spontaneously 3
Important Caveats Before Surgery
- A 12-month observation period is recommended before proceeding with tonsillectomy, as spontaneous improvement occurs in many cases 1
- Watchful waiting is strongly recommended if infection frequency falls below the Paradise criteria 4, 2
- Surgical morbidity includes bleeding (0.2-3%), pain, dehydration, and anesthetic risks 5
Perioperative Management (If Surgery Proceeds)
Intraoperative Care
- Administer a single intraoperative dose of IV dexamethasone (0.15-1.0 mg/kg) to reduce postoperative nausea, vomiting, pain, and time to oral intake 6
Postoperative Pain Management
- Multimodal analgesia with scheduled acetaminophen combined with NSAIDs as baseline therapy 1
- Opioids reserved only as rescue medication 1
- Avoid codeine in children younger than 12 years 1
- Monitor for adequate pain control to prevent poor oral intake and dehydration 1
Clinical Pitfalls to Avoid
- Do not perform tonsillectomy solely for tonsil stones without meeting recurrent infection criteria—this exposes patients to unnecessary surgical risk 5, 1
- Do not rush to surgery without the recommended 12-month observation period 1
- Recognize that tonsil stones causing halitosis alone do not warrant surgical intervention 7, 2
- Be aware that topical agents (lidocaine spray, benzydamine) have limited evidence for post-tonsillectomy recovery and only provide short-term benefit 8