Treatment of Tonsilloliths
Tonsilloliths (tonsil stones) should be managed expectantly with watchful waiting, as small tonsilloliths are common clinical findings that typically pass on their own, with surgical intervention (tonsillectomy) reserved only for rare cases where stones become too large to pass spontaneously. 1
Conservative Management Approach
The primary treatment strategy for tonsilloliths is expectant management, meaning no active intervention is required in most cases. 1 This approach is justified because:
- Most tonsilloliths are small and resolve spontaneously without causing significant symptoms or complications 1
- The natural history favors self-resolution as these calcified debris formations eventually dislodge and are expelled 1
When to Consider Surgical Intervention
Tonsillectomy should only be considered in exceptional circumstances when tonsilloliths become problematic. 1 Specifically:
- Surgery is rarely required and should be reserved for tonsilloliths that become too large to pass on their own 1
- Before considering tonsillectomy, patients should meet strict frequency criteria if recurrent tonsillitis is also present: fewer than 7 episodes in the past year, fewer than 5 episodes per year for the past 2 years, or fewer than 3 episodes per year for the past 3 years 2, 1
Important Clinical Considerations
Watchful waiting does not mean inaction - patients should be monitored for symptom progression, but active treatment is typically unnecessary. 3 The key pitfall to avoid is performing unnecessary tonsillectomy for a largely benign, self-limited condition that carries surgical risks including hemorrhage, pain, infection, and anesthesia complications. 3
The evidence strongly supports conservative management as the standard of care, with surgical intervention representing an outlier approach reserved for truly refractory cases where stone size prevents natural passage. 1