What is the treatment for tonsil stones?

Treatment for Tonsil Stones

For most patients with tonsil stones, conservative management with adequate hydration and observation is the first-line approach, reserving tonsillectomy only for those meeting strict Paradise criteria for recurrent infections or those with symptomatic stones that fail conservative measures. 1, 2

Conservative Management (First-Line)

• Adequate fluid intake is the cornerstone of initial management, helping to naturally flush debris from tonsillar crypts and providing relief from discomfort 1
• Honey can be used as adjunctive therapy due to its antimicrobial properties and throat-soothing effects 1
• Expectant management is appropriate for small tonsilloliths, which are common clinical findings that often pass spontaneously 2
• Most patients can manually remove visible stones using cotton swabs or water irrigation, though this should be done carefully to avoid trauma 2

When to Consider Surgical Intervention

Indications for Tonsillectomy

Tonsillectomy should be considered only when patients meet the Paradise criteria: 1, 3

• ≥7 episodes of adequately treated tonsillitis in the past year, OR
• ≥5 episodes per year for 2 consecutive years, OR
• ≥3 episodes per year for 3 consecutive years

Modifying Factors That Lower the Surgical Threshold

• Multiple antibiotic allergies or intolerance 1
• History of peritonsillar abscess 1
• Large tonsilloliths that cannot pass spontaneously and cause significant symptoms 2

Important Caveats

• A 12-month observation period is typically recommended before proceeding with tonsillectomy, as spontaneous improvement occurs in many cases 1, 3
• The differentiation between sore throat episodes and true tonsillitis is often not feasible and should not delay appropriate treatment decisions 3

Minimally Invasive Options

For patients with symptomatic tonsil stones who don't meet criteria for full tonsillectomy:

• Coblation tonsil cryptolysis can be performed under local anesthesia in adults, offering significant reduction or elimination of tonsil stones after a single session with minimal recovery time (approximately 1 week) 4
• This technique avoids the significant morbidity of traditional tonsillectomy while eliminating the disadvantages of laser cryptolysis (airway fire risk, retinal damage, high equipment costs) 4

Surgical Technique Options (If Tonsillectomy Indicated)

Available surgical approaches include: 5, 1

• Cold dissection (traditional method)
• Electrocautery dissection
• Coblation technique (uses moderate heat with slightly less postoperative pain on day 1 compared to other methods)
• Vessel seal technology (newer, using ultrasound)

Note: Laser tonsillotomy has higher recurrence rates and is not considered complete tonsillectomy 5

Perioperative Pain Management (If Surgery Performed)

Multimodal analgesia is mandatory: 1, 6

Baseline Therapy

• Paracetamol (acetaminophen) started pre-operatively or intra-operatively, continued postoperatively on a scheduled (not as-needed) basis 1, 6
• NSAIDs (such as ibuprofen) combined with paracetamol unless contraindicated—this combination provides superior analgesia 1, 6
• Single dose of IV dexamethasone administered intraoperatively for analgesic and anti-emetic effects 5, 1, 6

Important Note on NSAIDs

• Previous concerns about NSAIDs increasing bleeding risk have not been substantiated in recent meta-analyses 5, 6

Second-Line Options (When NSAIDs Contraindicated)

• Pre-operative gabapentinoids 5, 6
• Intra-operative ketamine (use cautiously due to hallucinations and sedation risk) 5, 6
• Dexmedetomidine (carries risks of sedation, hypotension, bradycardia) 5, 6

Adjunctive Therapies

• Honey postoperatively as analgesic adjunct with no reported side effects 5, 6
• Acupuncture (if available and provider trained) 5, 6

Rescue Medication

• Opioids should be reserved only as rescue medication when above measures are insufficient 1, 6
• Codeine must be avoided in children younger than 12 years 1

Postoperative Monitoring

• Monitor for adequate pain control to prevent poor oral intake and dehydration 1, 6
• Adequate hydration is essential, particularly in febrile patients 6
• Patients should be encouraged to maintain nutrition as tolerated—no benefit to restricting diet to liquids or cold foods only 6

Key Clinical Pitfalls to Avoid

• Do not perform tonsillectomy for tonsil stones alone unless Paradise criteria are met or stones are causing severe, refractory symptoms 1, 2
• Do not routinely prescribe perioperative antibiotics for tonsillectomy 5
• Do not underestimate postoperative pain—tonsillectomy carries significant morbidity with severe pain expected in most patients requiring stringent pain management protocols 3
• Do not use codeine in children under 12 years due to safety concerns 1