Treatment of Tonsil Stones
For most patients with tonsil stones, conservative management with adequate hydration is the first-line approach, reserving tonsillectomy only for those meeting Paradise criteria (≥7 episodes of recurrent throat infections in the past year, OR ≥5 episodes per year for 2 years, OR ≥3 episodes per year for 3 years). 1
Conservative Management (First-Line)
Initial treatment focuses on non-invasive measures:
- Adequate fluid intake is the cornerstone of management, as it naturally flushes debris from tonsillar crypts and provides symptomatic relief 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 and often pass spontaneously 2
When to Consider Surgical Intervention
Tonsillectomy should be reserved for specific clinical scenarios:
Paradise Criteria for Surgery
The threshold for tonsillectomy requires meeting any one of the following 1:
- ≥7 episodes of throat infections in the past year
- ≥5 episodes per year for 2 consecutive years
- ≥3 episodes per year for 3 consecutive years
Modifying Factors That Lower Surgical Threshold
- Multiple antibiotic allergies or intolerance 1
- History of peritonsillar abscess 1
- Giant tonsilloliths that cannot pass spontaneously (rare cases requiring surgical removal) 2, 3
Important Caveat: Observation Period
- A 12-month observation period is recommended before proceeding with tonsillectomy, as spontaneous improvement occurs in many cases of recurrent tonsillitis 1
Surgical Technique Options (When Surgery Is Indicated)
Available surgical approaches include 1:
- Electrocautery dissection
- Coblation technique (uses moderate heat; results in slightly less postoperative pain on day 1)
- Vessel seal technology
- Cold dissection
Avoid laser tonsillotomy as it is not considered complete tonsillectomy and has higher recurrence rates 1
Perioperative Pain Management Protocol
For patients undergoing tonsillectomy, use multimodal analgesia 1:
- Scheduled paracetamol (acetaminophen): Start pre-operatively or intra-operatively, continue postoperatively on scheduled basis
- NSAIDs (ibuprofen): Combine with paracetamol unless contraindicated (previous concerns about bleeding risk have not been substantiated) 1
- Single dose IV dexamethasone: Administer intraoperatively for analgesic and anti-emetic effects 1
- Opioids: Reserve only as rescue medication 1
- Avoid codeine in children younger than 12 years 1
Antibiotic Use
- Do not routinely prescribe perioperative antibiotics for tonsillectomy 1
Post-Procedure Monitoring
Monitor for adequate pain control to prevent poor oral intake and dehydration, which are common complications 1
Common Pitfalls to Avoid
- Do not rush to surgery: Watchful waiting with the Paradise criteria prevents unnecessary tonsillectomies in patients who will improve spontaneously 4, 1
- Do not underestimate tonsillectomy risks: Complications include bleeding, pain, dehydration, and rarely more serious events 1
- Do not use laser tonsillotomy as definitive treatment due to higher recurrence rates 1