What is the treatment for tonsiloliths (tonsil stones)?

Treatment of Tonsiloliths (Tonsil Stones)

Most tonsiloliths should be managed conservatively with adequate fluid intake and observation, as they are typically benign and often pass spontaneously; tonsillectomy is reserved only for patients who also meet strict criteria for recurrent tonsillitis (≥7 episodes 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 Approach)

The vast majority of tonsiloliths can be managed without surgery:

• Adequate fluid intake is the cornerstone of conservative management, helping to naturally flush debris from tonsillar crypts and providing relief from associated 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 rarely require intervention 2
• Most tonsiloliths will pass on their own without requiring surgical intervention 2

When to Consider Surgical Intervention

Surgery for tonsiloliths alone is rarely indicated. The decision to proceed with tonsillectomy should be based on recurrent tonsillitis criteria, not the presence of tonsilloliths:

Strict Surgical Criteria (Paradise Criteria)

Tonsillectomy may be recommended only when patients meet ALL of the following: 1

• Frequency threshold: ≥7 documented episodes in the past year, OR ≥5 episodes per year for 2 years, OR ≥3 episodes per year for 3 years 3, 1
• Documentation requirements for each episode: Temperature >38.3°C (101°F), cervical adenopathy, tonsillar exudate, OR positive test for group A beta-hemolytic streptococcus 3
• Observation period: A 12-month period of watchful waiting is recommended before considering tonsillectomy, as spontaneous improvement occurs in many cases 1, 3

Modifying Factors That May Lower the Surgical Threshold

• Multiple antibiotic allergies or intolerance 1
• History of peritonsillar abscess 1

Important Caveats and Pitfalls

Do not perform tonsillectomy for tonsiloliths alone. The evidence base for tonsillectomy relates to recurrent tonsillitis, not isolated tonsillolith formation. Key considerations:

• Limited long-term benefit: Even when criteria are met, tonsillectomy reduces sore throat episodes modestly and this effect does not extend beyond the first postoperative year 3
• Surgical risks: Tonsillectomy carries significant morbidity including bleeding (0.2-3%), pain, dehydration, and anesthetic complications 4, 3
• Natural history: High rates of spontaneous resolution occur with observation alone 3
• Giant tonsiloliths: Only in extremely rare cases of very large stones (>3 cm) that cannot pass spontaneously should surgical removal be considered, and this can sometimes be accomplished with stone removal alone rather than complete tonsillectomy 5

If Surgery Is Pursued

When tonsillectomy is indicated based on recurrent tonsillitis criteria (not tonsiloliths alone):

Perioperative Pain Management

• Multimodal analgesia with scheduled acetaminophen combined with NSAIDs (such as ibuprofen) as baseline therapy 1
• Single intraoperative dose of IV dexamethasone for analgesic and anti-emetic effects 1, 3
• Opioids reserved only as rescue medication 1
• Codeine must not be used in children younger than 12 years 3, 1

Surgical Technique Options

• Cold dissection, electrocautery, coblation, and laser tonsillotomy are available techniques with varying outcomes 1
• Coblation technique results in slightly less postoperative pain on day 1 compared to other methods 1
• Previous concerns about NSAIDs increasing bleeding risk have not been substantiated in recent meta-analyses 1

Postoperative Monitoring

• Monitor for adequate pain control to prevent poor oral intake and dehydration 1
• Follow up to document presence or absence of bleeding within 24 hours (primary bleeding) and after 24 hours (secondary bleeding) 3