Treatment for Tonsil Stones
For most patients with tonsil stones, conservative management with adequate hydration and observation is the appropriate first-line approach, reserving tonsillectomy only for those meeting strict Paradise criteria for recurrent infections. 1
Conservative Management (First-Line Treatment)
Adequate fluid intake is the cornerstone of initial management, helping to naturally flush debris from tonsillar crypts and providing relief from discomfort associated with tonsil stones 1
Honey can be used as adjunctive therapy due to its antimicrobial properties and ability to soothe the throat 1
Most small tonsilloliths are common clinical findings that should be managed expectantly, as they often pass on their own 2
Spontaneous improvement is possible in many cases, making observation a reasonable and often preferred approach 1
When to Consider Surgical Intervention
Tonsillectomy should only be considered when patients meet the Paradise criteria for recurrent throat infections, which requires documentation of:
- ≥7 episodes in the past year, OR
- ≥5 episodes per year for 2 years, OR
- ≥3 episodes per year for 3 years 1, 3
Modifying Factors That Lower the Surgical Threshold
- Multiple antibiotic allergies or intolerance 1
- History of peritonsillar abscess 1
- Giant tonsilloliths that become too large to pass spontaneously (rare cases) 4, 2
Important Caveats Before Surgery
A 12-month period of observation is usually recommended prior to consideration of tonsillectomy to allow for potential spontaneous improvement 1
Tonsillectomy carries risks including bleeding, pain, dehydration, and rarely more serious complications 1
Surgical Technique Options (If Surgery Is Indicated)
Electrocautery dissection, coblation technique, and vessel seal technology are acceptable surgical approaches 1
Coblation technique uses moderate heat and results in slightly less postoperative pain on day 1 compared to other methods 1
Laser tonsillotomy should be avoided as it is not considered complete tonsillectomy and has higher recurrence rates 1
Perioperative Pain Management Protocol
Multimodal analgesia is mandatory for patients undergoing tonsillectomy:
Scheduled paracetamol (acetaminophen) started pre-operatively or intra-operatively and continued postoperatively 1
NSAIDs (such as ibuprofen) combined with paracetamol unless contraindicated, providing superior analgesia 1
Single intraoperative dose of IV dexamethasone for analgesic and anti-emetic effects 1
Opioids should be reserved only as rescue medication, and codeine must be avoided in children younger than 12 years 1
Previous concerns about NSAIDs increasing bleeding risk have not been substantiated in recent meta-analyses 1
Antibiotic Use
- Routine perioperative antibiotics are not recommended for tonsillectomy 1
Critical Follow-Up Considerations
- Monitor for adequate pain control after any procedure to prevent poor oral intake and dehydration 1