What is the treatment for tonsil stones?

Treatment for Tonsil Stones

Start with conservative management using adequate fluid intake and honey for symptomatic relief, reserving tonsillectomy only for patients who meet strict Paradise criteria for recurrent throat infections. 1

Conservative Management (First-Line Approach)

Most tonsil stones should be managed expectantly, as small tonsilloliths are common clinical findings and rarely require intervention. 2

• Increase fluid intake to naturally flush debris from tonsillar crypts and provide relief from discomfort 1
• Use honey as adjunctive therapy for its antimicrobial properties and throat-soothing effects 1
• Watchful waiting is appropriate since spontaneous improvement occurs in many cases 1

When to Consider Surgical Intervention

Tonsillectomy should only be considered when patients meet the Paradise criteria for recurrent throat infections, NOT simply for the presence of tonsil stones alone. 1

Paradise Criteria Requirements:

• ≥7 episodes of throat infections in the past year, OR 1
• ≥5 episodes per year for 2 consecutive years, OR 1
• ≥3 episodes per year for 3 consecutive years 1

Modifying Factors That Lower the Surgical Threshold:

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

Observation Period:

• A 12-month observation period is recommended before proceeding with tonsillectomy 1
• Patients not meeting Paradise criteria should continue watchful waiting 3

Surgical Management Details

If tonsillectomy is indicated, electrocautery dissection or coblation technique are the preferred surgical approaches. 1

Surgical Technique Options:

• Electrocautery dissection, coblation technique, or vessel seal technology are acceptable approaches 1
• Coblation uses moderate heat and results in slightly less postoperative pain on day 1 1
• Avoid laser tonsillotomy as it is not complete tonsillectomy and has higher recurrence rates 1

Perioperative Pain Management Protocol:

• Start scheduled paracetamol (acetaminophen) pre-operatively or intra-operatively and continue postoperatively 1
• Combine with NSAIDs (such as ibuprofen) unless contraindicated for superior analgesia 1
• Administer single intraoperative dose of IV dexamethasone for analgesic and anti-emetic effects 1
• Reserve opioids 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

Important Caveats and Risks

Surgical Complications to Counsel Patients About:

• Bleeding (0.2-3% incidence) 4
• Pain and dehydration 1, 4
• Anesthetic risks 4

Postoperative Monitoring:

• Monitor for adequate pain control to prevent poor oral intake and dehydration 1

Common Pitfall to Avoid:

Do not perform tonsillectomy solely for tonsil stones without meeting Paradise criteria for recurrent infections. The presence of tonsilloliths alone, even if large, does not justify surgery unless the patient has documented recurrent throat infections meeting the strict frequency thresholds outlined above. 1, 2 Rarely, surgical intervention may be required only if stones become too large to pass on their own and cause significant symptoms. 2