What is the treatment for tonsil stones?

Treatment of Tonsil Stones (Tonsilloliths)

Conservative management with watchful waiting is the recommended first-line approach for tonsil stones, as tonsillectomy is NOT indicated unless the patient meets strict criteria for recurrent throat infections (Paradise criteria) or has significant obstructive sleep-disordered breathing. 1

Initial Conservative Management

Most tonsil stones are small, common clinical findings that should be managed expectantly without surgical intervention 2. The treatment approach depends on symptom severity and frequency:

Non-Surgical Options

• Expectant management is appropriate for small, asymptomatic tonsilloliths that typically pass on their own 2
• Manual removal can be attempted for accessible stones causing discomfort
• Oral hygiene measures and gargling may help prevent recurrence
• Patients with persistent halitosis and tonsil stones for 6 months should still receive conservative management first 1

When Surgery is NOT Indicated

Tonsillectomy should NOT be performed for tonsil stones alone, even with 6 months of symptoms, unless the patient meets one of these specific criteria 1:

• Paradise criteria for recurrent throat infections (≥7 episodes in past year, ≥5 episodes/year for 2 years, or ≥3 episodes/year for 3 years with proper documentation)
• Obstructive sleep-disordered breathing with tonsillar hypertrophy
• Modifying factors such as multiple antibiotic allergies or history of peritonsillar abscess

Documentation Requirements Before Considering Surgery

If recurrent throat infections are present alongside tonsilloliths, each episode must be documented with qualifying features 1:

• Temperature ≥38.3°C (101°F)
• Cervical lymphadenopathy
• Tonsillar exudate
• Positive test for group A beta-hemolytic streptococcus

Important caveat: Many patients awaiting tonsillectomy no longer meet criteria by the time of surgery, highlighting the self-limited nature of these conditions 1. This underscores the importance of watchful waiting.

Surgical Intervention for Large Tonsilloliths

Rarely, surgical intervention is required if tonsilloliths become too large to pass spontaneously 2. In documented cases of giant tonsilloliths (e.g., >3 cm), elective stone removal with or without tonsillectomy may be performed 3.

Surgical Risks to Discuss

If surgery is being considered, patients must be counseled on 1:

• Primary hemorrhage: 0.2-2.2%
• Secondary hemorrhage: 0.1-3%
• Prolonged throat pain requiring standardized pain management
• Postoperative nausea/vomiting
• Dehydration
• Readmission rates up to 3.9% for complications

Benefits Are Modest

Even when Paradise criteria are met for recurrent infections, the anticipated benefits of tonsillectomy are only modest and must be balanced against natural resolution with watchful waiting 1.

Clinical Algorithm

1. Assess for tonsilloliths: Confirm presence and size
2. Evaluate symptoms: Halitosis, throat discomfort, foreign body sensation
3. Document any throat infections: Use validated scoring systems (Centor, McIsaac, FeverPAIN) and count episodes over time 4
4. Initiate conservative management: Expectant observation, manual removal if accessible
5. Continue watchful waiting: Unless Paradise criteria met or obstructive symptoms present
6. Consider surgery only if: Giant tonsillolith unable to pass OR meets strict Paradise criteria for recurrent infections OR significant sleep-disordered breathing 1, 2

Common pitfall: Performing tonsillectomy for isolated tonsilloliths or halitosis without meeting established criteria exposes patients to surgical risks without proven benefit 1.