Treatment of Enlarged Tonsils with Tonsil Stones
For adults with enlarged tonsils and tonsil stones causing symptoms, tonsillectomy is the definitive treatment, particularly when associated with recurrent infections, obstructive symptoms, or significantly impaired quality of life. 1, 2
Initial Assessment
Document the degree of tonsillar enlargement using the Brodsky grading scale (0-4+, with 4+ representing "kissing tonsils" occupying ≥75% of the oropharyngeal space) to objectively quantify obstruction. 2
Evaluate for obstructive sleep-disordered breathing by asking specifically about:
- Witnessed apneas or gasping during sleep
- Loud snoring
- Daytime somnolence or fatigue
- Morning headaches
- Difficulty concentrating or behavioral changes 3
Assess symptom burden from tonsilloliths, including:
- Halitosis (bad breath) - the most common complaint 4
- Foreign body sensation in the throat
- Recurrent sore throat or chronic throat discomfort
- Painful swallowing
- Chronic cough 4, 5
Treatment Algorithm
Conservative Management (First-Line for Isolated Small Tonsilloliths)
Expectant management is appropriate for small, asymptomatic tonsilloliths that pass spontaneously, as these are common clinical findings. 4
Manual removal techniques can be attempted for symptomatic stones, though this provides only temporary relief as stones typically recur in cryptic tonsils. 6, 4
Surgical Intervention (Definitive Treatment)
Tonsillectomy is indicated when:
- Tonsilloliths become too large to pass spontaneously (>2-3 cm) 6
- Recurrent tonsillitis meets Paradise criteria: ≥7 episodes in the past year, ≥5 episodes per year for 2 years, or ≥3 episodes per year for 3 years 2
- Grade 3-4 tonsillar hypertrophy causes obstructive sleep apnea confirmed by polysomnography 1, 2
- Chronic symptoms (halitosis, foreign body sensation, recurrent throat pain) significantly impair quality of life despite conservative measures 3, 4
Complete tonsillectomy is preferred over partial tonsillotomy because residual lymphoid tissue may harbor crypts that continue producing stones and contributing to obstruction. 1, 2
Consider polysomnography before surgery if there is discordance between tonsillar size and reported severity of sleep symptoms, or if the patient has risk factors including obesity, craniofacial abnormalities, or neuromuscular disorders. 1, 2
Special Considerations
In adults with tonsillar hypertrophy and confirmed OSA, tonsillectomy produces significant improvements in respiratory parameters and can reduce CPAP pressure requirements when patients are CPAP-intolerant due to tonsillar obstruction. 3
Adenoidectomy is typically not performed concurrently in adults (unlike pediatric cases), as adenoid tissue usually regresses after childhood. 1, 2
Radiofrequency tonsil reduction may be considered for poor surgical candidates who refuse traditional tonsillectomy, though it provides unpredictable reduction and is less effective than complete tonsillectomy. 1
Critical Pitfalls to Avoid
Do not delay evaluation of unilateral tonsillar enlargement, as asymmetric enlargement requires assessment to exclude malignancy, particularly in adults with risk factors. 1
Never assume tonsillectomy will completely resolve OSA in obese patients or those with severe preoperative disease - arrange postoperative polysomnography if symptoms persist. 3, 2
Recognize that acute severe tonsillar enlargement can rapidly progress to airway obstruction requiring emergency intervention, particularly with infectious causes. 7