What is the management and treatment of tonsil stones?

Management and Treatment of Tonsil Stones

For symptomatic tonsil stones (tonsilloliths), conservative management with observation and manual removal is the primary approach, reserving tonsillectomy only for patients with large stones causing persistent symptoms or recurrent complications that significantly impact quality of life. 1

Understanding Tonsilloliths

Tonsil stones are calcified accumulations of cellular debris and microorganisms that form within the crypts of palatine tonsils. 2, 3 They are common clinical findings that typically present with:

• Halitosis (bad breath) - the most prominent symptom 2, 1
• Foreign body sensation in the throat 1, 4
• Sore throat and painful swallowing 1, 4
• Chronic cough 4

Small tonsilloliths are frequently encountered and usually asymptomatic. 1

Conservative Management (First-Line)

Watchful waiting and expectant management should be the initial approach for most patients with tonsilloliths. 1 This includes:

• Manual removal of visible stones using cotton swabs or water irrigation 1
• Oral hygiene optimization to reduce bacterial accumulation 3
• Gargling with salt water to help dislodge small stones 1
• Patient education about the benign nature of the condition 3

Most small tonsilloliths will pass spontaneously without intervention. 1

Indications for Surgical Intervention

Tonsillectomy should be considered only when tonsilloliths become too large to pass spontaneously or cause persistent, severe symptoms despite conservative measures. 1 Surgical removal is rarely required. 1

Specific surgical indications include:

• Giant tonsilloliths (>2-3 cm) that cannot be removed conservatively 2
• Recurrent formation causing significant social or physical impairment 3
• Persistent halitosis unresponsive to conservative management 2, 3
• Associated recurrent tonsillitis meeting criteria for tonsillectomy (see below) 2

When Tonsillectomy Is Appropriate

If considering tonsillectomy for associated recurrent throat infections, the American Academy of Otolaryngology criteria must be met: 5

At least 7 episodes in the past year, OR at least 5 episodes per year for 2 years, OR at least 3 episodes per year for 3 years - with documentation of each episode including: 5

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

Watchful waiting is strongly recommended if infection frequency falls below these thresholds. 1

Important Clinical Caveats

• Do not perform tonsillectomy solely for tonsilloliths unless they meet the specific criteria above for size or persistent symptoms 1
• Tonsillectomy carries significant morbidity including pain, bleeding (0.2-3% hemorrhage rate), dehydration, and rarely death 5
• Benefits of tonsillectomy for recurrent infections are modest and do not extend beyond the first year postoperatively 5
• The natural history favors spontaneous resolution in most cases of both tonsilloliths and recurrent throat infections 5, 1

Perioperative Management (If Surgery Indicated)

When tonsillectomy is performed: 5

• Administer single intraoperative dose of IV dexamethasone (0.5 mg/kg) to reduce postoperative nausea, vomiting, and pain 5
• Use ibuprofen and/or acetaminophen for postoperative pain control 5
• Never prescribe codeine in children <12 years 5
• Do not routinely prescribe perioperative antibiotics 5