Tonsillar Stone Treatment
For most patients with tonsillar stones, conservative management with adequate hydration and observation is the first-line approach, reserving tonsillectomy only for those meeting Paradise criteria for recurrent tonsillitis (≥7 episodes in the past year, OR ≥5 episodes per year for 2 years, OR ≥3 episodes per year for 3 years). 1, 2
Conservative Management (First-Line)
Most tonsillar stones can be managed expectantly without surgical intervention. 3
- Adequate fluid intake is the cornerstone of conservative therapy, helping to naturally flush debris from tonsillar crypts and providing relief from associated discomfort 1
- Honey can be used as an adjunctive therapy due to its antimicrobial properties and ability to soothe the throat 1
- Small tonsilloliths are common clinical findings and typically pass on their own without intervention 3
When Conservative Management Fails
If stones become symptomatic (causing halitosis, recurrent sore throat, or physical discomfort) despite conservative measures, consider the following:
- Coblation cryptolysis can be performed in adults under local anesthesia without sedation, with pain lasting only a few days and normal activity resuming within 1 week 4
- This technique avoids the significant morbidity of tonsillectomy while achieving significant reduction or elimination of tonsil stones after a single session 4
Surgical Management (Reserved for Specific Indications)
Tonsillectomy should only be considered when patients meet Paradise criteria for recurrent tonsillitis, NOT solely for tonsillar stones. 1, 2
Paradise Criteria for Tonsillectomy:
- ≥7 episodes of throat infection in the past year, OR
- ≥5 episodes per year for 2 consecutive years, OR
- ≥3 episodes per year for 3 consecutive years 1
Modifying Factors That Lower the Surgical Threshold:
Observation Period:
- A 12-month period of watchful waiting is recommended before proceeding with tonsillectomy, as spontaneous improvement is possible in many cases 1, 2
Surgical Technique Options (if tonsillectomy is indicated):
- Electrocautery dissection is a standard approach 1
- Coblation technique uses moderate heat and results in slightly less postoperative pain on day 1 compared to other methods 1
- Laser tonsillotomy is NOT considered complete tonsillectomy and has higher recurrence rates—avoid this approach 1
Perioperative Pain Management (If Surgery Performed)
Multimodal analgesia is mandatory for tonsillectomy patients: 1, 5
- Paracetamol (acetaminophen) started pre-operatively or intra-operatively, continued postoperatively on a scheduled (not as-needed) basis 1, 5
- NSAIDs (ibuprofen) combined with paracetamol unless contraindicated—this combination provides superior analgesia 1, 5
- Single intraoperative dose of IV dexamethasone for analgesic and anti-emetic effects 1, 5
- Opioids reserved only as rescue medication—codeine should be avoided in children younger than 12 years 1, 5
Important Caveat:
Previous concerns about NSAIDs increasing bleeding risk have NOT been substantiated in recent meta-analyses 1, 5
Antibiotic Use
- Perioperative antibiotics are NOT routinely recommended for tonsillectomy 1
Post-Procedure Monitoring
- Monitor for adequate pain control to prevent poor oral intake and dehydration 1, 5
- Encourage adequate hydration and nutrition as tolerated—there is no benefit to restricting diet to liquids or cold foods only 5
- Patients should be educated on proper pain assessment and when to contact healthcare providers if pain is inadequately controlled 5
Key Clinical Pitfalls to Avoid
- Do not perform tonsillectomy solely for tonsillar stones unless Paradise criteria for recurrent tonsillitis are met 1, 2
- Do not rush to surgery—observation for 12 months is appropriate as spontaneous improvement occurs in many cases 1
- Do not withhold NSAIDs due to outdated bleeding concerns—recent evidence does not support this practice 1, 5
- Rarely, giant tonsilloliths (>3 cm) may require surgical removal if they cannot pass spontaneously 6