What are tonsil stones (tonsilloliths) and what is the appropriate management—including conservative care, indications for antibiotics, and criteria for tonsillectomy referral—in otherwise healthy adolescents and adults?

Tonsil Stones (Tonsilloliths): Definition and Management

What Are Tonsil Stones?

Tonsilloliths are calcified concretions composed of calcium salts, cellular debris, and microorganisms that form within the crypts of the palatine tonsils. 1, 2 They are common findings with a prevalence ranging from 16% to 46.1% in the general population. 3

Clinical Presentation

Most tonsilloliths are small and asymptomatic, but when symptomatic they typically cause:

• Chronic halitosis (bad breath) - the most common complaint 2, 3
• Foreign body sensation in the throat 1, 3
• Pharyngeal discomfort or irritation 1
• Irritating cough 3
• Dysphagia (difficulty swallowing) - particularly with larger stones 1, 4
• Otalgia (ear pain) 3
• Foul taste in the mouth 3

Large tonsilloliths (>2 cm) are rare but can mimic abscesses or neoplasms on examination. 5, 4

Conservative Management

For asymptomatic or mildly symptomatic tonsilloliths, conservative management is the appropriate first-line approach:

• Manual removal - patients can often dislodge small stones themselves using cotton swabs or water irrigation 1, 2
• Oral hygiene optimization - regular gargling and good dental hygiene may help prevent recurrence 2
• Observation - many small tonsilloliths are incidental findings requiring no intervention 3

Role of Antibiotics

Antibiotics are NOT indicated for tonsilloliths alone. 6 Tonsilloliths are calcified deposits, not active infections requiring antimicrobial therapy.

Antibiotics should only be prescribed if there is concurrent acute bacterial tonsillitis with:

• Temperature ≥38.3°C (101°F) 6, 7
• Cervical adenopathy 6, 7
• Tonsillar exudate 6, 7
• Positive rapid antigen detection test or culture for group A beta-hemolytic streptococcus 6, 7

When bacterial tonsillitis is confirmed, first-line treatment is penicillin or amoxicillin for 10 days. 7

Surgical Management: When to Refer for Tonsillectomy

Tonsillectomy should be considered for recurrent tonsilloliths only when they cause significant symptoms AND the patient meets established criteria for surgery.

Indications for Tonsillectomy Referral:

1. Recurrent Throat Infections Meeting Paradise Criteria 6, 7

Tonsillectomy may be considered when ALL of the following are documented:

• Frequency threshold:

  • ≥7 episodes in the past year, OR
  • ≥5 episodes per year for 2 consecutive years, OR
  • ≥3 episodes per year for 3 consecutive years 6, 7

• Each episode must be documented with:

  • Temperature ≥38.3°C (101°F), AND/OR
  • Cervical adenopathy, AND/OR
  • Tonsillar exudate, AND/OR
  • Positive test for group A beta-hemolytic streptococcus 6, 7

• Antibiotics were administered for proven or suspected streptococcal episodes 7

• Contemporaneous notation in the medical record 6, 7

2. Watchful Waiting is Recommended When Criteria Are Not Met 6, 7

Do not refer for tonsillectomy if the patient has:

• <7 episodes in the past year, AND
• <5 episodes per year in the past 2 years, AND
• <3 episodes per year in the past 3 years 6, 7

3. Modifying Factors That May Favor Earlier Tonsillectomy 6, 8, 7

Even without meeting full Paradise criteria, consider referral when tonsilloliths are associated with:

• History of >1 peritonsillar abscess 6, 8, 7
• Multiple antibiotic allergies or intolerance 6, 7
• PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, adenitis) 6, 7
• Severe dysphagia or speech alteration from giant tonsilloliths 1, 4
• Recurrent severe infections requiring hospitalization 7

Important Surgical Considerations:

Tonsillectomy provides only modest short-term benefit for recurrent infections, reducing throat infection frequency primarily in the first postoperative year only. 7 In randomized trials, children meeting Paradise criteria who were observed without surgery experienced an average of only 1.17 infection episodes in the following year, indicating high rates of spontaneous improvement. 7

Common Pitfalls to Avoid

• Do NOT prescribe antibiotics for tonsilloliths without documented bacterial infection 6
• Do NOT recommend tonsillectomy without adequate documentation of infection frequency and severity 6, 7
• Do NOT refer for surgery without a 12-month observation period unless modifying factors are present 6, 7
• Do NOT prescribe codeine for pain control in patients younger than 12 years 7
• Do NOT use perioperative antibiotics for tonsillectomy - this is a strong recommendation against their use 6

Pain Management

For symptomatic tonsilloliths or post-removal discomfort, provide adequate analgesia with acetaminophen or ibuprofen. 6, 8, 7 Never prescribe codeine-containing medications to children younger than 12 years. 7

Diagnostic Workup for Large or Atypical Stones

When tonsilloliths are large (>2 cm) or presentation is atypical, obtain imaging to rule out other pathology:

• Computed tomography (CT) reveals well-defined, highly calcified oval masses and helps differentiate from abscesses or neoplasms 1, 5, 4
• Panoramic radiography may incidentally detect tonsilloliths as radioopacities in the area of the mandibular ramus 3