How should tonsil stones (tonsilloliths) be managed initially and when is tonsillectomy indicated?

Treatment of Tonsil Stones (Tonsilloliths)

Conservative management with watchful waiting is the recommended first-line approach for tonsil stones, as tonsillectomy is NOT indicated for tonsilloliths alone unless the patient meets strict Paradise criteria for recurrent throat infections or has significant obstructive sleep-disordered breathing. 1, 2

Initial Conservative Management

The evidence for tonsillectomy specifically for tonsilloliths and halitosis is limited and generally of lesser quality, making shared decision-making essential 1. Most tonsilloliths are small, common clinical findings that can be managed expectantly 3.

Conservative options include:

• Manual removal or expression of visible stones by the patient or clinician 3
• Oral hygiene measures including tongue scraping to rule out oral causes of halitosis before attributing symptoms to tonsils 4
• Watchful waiting as many tonsilloliths pass spontaneously 3

When Tonsillectomy Is NOT Indicated

Tonsillectomy should NOT be performed for tonsilloliths unless the patient meets one of the following strict criteria: 1, 2

• Paradise criteria for recurrent throat infections: ≥7 documented episodes in the past year, OR ≥5 episodes per year in the past 2 years, OR ≥3 episodes per year in the past 3 years, with each episode documented to include fever >38.3°C, cervical lymphadenopathy, tonsillar exudate, or positive strep test 1
• Obstructive sleep-disordered breathing with tonsillar hypertrophy 1, 2
• Modifying factors such as multiple antibiotic allergies, PFAPA syndrome, or history of peritonsillar abscess 1, 2

Important Caveats About Surgical Risk

If tonsillectomy is being considered, patients must be counseled that even when Paradise criteria are met, the anticipated benefits are only modest and balanced against natural resolution with watchful waiting 1, 2. The surgical risks include 1, 2:

• Primary hemorrhage: 0.2-2.2% within 24 hours
• Secondary hemorrhage: 0.1-3% after 24 hours, potentially requiring readmission or repeat surgery
• Readmission rates: up to 3.9% for complications including pain, vomiting, fever, or bleeding
• Prolonged throat pain lasting several weeks
• Mortality risk: 1 per 2,360 in inpatient settings and 1 per 18,000 in ambulatory settings 1

Alternative Minimally Invasive Options

For adults with persistent symptomatic tonsilloliths who do not meet criteria for tonsillectomy, Coblation tonsil cryptolysis may be considered as a less invasive alternative 5, 4. This technique:

• Can be performed under local anesthesia without sedation in adults 5
• Results in significant pain for only a few days with return to normal activity within 1 week 5
• Avoids the significant morbidity of several weeks associated with tonsillectomy 5
• May achieve significant decrease or elimination of tonsil stones after a single session 5

Laser cryptolysis is another option that may be preferable to tonsillectomy in adults, potentially avoiding general anesthesia and the higher risks associated with tonsillectomy in this age group 4.

Critical Documentation Requirements

Many children awaiting tonsillectomy no longer meet criteria by the time of surgery, highlighting the self-limited nature of these conditions 2. If recurrent infections are claimed, each episode must be documented with contemporaneous clinical notation including specific qualifying features 1. Without proper documentation, watchful waiting remains the appropriate approach 1.