RAG rating
Document type
Clinical policy
Hertfordshire and West Essex ICB
Output type
Clinical Policies & Evidence-based Interventions

Tonsillectomy for tonsilloliths


This policy applies to tonsillectomy for tonsilloliths. 

Tonsillectomy for other indications is outside of the scope of this policy.

Please refer to the national EBI programme for tonsillectomy for recurrent tonsillitis, recurrent quinsy, emergency presentations and suspected cancer. see https://ebi.aomrc.org.uk/.  Please refer to the local policy on obstructive sleep apnoea for tonsillectomy in obstructive sleep apnoea.

Tonsillectomy is not routinely commissioned for tonsilloliths

Removal of the stone under local anaesthetic in the outpatient setting may be appropriate for symptomatic patients where self- care has failed. Requests for tonsillectomy for tonsilloliths will need to be via the Individual Funding requests department.

Tonsilloliths (also known as tonsil stones) are concretions stemming from a reactive foreign nidus such as exfoliated epithelium cells, keratin debris, organic debris, and bacteria.

Tonsilloliths form in the tonsillar crypts (7). They can occur in up to 10% of the population and often form following recurrent episodes of tonsillitis. 

They most commonly occur in young adults and are not frequently seen in children (8). Patients with tonsilloliths may be asymptomatic or may present with halitosis (bad breath), sore throat, difficulty swallowing and the sensation of a foreign body in the throat (9). Diagnosis is usually made on clinical signs and symptoms (inspection).

Management and National guidelines:

There are no published guidelines on the management of tonsilloliths. Consensus as summarised on patient.info and Mayo clinic website describes:

Good dental hygiene helps to prevent tonsil stones. Teeth should be brushed twice a day as advised by the patient’s dentist, including the spaces in between them, to stop any debris accumulating. A tongue scraper may keep the tongue clear of any bacteria which might contribute to a stone forming. Regular gargling with a mouthwash or saltwater solution may also help. Smoking and alcohol should be avoided as they may make tonsilloliths more likely to build up.

Treatment is not necessarily needed if there are no symptoms. If there are symptoms, options for tonsil stone self-management include:

  • Regular gargling (then spitting out) with mouthwash or a saltwater solution. This may dislodge the stones.
  • When stones form, the patient can remove them either by gently pressing them out with a cotton swab or the back of a toothbrush, or by washing them out with a low-pressure water irrigator. This device can be used to aim a gentle stream of water at the tonsil craters and rinse out debris that may be caught in them.