To the Editor:

I appreciated the article by Smith and colleagues on tonsillitis and tonsilloliths.¹ Recurrent or severe tonsillitis can be frustrating for the patient and physician. Clinical experience has led me to believe that much of the pain, recurrence of acute tonsillitis, and chronic halitosis is due to debris—stones or food—in the tonsillar crypts. Removal of stones or food is simple and results in an almost immediate decrease in tonsillar swelling, pain, and future episodes.

I examined an adult patient whose tonsils were severely swollen with numerous large crypts, most with large amounts of debris. The patient was in obvious pain. I sprayed her throat with benzocaine and removed some of the debris. The patient called four hours later to thank me. She stated that she had never felt relief so quickly or thoroughly in all the years she has had sore throats. This encounter changed my approach to acute and chronic tonsillitis when cryptic debris or tonsilloliths are present.

The first step to stone or debris removal is to explain the procedure to the patient. They should be warned that the material removed from the tonsils is foul-tasting. Next, the patient is given a warm, moist washcloth to wipe the debris from their mouth should they not wish to swallow it. Benzocaine is sprayed onto the tonsils. The patient is asked not to swallow for 15 seconds. This step is repeated.

The patient is placed in the sniffing position, leaning forward with their chin extended as though leaning forward to sniff a flower. A 4 × 4 inch gauze pad is used to grasp the tongue, which is pulled with slight pressure to maximally expose the oropharynx. With a light via a head mirror or lamp, an ear curette is used to remove the debris from each of the tonsillar crypts, similar to wax removal from the auditory canal. A tongue blade may be required to press the tongue down or the anterior tonsillar folds laterally to get total exposure. It is not unusual for blood-streaked pus to drain after debris removal.

With a gloved hand, the index finger can apply mild pressure to the lateral edge of the tonsil and be swept medially. After clearing both tonsils, the patient is asked to gargle with cool water and spit out the residue until there is no more blood or pus.

In Reply:

Thank you for your interest in our article. A recent literature search of PubMed did not find similar management recommendations for patients with tonsilloliths. As you are likely aware, patients should be discouraged from trying to remove tonsil stones on their own. Our article was accompanied by a patient handout on tonsil stones discussing potential treatment, including brushing teeth and gargling with salt water.¹ Note that this information was adapted from the Cleveland Clinic.² We appreciate your perspective and thank you for sharing your practice experience.