Tonsil stones: what they are, symptoms, how to remove them and when to see a GP

The tonsils are gland-like structures in the back of the throat made of tissue that plays a role in the body's immune system. MyHealth Devon, an NHS information service, says they work like nets trapping bacteria and virus particles. Tonsil stones occur when food debris, bacteria and dead cells get trapped in the crevices and pits of the tonsils and become calcified, which turns the debris into hard white or yellow deposits.

Patient, a UK patient information site, says tonsil stones are made up of minerals, mainly calcium salts, plus cells, tissue and bacteria. They can be hard, like tiny rocks, or quite soft, and are usually small, but can sometimes get bigger. They are not cancerous growths and are not attached to the tissue around them, but stuck in the crevices.

Patient adds that tonsil stones can occur at any age but are more common in adults than in children. Some people develop one, while others have several, and in some people another forms somewhere else on the tonsils when one is removed.

MyHealth Devon says that in general tonsil stones cause minimal symptoms and most people may not even realise they have them. Patient agrees that often there are no symptoms at all. When symptoms do occur, they can include the following.

• Bad breath (halitosis).

• A feeling of something being stuck at the back of the throat.

• Discomfort or pain when swallowing.

• A sore throat.

• A persistent, irritating cough.

• A bad taste in the mouth.

• Earache, as a problem in the mouth can radiate to the ear (Patient).

• Swollen or enlarged tonsils and visible white or yellow debris (MyHealth Devon).

• Coughing up a small, irregular lump of offensive cream or white matter.

MyHealth Devon says tonsil stones are usually harmless and go away on their own. There are several self-administered treatments described in the literature and on social media, but there is little firm evidence to recommend any of them as definitive. Patient says treatment is not necessarily needed, especially if there are no symptoms.

NHS Scotland's Right Decisions guidance (NHS Greater Glasgow and Clyde) says that conservative management should be adopted and that salt water gargles or chlorhexidine mouthwash gargles may help.

The two sources disagree on irrigation and swabbing, so it is worth being careful. MyHealth Devon says that water jet irrigation and manual removal with a finger or a cocktail stick should be avoided because they risk damaging the tonsils and can lead to bleeding, infection and inhalation of a foreign body. Patient describes gentle irrigation and cotton swabbing as options but says it is important to follow instructions carefully because the tonsils can be damaged if too much force is used, causing pain and bleeding.

MyHealth Devon lists the causes as chronically inflamed tonsils, large tonsils (which provide more pits and crevices for build-up), poor oral hygiene that allows bacteria to continuously interact with the tonsils, and sinus issues, which increase mucus in the throat via post-nasal drip and catarrh.

Patient lists risk factors as smoking, poor oral hygiene, recurrent tonsil infections and having tonsillar crypts, which are the folds, gaps and crevices found in some people's tonsils and are more common in larger or craggy-looking tonsils. It adds that people whose tonsils are not visible are unlikely to develop tonsil stones.

MyHealth Devon says tonsil stones can usually be seen at the back of the mouth and no special tests are needed to confirm the diagnosis. Sometimes they are seen coincidentally on X-rays or scans done for other reasons. Patient agrees that no special tests are usually needed.

Tonsil stones are not typically associated with acute infection such as bacterial tonsillitis, although MyHealth Devon says they can co-exist in people with a history of recurrent tonsillitis. The NHS describes tonsillitis as an infection of the tonsils, with red and swollen tonsils, a sore throat, problems swallowing, a high temperature and sometimes pus-filled spots or white patches on the tonsils.

MyHealth Devon says tonsil stones are harmless and, in the absence of symptoms suggestive of infection or other abnormalities, do not warrant medical assessment or intervention. However, it says to consult your GP if you have:

• A chronic sore throat that lasts more than a month.

• Recurrent bouts of tonsillitis that interfere with daily activities such as school or work.

• Breathing problems.

• Trouble swallowing.

• Severe pain, especially on one side, which could be a sign of an infection such as quinsy (a peri-tonsillar abscess).

• One tonsil larger than the other; in rare circumstances this may be a symptom of cancer.

The NHS says to call 999 or go to A&E if you have a severe sore throat that quickly gets worse, swelling inside the mouth and throat, difficulty speaking, difficulty swallowing, difficulty breathing or difficulty opening your mouth, as these are signs of quinsy. Do not drive to A&E.

The NHS also says to get help from NHS 111 if you have pus-filled spots on your tonsils or a sore throat so painful that it is difficult to eat or drink.

MyHealth Devon says a thorough oral hygiene routine may help reduce the formation of tonsil stones, although they are not, in themselves, evidence of poor oral hygiene. Patient also lists avoiding smoking as helpful.

• Brush your teeth twice a day or after meals, with anti-bacterial toothpaste if you wish.

• Floss at least once a day.

• Clean your tongue regularly; Patient suggests a tongue scraper.

• Rinse and gargle with salt water or an alcohol-free mouthwash.

• Drink plenty of water to keep saliva production up.

• See your dentist regularly.

• Avoid smoking.

On the NHS most people never need an appointment. MyHealth Devon says NHS Devon has determined that surgical tonsillectomy for tonsil stones alone is not a good use of local NHS resources and cannot be justified on clinical grounds, and NHS Scotland guidance says it does not perform tonsillectomy for tonsil stones. Local policies vary, so ask your GP.

A GP or dentist can examine your throat and refer you to an ENT surgeon if stones are large, painful or causing repeated infections. If you consult privately, ask about the evidence for the procedure offered and the risks, particularly of tonsillectomy, which MyHealth Devon says carries a small but significant risk of complications.