Definitive surgical treatment for frequent symptomatic tonsilloliths unresponsive to conservative measures

 # For a patient with frequent, symptomatic tonsilloliths unresponsive to conservative measures, what is considered the definitive surgical treatment?

a) Tonsillectomy

b) Palatoplasty (surgical modification of the soft palate)

c) Sialendoscopy

d) Local excision of the stone only

The correct answer is A. Tonsillectomy.

Tonsillectomy—complete surgical removal of the palatine tonsils—is the definitive treatment for patients with frequent, symptomatic tonsilloliths (tonsil stones) that do not respond to conservative approaches like manual disimpaction, saline irrigation, laser cryptolysis, or antibiotics. By excising the tonsils, it eliminates the deep crypts where debris accumulates and calcifies, preventing recurrence (success rate >95% in refractory cases). This is endorsed by guidelines from the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) and European Society of Otorhinolaryngology, particularly for adults with ≥3–5 episodes/year impacting quality of life (e.g., chronic halitosis, dysphagia). Risks include bleeding (2–5%) and pain, but benefits outweigh for severe cases.

The other options are inappropriate: Palatoplasty (b) addresses velopharyngeal incompetence or snoring, not tonsillar crypts; sialendoscopy (c) targets salivary gland calculi via ductal endoscopy; and local stone excision (d) offers only temporary relief, as crypts reform stones rapidly (recurrence in 70–80% within months). For partial crypt reduction, diode laser cryptolysis may be trialed first, but full tonsillectomy remains gold standard for unresponsiveness.