Tonsillitis

Tonsillitis is a common condition that causes swelling and infection of the tonsils, the two oval-shaped pads of tissue at the back of your throat. While it can affect people of all ages, it is most common in children and teenagers, and most people will experience it at least once in their lifetime.

Table of contents

• What is tonsillitis?
• Symptoms
• Causes and transmission
• Diagnosis
• Treatment
• Home care and self-treatment
• Complications
• Prevention
• When to see a doctor

What is tonsillitis?

Tonsillitis is swelling and irritation, called inflammation, of the tonsils^[1]. The tonsils are two oval-shaped pads of tissue at the back of the throat, one on each side. You can see your tonsils in a mirror by opening your mouth and sticking out your tongue^[11].

Your tonsils are part of your immune system, which helps your body fight infection. They work by trapping germs that come in through your mouth and nose^[2]. The tonsils sit in the lateral oropharynx between the palatoglossal and palatopharyngeal arches and are made of lymphoid tissue. They serve as a first-line defense against pathogens that are inhaled or swallowed^[3].

Tonsillitis is most common in children over age two and teenagers. Almost every child in the United States gets it at least once^[2]. It rarely occurs in children under the age of 3^[11]. Adults can get tonsillitis, but it is not very common^[2].

The medical term for tonsillitis is tonsillopharyngitis, but most people call it a sore throat because that’s what it feels like^[11].

Symptoms

Common symptoms of tonsillitis include red, swollen tonsils, sore throat, and fever. Tonsillitis symptoms usually come on suddenly^[11]. The main symptoms are inflamed and swollen tonsils, sometimes severe enough to make it hard to breathe through your mouth^[4].

The most common symptoms include^[1][2][11]:

• Red, swollen tonsils
• White or yellow coating or patches on the tonsils
• Sore throat, which may be severe
• Trouble swallowing or painful swallowing
• Fever above 100.4 degrees Fahrenheit (38 degrees Celsius)
• Enlarged, tender glands called lymph nodes in the neck
• A scratchy, muffled or throaty voice
• Bad breath
• Stomachache
• Neck pain or stiff neck
• Headache
• Earache

In young children who cannot tell how they feel, symptoms of tonsillitis may include^[1][4]:

• Drooling due to trouble swallowing or painful swallowing
• Not eating
• Being fussier than usual
• Upset stomach or vomiting

A sore throat is often the first symptom of tonsillitis. If you develop a sudden sore throat, keep an eye on your tonsils to see if they get red or swollen^[11].

Causes and transmission

The cause of tonsillitis is usually a viral infection. Bacterial infections such as strep throat can also cause tonsillitis^[2]. Tonsillitis is most often caused by viral or bacterial infection^[9].

Viral pathogens are responsible for 70% to 95% of cases, while bacterial pathogens, particularly Streptococcus pyogenes (group A Streptococcus), account for 5% to 15% of adult cases and 15% to 30% of pediatric cases, especially in children aged 5 to 15^[3]. Viral infections that cause tonsillitis include those from common cold viruses, influenza, Epstein-Barr virus (which causes mono), herpes simplex virus, and adenoviruses^[4].

Bacterial tonsillitis, often called strep throat, is most commonly caused by Streptococcus (strep) bacteria. Other bacteria, such as Staphylococcus aureus, can also inflame your tonsils^[4]. Generally, bacterial tonsillitis causes more severe symptoms than viral tonsillitis^[11].

Although tonsillitis itself is not contagious, the viruses and bacteria that cause it are contagious^[2]. The viruses and bacteria that cause tonsillitis are highly contagious. They’re passed along by^[11]:

• Kissing or sharing utensils, foods or drinks
• Coming into close contact with someone who’s sick
• Touching a contaminated surface and then touching your nose or mouth
• Inhaling tiny particles that become airborne when a sick person sneezes or coughs

Transmission occurs via droplets from patients with acute tonsillitis or rarely by asymptomatic carriers^[17].

Diagnosis

To diagnose tonsillitis, your healthcare professional starts with a physical exam. In the exam, they use a lighted instrument to look at your throat, ears and nose, check for a rash, gently feel your neck to check for swollen glands, and listen to your breathing^[12].

Your healthcare professional will look at your throat to see if you have red and swollen tonsils with spots or sores^[7]. The provider will look at your throat and neck, checking for things such as redness or white spots on the tonsils and swollen lymph nodes^[2].

Your child will probably also have one or more tests to check for strep throat, since it can cause tonsillitis and it requires treatment. It could be a rapid strep test, a throat culture, or both^[2]. With this simple test, a healthcare professional rubs a sterile swab over the back of your throat^[12].

Many clinics have a lab that can get a test result in minutes. But there’s a second, better test. Getting results from this throat culture can take hours. The culture often is sent to a lab. Results then can take hours to days^[12]. The throat culture is a more reliable test. So sometimes if the rapid strep test is negative (meaning that it does not show any strep bacteria), the provider will also do a throat culture just to make sure that your child does not have strep^[2].

Your healthcare professional may order a complete blood count (CBC) that uses a small sample of your blood. The test measures the types of cells in the blood, such as red cells and white cells. The results can show whether an infection is more likely caused by bacteria or viruses^[12].

Treatment

Treatment for tonsillitis depends on the cause. If the cause is a virus, there is no medicine to treat it. If the cause is a bacterial infection, such as strep throat, your child will need to take antibiotics^[2].

Tonsillitis caused by a virus goes away on its own. Tonsillitis caused by the bacteria that causes strep throat is treated with antibiotics^[6]. If a bacterial infection is causing tonsillitis, a doctor will usually prescribe antibiotics^[10].

If the cause is a bacterial infection, such as strep throat, penicillin should be used as the first-line antibiotic^[17]. It is important for your child to finish the antibiotics even if he or she feels better. If treatment stops too soon, some bacteria may survive and re-infect your child^[2].

Treatment of acute tonsillitis is largely supportive and focuses on maintaining adequate hydration and caloric intake and controlling pain and fever^[13]. Viral tonsillitis usually gets better without additional treatment. Hydration and pain control are important, and hospitalization may be required in severe cases^[9].

Surgery to remove tonsils used to be a common way to treat tonsillitis. Now surgery is done mainly when tonsillitis happens often, doesn’t respond to other treatments or causes serious complications^[1]. Tonsillectomy is indicated for individuals who have experienced more than six episodes of streptococcal pharyngitis (confirmed by positive culture) in 1 year, five episodes in 2 consecutive years, or three or more infections of the tonsils and/or adenoids per year for 3 years in a row despite adequate medical therapy^[13].

In cases of recurrent tonsillitis, watchful waiting is typically preferred over tonsillectomy if there have been less than seven episodes in the past year, less than five episodes per year in the past two years, or less than three episodes per year in the past three years^[17].

Home care and self-treatment

No matter what is causing the tonsillitis, there are some things you can do to help your child feel better. Make sure that your child^[2][6]:

• Gets a lot of rest
• Drinks plenty of fluids. Fluids may help soothe an irritated throat. Drink warm or cold liquids (whichever feels better). These include tea, soup, ice, and flavoured ice pops
• Tries eating soft foods if it hurts to swallow
• Tries eating warm liquids or cold foods like popsicles to soothe the throat
• Isn’t around cigarette smoke or anything else that could irritate the throat
• Sleeps in a room with a humidifier
• Gargles with saltwater (children should not do this if they are too young)
• Sucks on a lozenge (but do not give them to children under four; they can choke on them)
• Takes an over-the-counter pain medicine, such as acetaminophen (Tylenol), ibuprofen (Advil, Motrin), or naproxen (Aleve)

To make saltwater for gargling, mix half a teaspoon of salt in a glass of warm water and stir until it has dissolved. Gargle with the salty water (do not swallow it), then spit it out. Repeat as often as you like. Young children should not gargle with salty water^[16].

Lozenges containing licorice can have strong anti-inflammatory benefits, soothing discomfort and swelling in the tonsils and throat. Lozenges should not be given to young children due to the choking risk^[25].

Use a vaporizer or humidifier to add moisture to the area where you sleep. Follow the directions for cleaning the machine^[6].

If you smoke, try to quit. If you can’t quit, cut back as much as you can. Smoking can interfere with healing^[6].

Complications

Tonsillitis can sometimes result in complications. People with untreated bacterial tonsillitis have a higher risk of developing^[11]:

• Poststreptococcal reactive arthritis (joint pain and swelling that occurs within 10 days of a strep infection)
• Rheumatic fever
• Scarlet fever
• Kidney inflammation

Other complications can include^[11]:

• Obstructive sleep apnea
• Peritonsillar abscess
• Tonsil stones
• Tonsillar cellulitis

Bacterial tonsillitis is caused by group A beta-hemolytic Streptococcus. It is important to differentiate group A beta-hemolytic streptococcus from other bacterial or viral causes of pharyngitis and tonsillitis because of the risk of progression to more systemic complications such as abscess, acute glomerulonephritis, rheumatic fever, and scarlet fever after infection^[17].

Bacterial tonsillitis sometimes leads to a condition called quinsy. This occurs when an abscess (or a buildup of pus) develops next to your tonsil, pushing it toward the center of your throat. Quinsy can be quite painful^[4]. Complications of tonsillitis are very rare. Sometimes you can get an area filled with pus (abscess) between your tonsils and the wall of your throat. This is called quinsy^[16].

Prevention

Although tonsillitis is not contagious, the viruses and bacteria that cause it are contagious. Frequent handwashing can help prevent spreading or catching the infections^[2].

To stop these infections spreading^[16]:

• If you or your child have a high temperature or you do not feel well enough to do your usual activities, try to stay at home and avoid contact with other people until you feel better
• Use tissues when you cough or sneeze and throw them away
• Wash your hands after coughing or sneezing

If your child has tonsillitis they should stay at home until their fever has gone and they are able to swallow comfortably again. This will usually be 3 to 4 days^[26].

When to see a doctor

It’s important to get a diagnosis if your child has symptoms that may mean tonsillitis. You should call your healthcare professional if your child^[1][2]:

• Has a sore throat with fever
• Has a sore throat that doesn’t go away within 24 to 48 hours
• Has a sore throat for more than two days
• Has painful swallowing or trouble swallowing
• Has extreme weakness, tiredness or fussiness
• Feels very sick or very weak

Get care right away if your child has any of these symptoms^[1][2]:

• Trouble breathing
• Extreme trouble swallowing
• A lot of drooling
• Starts drooling

You should get emergency care right away if your child has trouble breathing, starts drooling, or has a lot of trouble swallowing^[2].

Call 999 or go to A&E if you have a severe sore throat that quickly gets worse, you have swelling inside the mouth and throat, you have difficulty speaking, you cannot swallow, you have difficulty breathing, or you have difficulty opening your mouth. These are signs of quinsy^[16].

Symptoms of tonsillitis usually go away after 3 to 4 days but can last longer. Tonsillitis typically lasts from a few days up to a couple of weeks^[6][16].