Tonsillitis

Overview

The tonsils are lymphoid tissue at the back of the throat, one on each side. Tonsillitis is usually caused by a virus, such as the kind behind a cold, though bacteria such as group A streptococcus (strep throat) can also be responsible. It is common in children, teenagers and young adults. The NHS says symptoms usually ease within three to four days, though they can last longer, and NHS sources describe it as usually getting better on its own within a week. Viral cases usually clear up on their own, and a GP may prescribe antibiotics if a bacterial cause is found.

Symptoms

What a clinician may find

• Swollen, red tonsils
• White, pus-filled spots on the tonsils in some people
• Swollen, tender glands in the neck
• Fever

Complications

• Quinsy, a pocket of pus between a tonsil and the throat wall, which the NHS describes as a rare but potentially serious complication
• Rheumatic fever, which can follow strep throat; MedlinePlus says it does not often occur in the US and other developed countries
• Infection that does not improve with antibiotics by mouth and gets worse, for which a GP may refer a person to hospital for antibiotics given into a vein

Diagnosis

A doctor can usually tell that a person has tonsillitis by asking about the symptoms and looking in the throat. A GP may swab the throat to check whether bacteria are the cause; results usually take a few days. A blood test for glandular fever is usually considered when symptoms are severe or persist. For sore throats in general, NICE guidance recommends two scoring tools, FeverPAIN and Centor, to identify people more likely to benefit from an antibiotic.

Treatment

Tonsillitis caused by a virus usually clears up on its own, so treatment is mostly about easing symptoms. The NHS suggests paracetamol or ibuprofen for pain, rest, cool drinks and gargling with warm salty water (which it says children should not do), and advises that aspirin is not given to children under 16. A pharmacist can suggest lozenges. If a bacterial cause is found, a GP may prescribe a short course of antibiotics by mouth. NICE says antibiotics give only a small benefit for sore throat and that withholding them is unlikely to cause complications, so it recommends a back-up prescription for some people and an immediate prescription for people who are systemically very unwell, have signs of a more serious illness or are at high risk of complications. The NHS says it is very rare for someone to need the tonsils removed (tonsillectomy), and that it is usually only done for severe tonsillitis that keeps coming back.

Prevention

NHS guidance on limiting the spread of colds and flu, which are among the infections that can lead to tonsillitis, suggests washing hands regularly, covering coughs and sneezes with a tissue and putting it in the bin quickly, and not sharing cups, cutlery or towels.

Key facts

What are the symptoms of tonsillitis?

The usual symptoms of tonsillitis are a sore throat, pain when swallowing, earache and fever. The tonsils may look swollen and red, and some people have white, pus-filled spots on them. The glands in the neck can become swollen and tender.

The NHS says symptoms usually ease within three to four days, although they can last longer. NHS sources describe tonsillitis as an illness that usually gets better on its own within a week. Tonsillitis is common in children, teenagers and young adults.

When symptoms do not go away, the advice differs slightly by source. The NHS page advises a GP appointment if symptoms have not gone away within a week, while NHS inform advises contacting the GP practice if symptoms last longer than four days without showing signs of getting better. NHS inform adds that NHS 111 can advise when the surgery is closed.

What causes tonsillitis?

Most cases of tonsillitis are caused by a virus, such as the kind behind a cold. Bacteria can also be responsible. One bacterial cause is group A streptococcus, which also causes strep throat.

The NHS says tonsillitis itself is not contagious, but the infections that cause it, for example colds and flu, are. Tonsillitis is common in children, teenagers and young adults.

Telling a viral from a bacterial cause matters because treatment differs. Viral tonsillitis usually clears up on its own, while a GP may prescribe a short course of antibiotics by mouth if a bacterial cause is found. NICE says antibiotics give only a small benefit for sore throat and that withholding them is unlikely to cause complications. Quinsy, a pocket of pus beside a tonsil, usually develops after a bacterial infection spreads from the tonsil.

How is tonsillitis diagnosed?

A doctor can usually tell that a person has tonsillitis by asking about the symptoms and looking in the throat. A GP may swab the throat to check whether bacteria are the cause, and results usually take a few days. A blood test for glandular fever is usually considered when symptoms are severe or persist.

For sore throats in general, NICE recommends that clinicians use one of two scoring tools, FeverPAIN or Centor, to identify the people more likely to benefit from an antibiotic. People with low scores are unlikely to benefit and are given self-care advice rather than an antibiotic. For higher scores the clinician considers an immediate or a back-up prescription, which is handed over with advice not to start it straight away and to use it only if there is no improvement. NICE notes that its committee said the scoring tools have not been validated in a UK population.

Difficulty breathing is an emergency, and the NHS advises calling 999 or going to A&E.

How is tonsillitis treated?

Because viral tonsillitis usually clears up on its own, treatment is mostly about easing symptoms. The NHS suggests paracetamol or ibuprofen for pain, rest, cool drinks and gargling with warm salty water, which it says children should not do. NICE lists paracetamol for pain or fever, with ibuprofen as an alternative if preferred and suitable, and advises an adequate intake of fluids. The NHS advises that aspirin is not given to children under 16. A pharmacist can suggest lozenges, and NHS sources say gargles and sprays may soothe a sore throat but do not shorten the illness.

A GP may prescribe a short course of antibiotics by mouth if a bacterial cause is found. NICE says that for people who are systemically very unwell, have symptoms and signs of a more serious illness, or are at high risk of complications, an immediate antibiotic prescription should be offered. If antibiotics by mouth do not help and symptoms are getting worse, a GP may refer a person to hospital for antibiotics given into a vein.

What are the complications of tonsillitis?

Complications of tonsillitis are rare. The best known is quinsy, also called a peritonsillar abscess, in which a pocket of pus builds up between a tonsil and the wall of the throat, usually after a bacterial infection spreads from the tonsil. The NHS describes it as a rare but potentially serious complication. Quinsy can happen at any age but is most common in teenagers and young adults, and it can come back.

The NHS lists the signs that can point to quinsy as a severe sore throat that quickly gets worse, swelling inside the mouth or throat, and difficulty speaking, swallowing, breathing or opening the mouth. For these signs the NHS advises calling 999 or going to A&E.

Rheumatic fever is another possible complication of strep throat. MedlinePlus, a US source, says it does not often occur in the United States and other developed countries.

When is tonsil removal considered?

Removal of the tonsils is called a tonsillectomy. The NHS says it is very rare for someone to need it, and that it is usually only done for severe tonsillitis that keeps coming back. Eligibility criteria vary by area. Scottish referral guidance, used by several NHS areas, says the sore throats should be due to acute tonsillitis and disabling enough to prevent normal functioning, and it sets thresholds for how many episodes there have been over one or more years. If a person does not meet them, it advises a period of watchful waiting with a symptom diary.

Leaflets from NHS hospital trusts describe the operation as done under general anaesthetic, with the tonsils taken out through the mouth, so there is no cut on the outside of the neck. They describe a sore throat that can last about two weeks, with some saying up to three weeks, and earache is common. Bleeding can happen up to about two weeks afterwards. The leaflets advise going to A&E for fresh bleeding or coughing up or vomiting blood, and calling 999 if bleeding is heavy or will not stop. Trusts' advice differs, so the leaflet from the hospital involved applies.

Frequently asked questions