Overview
Tonsillitis is inflammation of the tonsils, the two oval-shaped lymph nodes at the back of the throat. It causes sore throat, difficulty swallowing, fever, and swollen lymph nodes in the neck. Most cases are viral and resolve without antibiotics. Bacterial tonsillitis (usually Group A Streptococcus) benefits from antibiotic treatment.
How common is it?
Tonsillitis is very common, particularly in children aged 5 to 15. Most adults have had it at least once. Recurrent tonsillitis affects a significant proportion of children and some adults.
Causes and risk factors
Viruses account for 70 to 80% of tonsillitis cases. Adenovirus, rhinovirus, and EBV are the most common viral causes. Group A Streptococcus (GAS) is the most important bacterial cause.
Common risk factors
- Viral: adenovirus, rhinovirus, EBV (Epstein-Barr virus, causes glandular fever), enterovirus, cytomegalovirus
- Bacterial: Group A Streptococcus (most important), Fusobacterium necrophorum, Staphylococcus aureus
- Close contact with infected individuals
- School-age children (communal exposure)
Symptoms
- Sore throat
- Difficulty and pain on swallowing
- High fever
- Red, swollen tonsils with white patches or pus (bacterial)
- Swollen, tender lymph nodes in the neck
- Headache
- Bad breath
- Muffled voice
- Earache (referred pain)
When to see a doctor
See a GP for tonsillitis with high fever, severe difficulty swallowing (particularly liquid), drooling, unilateral throat swelling (suggests peritonsillar abscess), or inability to open the mouth fully (trismus).
Diagnosis
FeverPAIN or Centor score guides antibiotic prescribing. Throat swab for GAS culture if scoring criteria met. Monospot or EBV serology if glandular fever suspected (avoid amoxicillin).
Treatments
Symptomatic management (viral tonsillitis)
Paracetamol or ibuprofen for fever and sore throat. Warm fluids, cold drinks, and ice lollies soothe the throat. Rest and hydration.
Phenoxymethylpenicillin (penicillin V)
10-day oral course for bacterial tonsillitis. Reduces duration and severity and prevents rheumatic fever. Erythromycin for penicillin allergy. Do not use amoxicillin if EBV is possible.
Peritonsillar abscess drainage
Needle aspiration or surgical incision and drainage for peritonsillar abscess (quinsy), combined with intravenous antibiotics and steroids.
Tonsillectomy
Surgical removal for recurrent tonsillitis meeting criteria: 7 episodes in 1 year, or 5 per year for 2 years, or 3 per year for 3 years. Reduces throat infections significantly for 2 years post-surgery.
Self-care and lifestyle
- Stay well hydrated — swallowing may be painful but adequate fluids are essential
- Rest from school or work until fever resolves and swallowing is comfortable
- Cold foods and drinks (ice cream, ice lollies) relieve throat pain
- Salt water gargling may reduce discomfort
Prevention
Good hand hygiene reduces transmission. No vaccine for the most common bacterial cause (Group A Streptococcus) is yet available.