Tonsillitis 101: Symptoms, Causes, Treatment & Prevention

When looking into your mouth through a mirror, you may have noticed a pair of palatine tonsils, which look like small fleshy pads, located at the sides along the back of your throat. Did you know that they are part of your immune system? 

There are also other hidden tonsils located around your face—the nasopharyngeal tonsil (adenoids) at the roof of your nasal cavity, the paired tubal tonsils on the sides behind your nasal cavity, and the lingual tonsil at the root of your tongue. These four groups of tonsils form the Waldeyer’s Ring, which is an almost closed ring of lymphatic tissues that are strategically located to come into contact with substances that enter your respiratory and digestive tract through your nose and mouth.

Tonsils are lymphoid organs that play a key role in your immune system. They are made up of dendritic cell subtypes, macrophages, and lymphocytes, such as B cells and T cells, which are all often simply referred to as white blood cells. By being the first point of contact, they act as sentries for our immune system to analyze foreign substances entering through the nose and mouth. As a result, they are unfortunately susceptible to infection by the many pathogens that pass through them. An infection of the tonsils, known as tonsillitis, can be frequent and painful, making its surgical removal (tonsillectomy) a popular but controversial treatment method.

What is Tonsillitis?

Tonsillitis is the inflammation of your tonsils caused by a bacterial or viral infection, such as the common flu. In most cases of tonsillitis, the palatine tonsils at the back of your throat are inflamed, causing a painful swelling of the throat that could lead to difficulties in swallowing and breathing. Other tonsils are also susceptible to tonsillitis and can lead to various symptoms such as earaches, headaches, and neck pain. Tonsillitis most frequently occurs in young children, although adults may rarely experience a bout of tonsillitis during an upper respiratory tract infection.

Tonsillitis is categorized into three types—acute, chronic, and recurrent—based on its frequency of occurrence and how long the inflammation lasts.

Acute Tonsillitis 

An acute onset of tonsillitis is caused by a viral or bacterial infection in the upper respiratory tract and is relieved after the infection passes in a matter of a few days or a couple weeks. The viral or bacterial infection is usually contagious and may result in tonsillitis in others who get infected as well. Widespread acute tonsillitis is most commonly observed when a viral infection is spread easily amongst school children. Acute tonsillitis from a viral infection will subside as the virus is naturally eradicated by the immune system, often within four days. Bacterial streptococcal infections, largely by Streptococcus pyogenes, can cause sudden nausea, headaches, and enlargement of the lymph nodes in addition to tonsillitis. This streptococcal infection is also known as strep throat. A 10-day course of antibiotics, usually penicillin, is used to treat streptococcal infections.

Recurrent Tonsillitis

If a person experiences tonsillitis on multiple separate occasions in a year, they may be diagnosed with recurrent tonsillitis. This is most commonly observed in children, where recurrent tonsillitis is predominantly caused by group A beta-hemolytic Streptococcus pyogenes that repeatedly infects the child and causes tonsillitis. Recurrent infections occur as the bacteria may have acquired resistance to antibiotics, or the child may have a weakened immune system or genetic predisposition.

Chronic Tonsillitis

Chronic tonsillitis arises when the tonsils remain inflamed from an ongoing chronic infection that does not subside and is most common in teens and adults. Chronic infections can be caused by antibiotic-resistant bacteria or occur in immunocompromised individuals. Tonsillectomy, which is the removal of the tonsils, is a common treatment for chronic tonsillitis as it would instantly and considerably relieve the uncomfortable symptoms and complications.

Tonsillitis Symptoms

The symptoms of tonsillitis usually overlap those of the infection that is causing it. They include:

• Sore throat
• Pain or difficulty swallowing (dysphagia)
• Coughing
• Headache
• Fever
• Tiredness
• Bad breath
• Stomachache

Nonetheless, there are symptoms that are diagnostic of tonsillitis, such as:

• Red and swollen tonsils
• White or yellow pus-filled spots on the tonsils
• Enlarged and painful lymph nodes (along the sides of the neck)
• Stiff and painful neck

Tonsillitis Complications

Complications from tonsillitis are rare but may arise from recurrent and chronic tonsillitis. In general, complications can occur when the swelling of the tonsils is severe enough to disrupt the airways or the infection spreads to adjacent tissues.

Obstructive Sleep Apnea

A severe swelling of the tonsils can obstruct the airways and result in difficulty breathing, especially as the muscles relax when asleep. Sleep apnea occurs when the throat is blocked and breathing stops for more than 10 seconds. As a result, sleep is frequently disrupted as someone experiencing apnea will awake abruptly to gasp for air. However, in cases where sleep apnea occurs for a long time without intervention, a reduction in oxygen in the blood can occur and lead to headaches, fatigue, depressed or irritable mood, and poor cognition and memory throughout the day. Although this is largely non-life threatening, obstructive sleep apnea due to tonsillitis is disruptive to the quality of life and should be treated using devices that help to open the airways, such as continuous positive airway pressure (CPAP) or mandibular advancement devices (MADs), as well as treatment of the infection causing tonsillitis. 

Peritonsillar Abscess

Peritonsillar abscess refers to the advancement of tonsillitis leading to the infection of deep tissue of the head and neck and pus production, and is most commonly observed in young adults. An advanced infection without pus is known as peritonsillar cellulitis. Peritonsillar abscess is caused by a combination of infections by aerobic and anaerobic bacteria, such as Streptococcus pyogenes and Fusobacterium sp. respectively. A person with peritonsillar abscess may not be able to open their mouth and have muffled speech due to the inflammation of muscles that control the jaw. While this is not deadly, the abscess generally makes it extremely difficult to talk and eat, accompanied with constant pain, and hence requires immediate medical intervention. Surgical procedures, such as needle aspiration, incision and drainage, or tonsillectomy, coupled with a course of antibiotics, can be utilized to relieve peritonsillar abscess and underlying tonsillitis.

Rheumatic Fever

When a streptococcal infection causing tonsillitis is not treated promptly, it can lead to the development of rheumatic fever after one to five weeks. Rheumatic fever is a generalized immune response that affects the heart, joints, skin, and brain, and occurs more commonly in children. It can lead to persistent fever, arthritis, heart murmur, uncontrollable spasm-like movements called chorea, and potentially life-threatening rheumatic heart disease. Symptomatic relief of rheumatic fever can be achieved with painkillers and antipyretics, but a course of antibiotics is required to defeat the bacterial infection in order to effectively treat rheumatic fever due to strep throat.

Tonsillitis Causes

Most cases of acute tonsillitis are caused by viral infections by common viruses such as the influenza virus. Rhinovirus, adenovirus, coronavirus, measles virus, and herpes simplex virus infections can also cause tonsillitis. 

Bacterial tonsillitis (strep throat) is caused by a Streptococcus pyogenes infection, and is the main cause for recurrent and chronic tonsillitis. Other bacteria that can cause tonsillitis and its complications include Staphylococcus aureus, Haemophilus influenzae, Fusobacterium sp., and Prevotella sp..

Tonsillitis Risk Factors

As tonsillitis is a condition brought about by the immune response to an infection, the risk factors of tonsillitis are synonymous with those of contracting a viral or bacterial infection. Risk factors that increase the likelihood of developing tonsillitis include:

• Smoking
• Poor hygiene
• Frequent exposure to viruses & bacteria (e.g. in a school or hospital)
• Young age (children aged 5–15 are most at risk of bacterial tonsillitis)
• Immune deficiency

Diagnosing Tonsillitis

If you suspect that you or your child has tonsillitis, look out for palatine tonsils (at the back of your throat) that are red, swollen, or have patches of yellowish-white pus. Mild cases of tonsillitis will be alleviated as the infection passes over a few days. However, if pus is present on the tonsils or if symptoms are severe and do not clear after four days, proceed to a doctor for a professional diagnosis as it may be a sign of a severe infection.

The diagnosis of tonsillitis begins with a physical exam where your doctor will visually examine the throat, ears, and nose, and gently feel the lymph nodes to assess the sites of infection.

If the doctor suspects bacterial tonsillitis, they will take a swab sample of the site of infection to identify the type of bacteria causing the infection. Swab tests normally detect streptococcal bacteria and results of a rapid test will be ready within a few minutes then further corroborated with lab test results after a couple days. A negative test result likely points to viral tonsillitis, while a positive result would indicate a streptococcal infection and possibly strep throat.

Blood tests, such as a complete blood cell count (CBC), can also be used to differentiate between viral and bacterial tonsillitis.

Tonsillitis Treatment

Since there is no direct medical treatment for viral infections, the treatment of viral tonsillitis consists of medication and care to reduce uncomfortable symptoms while the infection is eliminated by the body’s immune system, usually taking between 3–10 days. Medications include:

• Lozenges & painkillers for sore throat
• Antipyretics for a high fever
• Rehydration salts for patients that are experiencing dehydration due to dysphagia

Some ways to take extra care to alleviate symptoms and help your body fight off the infection are:

• Plentiful rest
• Adequate hydration
• Gargling with salt water
• Drinking warm water with honey
• Having iced water or ice pop for temporary relief of pain & swelling
• Avoiding respiratory irritants (e.g. cigarette smoke)

Bacterial tonsillitis can be treated with a course of antibiotics as prescribed by a doctor. A 10-day course of penicillin is often prescribed for streptococcal infections. It is of paramount importance to take antibiotics on schedule and complete the course as not doing so may worsen the case of tonsillitis, increase the risk of complications, and lead to the emergence of antibiotic-resistant bacteria.

The surgical removal of tonsils (tonsillectomy) was a customary treatment for recurrent or chronic tonsillitis as it was previously believed that the tonsils were not vital to immune function. However, an increasing number of studies suggest the importance of the tonsils in protecting against upper respiratory tract infections and immune-mediated diseases, coupled with novel alternative treatment methods such as biofilm disruption, means that tonsillectomy is not as highly recommended as it was in the past. Weighing the severity of tonsillitis and its adverse impacts on the patient’s quality of life against the potential impacts to immune health due to the loss of tonsil function will help the doctor decide whether tonsillectomy is required. For example, an adult patient with chronic tonsillitis that results in obstructive sleep apnea and disruptions to daily life will likely be recommended to undergo tonsillectomy.

How to Prevent Tonsillitis

To prevent tonsillitis, first take steps to avoid contracting an infection. Viral and bacterial infections that cause tonsillitis are contagious through common passageways such as a sneeze or cough from an infected person. Hence, you can prevent tonsillitis for your child and yourself by maintaining good hygiene and avoiding known outbreaks. Some precautions include:

• Avoid direct sharing of food & drinks (use serving utensils)
• Wash your hands regularly, especially before a meal
• Avoid attending or sending your child to school or daycare when there are multiple cases of tonsillitis amongst students

Maintaining a strong immune system can also help your body fight off infections and reduce the risk of occurrence and severity of tonsillitis. You can improve immune health by:

• Exercising regularly
• Getting enough sleep
• Eating a healthy diet with plenty of fruits and vegetables
• Avoiding frequent or over-consumption of alcohol
• Avoiding smoking
• Minimizing stress levels

Given the information above on how to prevent tonsillitis, the key is always about maintaining a balanced and healthy lifestyle.

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