Sore throat – Tonsillitis
Tonsillitis is inflammation of the tonsils. It's usually caused by a viral infection or, less commonly, a bacterial infection.
It's a common type of infection in children, although it can sometimes affect adults.
The symptoms of tonsillitis include:
sore throat that can feel worse when swallowing
high temperature (fever) over 38C (100.4F)
Symptoms usually pass within three to four days.
The tonsils are two small glands that sit on either side of the throat. In young children they help fight germs and act as a barrier against infection.
When the tonsils become infected they isolate the infection and stop it spreading further into the body.
As a child's immune system develops and gets stronger, the tonsils become less important and usually shrink. In most people, the body is able to fight infection without the tonsils.
Removal of the tonsils will usually only be recommended if they're causing problems such as severe or repeated episodes of tonsillitis (see below).
What causes tonsillitis?
Most cases of tonsillitis are caused by a viral infection, such as the viruses that cause the common cold or flu virus (influenza).
Some cases can also be caused by a bacterial infection, typically a strain of bacteria called group A streptococcus bacteria.
These types of infections spread easily, so it's important to try to avoid passing the infection on to others by:
staying away from public places, such as work, school or nursery until your GP says it's safe to return (this will usually be after the symptoms have passed)
coughing and sneezing into a tissue and disposing of the tissue
washing hands before eating, after going to the toilet and, if possible, after coughing and sneezing
When to see your GP
Tonsillitis isn't usually a serious condition. You only need to see your GP if symptoms:
last longer than four days and don't show any signs of improvement
are severe – for example, if you're unable to eat or drink due to the pain, or you have difficulty breathing
Your GP will examine your throat and ask you some questions about your symptoms.
There are four main signs that tonsillitis is caused by a bacterial infection rather than a viral infection. They are:
a high temperature
white pus-filled spots on the tonsils
swollen and tender lymph nodes (glands)
Further testing may be recommended if you have at least two of the above signs. If you have three, it's highly likely that you have bacterial tonsillitis and antibiotics may be prescribed (see below).
There's no specific treatment for tonsillitis, but there are several things that can help alleviate the symptoms. For example:
taking paracetamol or ibuprofen to help relieve pain
drinking plenty of fluids
getting plenty of rest
If test results show that your tonsillitis is caused by a bacterial infection, a short course of oral antibiotics may be prescribed.
If oral antibiotics are ineffective at treating bacterial tonsillitis, intravenous antibiotics (given directly into a vein) may be needed in hospital.
In most cases, tonsillitis gets better within a week. However, a small number of children and adults have tonsillitis for longer or it keeps returning. This is known as chronic tonsillitis and surgical treatment may be needed.
Surgery to remove the tonsils (a tonsillectomy) is usually only recommended in cases where there have been several severe episodes of tonsillitis over a long period of time, or if repeated episodes disrupt normal activities.
Complications of tonsillitis
Complications of tonsillitis are rare and usually only occur if it's caused by a bacterial infection.
They're usually the result of the infection spreading to another part of the body, such as the middle ear (otitis media)
Who's affected by tonsilitis?
Tonsillitis can affect both children and adults, but it's much more common in children. Most children have at least one episode of tonsillitis.
Viral infections that cause tonsillitis are easily spread through close contact with someone who is infected. Anyone who spends time in schools or nurseries is at increased risk of developing an infection that could lead to tonsillitis.
In teenagers and young adults, tonsillitis often follows glandular fever.
Symptoms of tonsillitis
A sore throat is the main symptom of tonsillitis.
Your tonsils will be red and swollen and your throat may be very painful, making swallowing difficult.
In some cases, the tonsils are coated or have white, pus-filled spots on them.
Other common symptoms of tonsillitis include:
high temperature (fever) over 38C (100.4F)
pain in the ears
swollen, painful lymph glands in your neck
loss of voice or changes to your voice
The symptoms of tonsillitis usually get better after three to four days.
If you have tonsillitis that's caused by a viral infection, such as the common cold or flu, your symptoms may be milder.
If your tonsillitis is caused by a bacterial infection, such as a streptococcal infection, it's likely that your symptoms will be more severe. Your tonsils will be swollen, your throat will be very sore and you may have a fever. You may also have bad breath.
It's difficult to tell just by looking at a person's throat whether they have tonsillitis as a result of a virus or a bacterial infection. Tests are needed to confirm this.
Antibiotics may be recommended if test results show that your tonsillitis is caused by a bacterial infection.
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Causes of tonsillitis
Most cases of tonsillitis are caused by a viral infection.
Viruses known to cause tonsillitis include:
rhinoviruses – which are viruses that cause the common cold
the influenza virus
parainfluenza virus – which causes laryngitis and croup
enteroviruses – which cause hand, foot and mouth disease
adenovirus – which is a common cause of diarrhoea
the rubeola virus – which causes measles
In rare cases, tonsillitis can also be caused by the Epstein-Barr virus, which causes glandular fever.
If this is the case, you'll probably feel very ill. You'll have a sore throat and the lymph glands in your throat may be swollen. You may also have a fever and feel very tired.
Bacterial tonsillitis can be caused by a number of different bacteria, but it's usually due to group A streptococcus bacteria.
In the past, serious bacterial infections, such as diphtheria and rheumatic fever, have been linked with tonsillitis. However, this is now rare because these conditions are vaccinated against and treatment for them has greatly improved.
How tonsillitis is spread
Tonsillitis itself isn't contagious but the infections that cause it are.
Viruses, such as those that cause colds and flu, are spread through coming into close contact with someone who's infected.
When an infected person coughs or sneezes, the virus is contained in the millions of tiny droplets that come out of their nose and mouth. You can become infected by breathing in the contaminated droplets. This is known as direct contact.
You can also become infected if you touch a surface or object that the droplets have landed on and then touch your face. This is known as indirect contact.
See your GP if you think you or your child has tonsillitis.
Your GP will examine your or your child's throat and ask some questions about the symptoms.
There are four main signs which indicate that tonsillitis is caused by a bacterial infection rather than a viral infection. They are:
a high temperature
white pus-filled spots on the tonsils
swollen and tender lymph glands
If two of the above signs are present, further testing may be recommended (see below).
If three or more signs are present, it's highly likely that you have bacterial tonsillitis and antibiotics may be prescribed.
If a more detailed diagnosis is needed, a swab sample can be sent to a laboratory for analysis. The results can take a few days to return.
Laboratory tests are mainly used for patients in high-risk groups, such as those with weakened immune systems, or if previous treatment has failed.
If you develop tonsillitis as a teenager or adult and you also have additional symptoms, such as a very painful throat and swollen lymph glands, your GP may recommend that you have a blood test to find out whether you have glandular fever.
There's no specific treatment for tonsillitis and most cases get better without treatment within a week.
While waiting for the infection to clear up, there are a number of things you can do to help relieve your symptoms (see below).
If your child has tonsillitis, make sure they have plenty to eat and drink, even if they find it painful to swallow. Being hungry and dehydrated can make other symptoms, such as headaches and tiredness, worse.
Over-the-counter painkillers, such as paracetamol and ibuprofen, can help relieve painful symptoms such as a sore throat.
If treating your children with painkillers, it's important that you use the correct type and dosage. Younger children only need small dosages. Your pharmacist will be able to advise you about this.
Children under 16 years of age shouldn't be given aspirin.
Over-the-counter treatments that can soothe a sore throat, such as lozenges and oral sprays, are also available. Some people find that gargling with a mild antiseptic solution can also help relieve a sore throat.
Alternatively, you could try gargling with warm, salty water. Mix half a teaspoon of salt (2.5g) with a quarter of a litre (eight ounces) of water. It's important not to swallow the water so this method may not be suitable for younger children.
Antibiotics may not be prescribed even if tests confirm that your tonsillitis is caused by a bacterial infection. The two main reasons for this are:
in most cases, antibiotics won't speed up the recovery but they can cause unpleasant side effects, such as stomach pain and feeling sick
the more an antibiotic is used to treat a non-serious infection, the greater the chance it won't be effective in treating more serious infections; this is known as antibiotic resistance
However, exceptions are usually made if:
symptoms are severe
symptoms show no sign of easing
you or your child has a weakened immune system
In these circumstances, a 10-day course of penicillin is usually recommended. If you or your child is known to be allergic to penicillin, an alternative antibiotic, such as erythromycin, can be used.
Hospital treatment may be required for particularly severe or persistent cases of bacterial tonsillitis that don't respond to oral antibiotics. In these cases, intravenous antibiotics that are given directly into a vein may be needed.
Antibiotics sometimes cause mild side effects, such as an upset stomach, diarrhoea or rash.
Surgery to remove the tonsils is known as a tonsillectomy.
For children with mild sore throats, watchful waiting is recommended rather than a tonsillectomy.
A tonsillectomy will only be considered for a recurrent sore throat in both children and adults if certain criteria are met. You must have:
a sore throat caused by tonsillitis
episodes of sore throat that are disabling and stop you functioning normally
seven or more well documented, clinically significant, adequately treated sore throats in the preceding year or
five or more such episodes in each of the preceding two years or
three or more such episodes in each of the preceding three years
Tonsillectomies are carried out under general anaesthetic, which means you'll be asleep during the procedure. Your mouth will be held open to allow the surgeon to see your tonsils and no cuts will be made in your skin.
The operation can be carried out in a number of ways as described below.
Cold steel surgery – this is the most common method, where a surgical blade is used to cut the tonsils out. Bleeding is controlled by applying pressure or the blood vessels may be sealed using heat generated by diathermy.
Diathermy – a diathermy probe is used to destroy the tissue around the tonsils and to remove the tonsils. At the same time, the heat seals the blood vessels to stop any bleeding.
Coblation (or cold ablation) – this method works in a similar way to diathermy but uses a lower temperature (60C). It's considered less painful than diathermy.
Lasers – high energy laser beams are used to cut away the tonsils and seal the underlying blood vessels shut.
Ultrasound – high energy ultrasound waves are used in a similar way to lasers.
Each of these techniques is relatively similar in terms of safety, results and recovery so the type of surgery used will depend on the expertise and training of the surgeon.
You'll usually be able to leave hospital on the same day as you have surgery or the day after.
After surgery it's likely you'll experience some pain at the site of the operation. This can last for up to a week. Painkillers can help relieve the pain.
Children who have had a tonsillectomy should be kept off school for two weeks. This is to reduce their risk of picking up an infection from another child that will make them feel more uncomfortable.
Swallowing will probably be difficult after having a tonsillectomy. However, it's important to eat solid foods because it will help your throat to heal more quickly. Drink plenty of fluids but avoid acidic drinks, such as orange juice, because they will sting.
Ensuring good oral hygiene by regularly brushing your teeth and using mouthwash can help prevent infection in the mouth.
The pain usually gets worse during the first week after having a tonsillectomy before gradually improving during the second week. Earache is common with tonsillectomies but isn't a cause for concern.
Bleeding at the site where the tonsils were removed is a fairly common complication of a tonsillectomy. This can occur during the first 24 hours following surgery or up to 10 days afterwards.
It's estimated that around one in 100 children and one in 30 adults will experience post-operative bleeding after having a tonsillectomy.
Minor bleeding isn't usually a cause for concern because in most cases it resolves by itself. Gargling with cold water can often help stem the bleeding because the cold helps to contract the blood vessels.
Occasionally, the bleeding can be more severe, causing people to cough up blood. Seek immediate medical advice if this happens. You should be given an emergency contact number before you're discharged from hospital. Alternatively, you can call 111
Extensive bleeding may need to be treated with surgery or a blood transfusion.
It's not always easy to avoid catching viral infections that are spread by coming into contact with germs.
However, following good hygiene practices can help prevent infections spreading.
For example, always:
wash your hands frequently
cough and sneeze into a tissue and dispose of it in the bin
avoid sharing glasses or utensils with people who are ill
Complications of tonsillitis
It's rare for complications to occur as a result of tonsillitis.
Some of the problems that can occur are outlined below.
Middle ear infection
A middle ear infection (otitis media) is where the fluid in the middle ear, between the eardrum and inner ear, becomes infected by bacteria. In most cases, the infection clears by itself.
Quinsy is an abscess (a collection of pus) that develops between one of the tonsils and the wall of the throat. It's a rare complication of tonsillitis that often affects teenagers and young adults.
If you develop quinsy, your symptoms will become rapidly worse. Symptoms include:
a worsening sore throat, usually on one side
a high temperature of 38C (100.4F) or above
difficulty opening the mouth
pain and difficulty swallowing, which may lead to drooling saliva
difficulty speaking or changes to the voice
earache on the affected side
headache and feeling generally unwell
swelling around the face and neck
Only one in 1,000 children with tonsillitis will go on to develop quinsy. It's treated with a combination of antibiotics and surgery to drain the pus from the abscess.
Persistent or recurring tonsillitis (chronic tonsillitis) may cause breathing difficulties during sleep. This is known as obstructive sleep apnoea (OSA).
OSA that's due to chronic tonsillitis tends to affect children more than adults. Your child won't usually wake up during sleep, but their deep sleep will be disturbed. This can make them feel very tired during the day.
Children affected by sleep apnoea will often snore or gasp loudly as they sleep.
If your child develops sleep apnoea as a result of tonsillitis, a tonsillectomy (surgical removal of the tonsils) will usually be recommended.
Other complications of tonsillitis are very rare and usually only occur if an underlying bacterial infection is left untreated. They include:
scarlet fever – a condition that causes a distinctive pink-red skin rash
rheumatic fever – this causes widespread inflammation throughout the body, leading to symptoms such as joint pain, rashes and jerky body movements
glomerulonephritis – an infection (swelling) of the filters in the kidneys that can cause vomiting and a loss of appetite
Sore throat - Tonsillitis