The palatine tonsils are two areas of lymphatic tissue at the sides of the throat. Together with the adenoids, they form part of the upper-airway defences. Tonsillitis is a common cause of sore throat; most cases are viral and resolve within a few days.
Viral or bacterial tonsillitis?
Most infections are viral, often with a cold, cough, hoarseness or conjunctivitis. Group A streptococcus is the most important bacterial cause and is more common in school-age children than adults. Fever, tonsillar exudate, tender enlarged neck glands and absence of cough make streptococcal infection more likely; a rapid test or throat swab helps guide decisions.
Epstein–Barr virus infection (infectious mononucleosis) can cause very swollen tonsils with exudate, marked fatigue and enlarged glands in several areas. Amoxicillin may cause a rash in mononucleosis. Antibiotics do not treat viral infection; any antibiotic indication must be assessed by a doctor.
Treatment
For viral infections, rest, fluids and pain relief or anti-inflammatory medicines according to medical advice are usually sufficient. Antibiotics are considered for confirmed or highly likely streptococcal infection. Their modest effect on symptom duration must be balanced against side effects and resistance. If prescribed, follow the full duration indicated.
Peritonsillar abscess and warning signs
A peritonsillar abscess is a collection of pus next to a tonsil. Severe one-sided pain, difficulty opening the mouth, a muffled voice, difficulty swallowing even saliva and a displaced uvula suggest it. It requires rapid drainage and treatment.
Urgent assessment is needed for difficult or noisy breathing, inability to drink, drooling, major neck swelling or high fever with a markedly unwell patient.
Recurrent tonsillitis: when tonsillectomy is considered
Tonsillectomy is considered for well-documented recurrent episodes. In children, the American guideline uses at least seven episodes in one year, five per year for two years or three per year for three years as reference criteria. Watchful waiting is preferable with fewer episodes. Adult decisions are individual, with less formally defined criteria.
Other indications include obstructive sleep apnoea due to large tonsils, repeated peritonsillar abscesses and, in adults, a markedly asymmetric or suspicious tonsil requiring investigation.
Tonsil stones
Small white deposits in tonsillar crypts can cause bad breath, an unpleasant taste or a foreign-body sensation. They are benign; oral hygiene and gargling are usually sufficient, with targeted treatment considered for troublesome cases.
Surgery and recovery
Tonsillectomy is performed under general anaesthesia. Throat pain may last about two weeks or longer and can worsen initially before improving. Any bleeding from the mouth or throat after surgery, even minor or stopped bleeding, requires urgent emergency-department assessment.
Frequently asked questions
Are white patches always bacterial?
No. Viral infections, including mononucleosis, can also cause exudate. Streptococcus is assessed using the overall signs and, when needed, a rapid test or swab.
Does removing the tonsils weaken immunity?
Studies do not show a clinically important deterioration in immune defences after tonsillectomy. Tonsils are only a small part of the throat and neck lymphatic tissue.
How long does recovery take?
Pain may last approximately two weeks or longer. Hydration, soft food and prescribed pain relief are important.
References
- Mitchell RB et al. Clinical Practice Guideline: Tonsillectomy in Children (Update). Otolaryngol Head Neck Surg 2019;160(1_suppl):S1-S42. PubMed
- Pelucchi C et al. Guideline for the management of acute sore throat (ESCMID Sore Throat Guideline Group). Clin Microbiol Infect 2012;18(Suppl 1):1-28. PubMed
- NICE. Sore throat (acute): antimicrobial prescribing. NICE guideline NG84, 2018. NICE
The information on this page is educational and does not replace medical consultation.