Tonsillitis – Causes, Signs and symptoms



Tonsillitis is a common occurrence during childhood. It occurs when the tonsils become inflamed as the body’s immune system attempts to fight off invading viruses or bacteria. Symptoms of tonsillitis include red, swollen tonsils that can be painful and make swallowing difficult. The tonsils may have whitish spots or white covering on them.

Most cases of tonsillitis are caused by viruses, and may include symptoms such as a runny nose, coughing or fatigue. Bacteria, such as those that cause strep throat, are responsible for less than one-third of all childhood cases of tonsillitis. In those cases, symptoms may appear suddenly and be more severe than in viral infections.

Most children experience at least one episode of tonsillitis. It is a contagious infection, common in settings where children are exposed to many other people (e.g., daycare facilities, playgrounds, schools).

Parents who suspect their child has tonsillitis should consult their child’s pediatrician. They may be referred to an ear, nose and throat specialist. A medical history and physical examination may be performed to identify the presence of tonsillitis.

Once diagnosed, determining whether the cause is a bacterial infection (e.g., strep throat) or a viral infection (e.g., cold, the flu) is very important. Bacterial infections will need to be treated with antibiotics, while viral infections generally resolve on their own without treatment.

Parents can help make their child as comfortable as possible during the course of the infection. Home remedies include various methods to soothe a sore throat and ensuring a child with tonsillitis gets adequate rest, nourishment and fluids.

Surgery (e.g., tonsillectomy) is no longer routinely recommended for children with tonsillitis as it was in past decades. However, surgery may be recommended in certain situations, depending on the frequency of infections and presence of complications (e.g., breathing difficulty).The only way to prevent tonsillitis is to avoid exposure to the viruses or bacteria that can cause infection. This includes avoiding contact with people who are sick, frequent handwashing and not sharing utensils and other items that may touch a child’s mouth.

About tonsillitis

Tonsillitis is inflammation or swelling of the tonsils. Viruses or bacteria transmitted to the tonsils cause the infection.

The tonsils are oval-shaped masses of tissue located inside the mouth, on either side of the throat. They are located toward the back of the throat – just behind and above the tongue. The tonsils should not be confused with the fleshy lobe (uvula) that hangs down the back of the throat.

Different children may have different-sized tonsils – there is no one size typical for all children. The tonsils are generally small at birth and gradually get larger until a child is about 6 or 7 years old. At that point, the tonsils begin to decrease in size, although they never completely disappear.  

The tonsils perform an important immune system function. They are made up of infection-fighting lymphoid tissue. This tissue stores lymphocytes (white blood cells) that destroy viruses and bacteria entering the body through the mouth or nose. The tonsils typically collect and destroy these invading organisms. Tonsillitis occurs when the tonsils are overwhelmed during this process, becoming red and swollen.

Like the tonsils, the adenoids (a mass of tissue located above the throat and behind the nose) also works to fight infectious viruses and bacteria that may enter the body. However, it is difficult to see the adenoids during a visual inspection of a child’s mouth.

Tonsillitis is a contagious infection that is rare in infants. Most cases of tonsillitis occur during childhood, although the infection may occur at any time in a person’s life. Almost all children in the United States develop tonsillitis at least once, according to the American Academy of Otolaryngology – Head and Neck Surgery. It is not unusual for tonsillitis to recur. Tonsillitis is especially common in environments where people are in close contact for hours every day (e.g., school, playground, daycare).

Tonsillitis is different from other conditions that may also cause a sore throat, but do not necessarily involve the tonsils. These conditions include:

  • Pharyngitis. Inflammation of the pharynx (back of the throat). Pharyngitis may be caused by viruses or bacteria. It often accompanies tonsillitis.
  • Coxsackie infection. Viral infection that usually begins in the throat. Symptoms include difficulty swallowing, fever and blisters in the throat, including on the tonsils. Also called hand, foot & mouth disease.
  • Chickenpox. Common viral infection that may cause a sore throat.
  • Croup. Common childhood condition that involves breathing difficulty due to swelling of the voice box (larynx) and windpipe (trachea). Croup may be caused by viruses or bacteria and involves a distinctive barking cough.
  • Measles.Viral infection that affects the respiratory system and can cause a spreading rash. Immunization prevents measles.
  • Mumps. A viral infection that affects the salivary glands and causes painful swallowing and swollen cheeks. Mumps was formerly a common childhood disease, but the measles, mumps, rubella (MMR) vaccine has made all three illnesses rare in the western industrialized world.
  • Diphtheria. Bacterial infection that can cause breathing difficulties and painful swallowing. Diphtheria is rare since most children are vaccinated against it.

Complications and related conditions

Complications of tonsillitis in children are rare. The most serious complications involve those that lead to breathing difficulty, which may result from:

  • Enlarged tonsils (obstructive tonsil hyperplasia). May occur due to swelling of tonsils during infection. Tonsils usually return to their normal size after the infection has cleared. However, they may sometimes remain enlarged, especially in cases of repeated infections. Enlarged tonsils can block the airway, making breathing and swallowing difficult. It can cause sleep apnea, loud snoring, mouth breathing while sleeping and feeding problems. Complications may be especially severe when enlarged tonsils are combined with enlarged adenoids. Additional problems include a failure to thrive and speech problems. Surgery to remove the tonsils (tonsillectomy) may be required.
  • Abscess. A collection or pocket of pus around the tonsils. This may occur when infection of the tonsils spreads into other areas of the throat. Swelling from the abscess may block airflow, causing breathing difficulty. Symptoms of an abscess near the tonsils include severe pain and significantly muffled speech. This type of abscess occurs more often in young adults than in children.

Dehydration may also occur as a result of tonsillitis when difficulty swallowing prevents a child from getting enough fluids.

Tonsillitis that is caused by the bacterial infection that causes strep throat and is left untreated may result in the following complications:

  • Ear infections (otitis media)
  • Scarlet fever
  • Kidney inflammation, kidney failure
  • Rheumatic fever

Risk factors and causes of tonsillitis

Tonsillitis occurs when invading organisms overwhelm the body’s immune system response. These organisms include:

  • Viruses. Viruses are the most common cause of tonsillitis, probably because viral infections are especially common in young children. Viral infections do not respond to antibiotics, and generally resolve without treatment. Viruses that can cause tonsillitis include those viruses that cause the following:
    • Common cold. There are hundreds of different viruses that can cause a cold.
    • Flu. Fewer viruses cause the flu, which has more severe symptoms than a cold. Flu vaccines are available that can reduce the likelihood of becoming infected with particular strains of flu viruses.
    • Mononucleosis. This infection is caused by the Epstein-Barr virus. Mononucleosis may also cause a fever, sore throat and enlarged lymph nodes (glands).
  • Bacteria. Bacteria that can cause tonsillitis include those bacteria that also cause:
    • Strep throat. This infection is caused by group A streptococci bacteria, which affect the pharynx (back of the throat) and tonsils or adenoids. A common bacterial cause of tonsillitis, strep is responsible for 15 to 30 percent of all cases of tonsillitis in children, according to the American Academy of Otolaryngology – Head and Neck Surgery. Strep throat occurs most often in children between the ages of 5 and 15 years.
    • Fungi and parasites. Very rarely, certain fungi and parasites may be the cause of tonsillitis.

Signs and symptoms of tonsillitis

Some of the signs and symptoms of tonsillitis may differ, depending on the cause of the infection. Symptoms can range from mild to severe. When symptoms are acute (severe and sudden), it may indicate a bacterial cause (e.g., strep throat) rather than a viral cause. Viral infections are more common in younger children. When symptoms are chronic, it may indicate an untreated bacterial infection.

Common signs and symptoms of tonsillitis include:

  • Sore throat
  • Red, swollen tonsils
  • Swollen lymph nodes (glands) in the neck
  • White spots or coating of the tonsils (may also be yellow or gray in color)
  • Difficulty swallowing (may be evidenced by a refusal to eat or drink)
  • Drooling (may indicate the inability to swallow one’s own saliva)
  • Fever (over 98.6 degrees Fahrenheit or 37 degrees Celsius)
  • Hoarseness or loss of voice
  • Bad breath
  • Headache

Tonsillitis caused by viral infections such as a cold or the flu may also include the following symptoms:

  • Stuffy nose
  • Runny nose
  • Sneezing
  • Coughing
  • Fatigue
  • Muscle aches
  • Chills
  • Sweats

Tonsillitis caused by the virus that causes mononucleosis (Epstein-Barr virus) may also include the following symptoms:

  • Skin rash
  • Loss of appetite
  • Soft, swollen spleen
  • Inflammation of the liver

Parents who observe the following symptoms should obtain immediate medical attention for their child:

  • Fever over 100.2 Fahrenheit (37.9 Celsius) in an infant under 3 months old
  • Worsening of symptoms
  • Breathing difficulty
  • Extreme difficulty swallowing
  • Fever clears, then returns

Diagnosis methods for tonsillitis

Parents who suspect their child may have tonsillitis should consult their child’s pediatrician. They may be referred to an ear, nose and throat specialist (otolaryngologist) for examination.

A medical history is usually gathered, and may include questions about the frequency of throat or other upper respiratory tract infections in the child.

A physical examination will include a visual examination of the throat to check for redness, swelling or pus on the tonsils. A physician may use a tongue depressor to hold the tongue down. In addition, a child may be asked to say “ahhhh,” which can keep the tongue flattened enough to enable a view of the back of the throat. The ears and nose may also be examined for other signs of infection. A physician may also listen to the child’s chest.   

Diagnosis of tonsillitis may be made based on the physical examination. However, there is no way to identify the cause of infection (e.g., whether viral or bacterial) by visual inspection alone. It is important to identify bacterial infections because they require antibiotic treatment.

Bacterial infections may be identified with several different tests, including a throat culture and a strep screen. For a throat culture, a physician uses a long cotton swab to obtain a tissue sample from the back of the child’s throat. Although painless, throat cultures may cause a child to momentarily gag. Results are not usually available for a day or two. A rapid strep test is performed in a similar manner, but results are available within minutes. This test is usually performed in conjunction with the throat culture. If these tests are negative, the tonsillitis may be caused by a virus. However, negative results from a rapid strep test are normally confirmed with the full strep screen test, to avoid missing any bacterial infections.

In cases where the suspected cause of tonsillitis is the Epstein-Barr virus (the virus that causes mononucleosis), a special blood test called the mononucleosis spot test (or monospot test) may be performed.

However, a regular – and more cost effective – blood test measuring the number of lymphocytes (a particular type of white blood cell involved in the body’s immune system response to infection) and overall white blood cell count can help distinguish between tonsillitis caused by bacterial infection or by the viral infection mononucleosis, according to a new study published in the Archives of Otolaryngology – Head & Neck Surgery. The research team recommends the lymphocyte-white blood cell count ratio as an indicator for physicians to determine whether the mononucleosis spot test is necessary. A ratio higher than 0.35 can confirm or rule out mononucleosis.

Treatment options for tonsillitis

Most cases of tonsillitis are caused by viruses. Thus, symptoms do not require treatment and usually resolve within a week. Managing a child’s symptoms is often the only treatment necessary. This allows parents to comfort their child while they monitor the condition and wait for their child to get better.

Home care remedies that may comfort a child with viral tonsillitis include:

  • Rest. Sleep and relaxation can help the body fight infection and begin to heal. Restful activities such as reading to a child from a favorite book can help calm and relax a sick child.
  • Proper nourishment. Ensuring adequate nourishment is important to help children with tonsillitis recover from their infection. If swallowing is difficult, soft foods (e.g., soup, broth, popsicles, applesauce, flavored gelatin, fruit smoothies) may be easier to consume than solid foods. Parents may wish to avoid dairy products (e.g., ice cream, yogurt) that can thicken saliva and make swallowing more difficult.
  • Plenty of fluids. This can help prevent dehydration in children with tonsillitis. Parents should avoid providing their child with caffeinated products (e.g., sodas, teas), which can increase the risk of dehydration. Adequate fluid intake can also help thin mucus and make it easy to expel.
  • Soothe a sore throat. Various methods may be used to help relieve a sore throat. In general, anything that may irritate the throat should be avoided (e.g., cigarette smoke, citrus drinks). Methods to soothe a sore throat include:
    • Gargle with warm salt water. Mix 1 teaspoon of table salt in 8 ounces of warm water. This remedy should only be attempted with children old enough to gargle (without swallowing).
    • Drink warm (not hot) liquids.
    • Add honey and lemon. Honey coats and soothes a sore throat while lemon thins mucus, aiding its elimination from the body. Both of these can be easily dissolved into a warm drink.
    • Drink very cold beverages.
    • Throat lozenges. These may stimulate the production of saliva, which can help cleanse the throat. Lozenges are not advised for young children since they may pose a choking hazard.
    • Use a cool-mist humidifier. This may help soothe a sore throat. However, it is important to clean this device often since it may breed bacteria and mold, which can worsen a child’s symptoms.
  • Over-the-counter pain and fever relief. Use of acetaminophen or ibuprofen may help relieve pain and fever in children with tonsillitis. Parents should not provide aspirin to any child or adolescent under 20 years old, since it may increase the risk of Reye syndrome, a life-threatening condition.

Tonsillitis caused by bacteria will require antibiotic treatment. This may be provided as a single injection or a 10-day course of pills. Parents should ensure their child takes all the pills prescribed. Symptoms may improve within a day or two of starting antibiotic treatment, but the infection is not cured until the full course of pills has been taken. Antibiotics do not speed recovery time, reduce symptoms or prevent tonsillitis from recurring. 

In the past, physicians may have prescribed antibiotics for all cases of tonsillitis (even viral infections, for which antibiotics are ineffective). However, nowadays physicians often advise against the unnecessary use of antibiotics. Overuse of antibiotics has led to the development of antibiotic-resistant strains of disease that are very difficult to treat. The Centers for Disease Control and Prevention (CDC) advises against using antibiotics for sore throats unless a patient tests positive for strep throat or other bacterial infection.

Surgery is no longer routinely recommended for children with tonsillitis. Tonsils serve an important immune system function and their removal does not necessarily prevent future throat or respiratory infections.

The surgical removal of the tonsils is called a tonsillectomy. This procedure may be recommended under the following conditions:

  • Tonsillitis recurs often despite the patient receiving antibiotic treatment:
    • Three to five episodes in one year
    • At least five episodes per year for two years
    • At least three episodes per year for three years

In addition, if the tonsils impair breathing or seriously impair swallowing, a tonsillectomy may be performed. Tonsillectomies also may help prevent recurrent strep throat infection (a common bacterial cause of tonsillitis) in children, according to a new study. However, more research is needed to establish this link.

Tonsillectomies generally take less than an hour and can be performed on an outpatient basis (no overnight stay in a hospital is necessary). Tonsil removal does not eliminate the body’s infection-fighting capabilities, since tissues in other areas of the body perform a similar task. Children undergoing a tonsillectomy may experience a sore throat and ear pain after the surgery. Complete recovery may take a couple of weeks. 

Prevention methods for tonsillitis

The only way to prevent tonsillitis is to avoid exposure to the viruses or bacteria that can cause tonsillitis. This includes avoiding contact with anyone who has an infection such as a cold or the flu. Because tonsillitis is contagious, it can be easily spread from person to person (via contact with fluid from the throat or nose of infected persons). Methods that can help prevent the spread of all infections include:

  • Frequent handwashing. The Centers for Disease Control and Prevention(CDC)recommend the following handwashing tips to help prevent the spread of infection:
    • Use soap
    • Rub hands vigorously under running water
    • Wash the wrists, between the fingers, under fingernails and the backs of hands
    • Wash for several minutes
    • Rinse well
    • Dry hands with a disposable paper towel
    • Use a clean paper towel to turn off water faucet
  • Use alcohol-based hand sanitizers when soap and water are not available. This kills the viruses and bacteria that can cause infection.
  • Do not share drinking glasses, eating utensils or toothbrushes.
  • Do not share food. Eat from separate plates and use separate utensils when eating.
  • Cover the mouth and nose when coughing or sneezing. This helps prevent the airborne spread of viruses or bacteria that cause infection.
  • Immediately dispose of used tissues.
  • Replace toothbrush after an illness. This prevents children from reinfecting themselves.
  • Avoid mouth-to-mouth kissing when infected, or potentially infected.
  • Avoid touching mouth to public telephones or drinking fountains.
  • Clean certain household devices. This includes anything that may touch a child’s mouth or nose, such as a telephone, remote control, computer keyboard or mouse. These items can also be wiped clean when outside the home (e.g., in hotels, when visiting family or friends).

Questions for your doctor regarding tonsillitis

Preparing questions in advance can help patients and parents have more meaningful discussions with physicians regarding their or their child’s treatment options. The following questions related to tonsillitis may be helpful:

  1. What symptoms indicate my child has tonsillitis and not just a sore throat?
  2. I think my child has tonsillitis. Do we need to see an ear, nose and throat specialist?
  3. What kind of tests need to be performed to identify whether my child’s tonsillitis is viral or bacterial? Will these tests be painful?
  4. In what cases should my child be treated with antibiotics?
  5. If my child won’t be treated with antibiotics, what can I do to make him/her more comfortable during the course of the infection?
  6. Would you recommend certain over-the-counter pain relievers for my child? What are their side effects? Are there any I should not give my child? Why?
  7. What change in my child’s symptoms should I be concerned about? In those cases, should I take my child to the emergency room or call you?
  8. I had my tonsils out when I was a child. Why isn’t this surgery recommended anymore?
  9. My child has had several episodes of tonsillitis. At what point would you recommend a tonsillectomy?
  10. Is it important for my child to keep his tonsils? Why?
  11. I think my child’s tonsils are very large. At what size do they become a problem?
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