Tonsillitis

Tonsillitis is inflammation of the tonsils. It's usually caused by a viral infection or, less commonly, a bacterial infection.

Tonsillitis is a common condition in children, teenagers and young adults.

The symptoms of tonsillitis include:

• a sore throat and pain when swallowing
• earache
• high temperature (fever) over 38C (100.4F)
• coughing
• headache

Symptoms usually pass within three to four days.

If necessary, your GP will examine your throat and ask you some questions about your symptoms. If needed, a throat swab can be taken to confirm the diagnosis. The results usually take a few days to return.

If your tonsillitis is caused by a bacterial infection, they may prescribe antibiotics. Typical signs of a bacterial infection include white pus-filled spots on the tonsils, no cough and swollen or tender lymph glands.

If you develop severe tonsillitis as a teenager or adult, your GP may recommend a blood test for glandular fever.

The tonsils

The tonsils are two small glands that sit on either side of the throat. In young children, they help to 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 is usually only 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 (usually 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

Read more about the causes of tonsillitis.

Treating tonsillitis

There's no specific treatment for tonsillitis, but you may be able to reduce the symptoms by:

• 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 aren't effective at treating bacterial tonsillitis, intravenous antibiotics (given directly into a vein) may be needed in hospital.

Chronic tonsillitis

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 if:

• you've had several severe episodes of tonsillitis over a long period of time
• repeated episodes are disrupting normal activities

Read more about treating tonsillitis.

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.

Possible complications of tonsillitis include:

• a middle ear infection (otitis media) – where fluid between the eardrum and inner ear becomes infected by bacteria
• quinsy (peritonsillar abscess) – an abscess (collection of pus) that develops between one of the tonsils and the wall of the throat
• obstructive sleep apnoea (OSA) – where the walls of the throat relax during sleep, which causes breathing difficulties and poor sleep

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

The main symptom of tonsillitis is a sore throat.

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)
• coughing
• headache
• earache
• feeling sick
• feeling tired
• 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, your symptoms will usually be more severe and 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.

Most cases of tonsillitis are caused by a viral infection.

Viruses known to cause tonsillitis include:

• rhinoviruses – which 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

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.

There's no specific treatment for tonsillitis and most cases get better within a week without treatment.

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.

Self-help

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 to use the correct type and dosage. Younger children only need small dosages. Your pharmacist can 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 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

Antibiotics may not be prescribed, even if tests confirm 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 (given directly into a vein) may be needed.

Antibiotics sometimes cause mild side effects, such as an upset stomach, diarrhoea or a rash.

Surgery

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 is only considered for a recurrent sore throat 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

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 to 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'll 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.

Post-operative bleeding

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 1 in 100 children and 1 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 NHS 24's '111' service.

Extensive bleeding may need to be treated with surgery or a blood transfusion.