Tonsillitis

In this article:

• What Is Tonsillitis?
• Symptoms
• Tonsillitis Symptoms in Children
• When to see a doctor
• Is tonsillitis contagious?
• Causes
• Why do tonsils get infected?
• Risk Factors
• Complications
• Strep infection
• Prevention
• Diagnosis
• Throat swab
• Complete blood cell count (CBC)
• Allergy testing
• References

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What Is Tonsillitis?

Tonsillitis (sometimes referred as tonsilitis) is a medical term describing an inflammation of the tonsils – two rounded glands in the back of the throat. Tonsils are glands that serve an immune protection function. These are outposts for the immune cells to guard the upper airways (trachea and larynx) and lungs from infections. In a way these are similar to the lymph nodes (oval structures that you may feel under the jaw. 

Tonsillitis can be confused with adenoid hyperthrophy. Adenoid hypertrophy is an obstructive condition due to enlarged adenoids. Adenoids is a similar to tonsils lymph tissue that sits at the roof of the throat and usually cannot be seen with just an open mouth. Doctors use a flexible laryngoscope to see if adenoids are also enlarged together with tonsils.

Tonsils and lymph nodes are connected by lymphatic vessels, and are parts of the whole-body protection from infectious intruders, such as bacteria and viruses. If a person inhales a bacteria or virus, it gets stuck on a tonsil and activates immune cells that sit right under the surface. Urgent attack response is initiated if the bacteria or virus is harmful for the body. This in turn causes tonsils to increase in size, become red and sometimes hurt.

Tonsilitis can happen as a result of the tonsil infection with a bacteria or virus, which is a localized problem. Or it can also be a symptom of a systemic viral and bacterial infection.

Before antibiotics and vaccines were invented, some infections of the tonsils were deadly. One of the severe infections of the tonsils became almost extinct – diphtheria. The vaccine that protects people from that is DTaP or DT (which stands for diphtheria, tetanus and pertussis).

One of the most known tonsilitis is Strep throat. Streptococci is a bacterium that can infect tonsils mainly in children, but adults also can get it. While some people get significantly sick with Strep, others can be asymptomatic carriers.

It is not known why some people get very frequent tonsillitis, while others never do. Children may develop very large tonsils that do not shrink between infections, and become a problem. In this case a surgery is recommended to take the tonsils out. This procedure was very common in the last century, when almost all children with large tonsils were undergoing tonsillectomy. 

Now, with the advances of the medical knowledge, it became obvious that tonsils are an important part of the immune protection. They should be saved whenever possible in the childhood, and they start shrinking by themselves in adults.

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Symptoms

Symptoms of tonsillitis may be different dependent on what exactly caused it. They can be local or systemic (whole body is involved). Here are the main symptoms of the Strep throat:

• Significant throat pain, worse with swallowing
• Fever, sometimes very high
• Excessive saliva
• Body aches
• Headache

Strep throat usually causes white film on the tonsils, or pus. Viral tonsillitis mostly causes tonsils to swell and hurt, but the white or yellow coating does not form.

Untreated tonsillitis takes about a week to resolve. It is a miserable sickness, as it hurts so much to swallow (what we do every few seconds). Most people with tonsillitis spend at least 3-4 days in bed eating only ice cream, as cold makes it at least less painful!

Tonsillitis Symptoms in Children

Tonsillitis Symptoms in Children:

• Inability to swallow
• Sore throat
• Neck pain and large lymph nodes on the neck
• Fever
• Trouble breathing if tonsils get too big
• Vomiting with food
• Absence of appetite

When to see a doctor

Tonsillitis is a very common sickness. Most people with call a primary care clinic for:

• High fever that does not want to drop with OTC meds
• Significant pain that cannot be easily tolerated
• Inability to swallow
• Significant fussiness and constant crying of the young children, refusal to drink

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Is tonsillitis contagious?

Yes, tonsillitis is very contagious. The infection is transmitted with saliva, so all the dishes must be put in dishwasher and never shared during the infection. Children with Strep should be kept at home until released to school by a pediatrician. Also, school must know about an infection to let other parents know.

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Causes

Here are the most common diseases that involve tonsillitis:

• Strep throat
• Common cold
• Adenoviral infection
• Hand-foot-mouth disease
• Flu
• Mono (“kissing disease” that is caused by EBV virus)
• Measles

Why do tonsils get infected?

Tonsils fight off the infection in mild cases without symptoms, but if the immune system is weak, the bacteria or virus takes over and intrudes tonsils. Then tonsils become inflamed, and sometimes form chronic infection.

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Risk Factors

Genetics plays a big role in some types of tonsillitis. It is known that if parents were sick with the Strep Throat frequently, children most likely will have it too. Some people seem to be immune to this problem and just don’t catch it. Viral infections are common for everyone. It is known that children who are in a daycare, or in the families with many kids, can get sick 1-2 times a year.

Allergy is known to cause large tonsils and weaken immune system. If your child has frequent tonsillitis or very large tonsils, it makes sense to visit an Allergist to check if there is a food allergy, or an indoor allergy to a cat or dust mites. Treating an allergy eliminates the need to remove tonsils – they will reduce in size on their own.

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Complications

Tonsillitis is a common condition that resolves within a week on its own in most of the cases. If the infection is not going away, it must be treated to avoid complications. Sometimes, when there are too many infections, or tonsils become too big, a surgical removal is recommended. There are few serious complications that require immediate medical attention:

1. Tonsillar (peritonsillar) abscess. A pus pocket forms behind a tonsil. 
2. Sleep apnea
3. Eating disorder due to severe gagging reflex
4. Tonsil stones
5. Bad breath (halitosis)
6. Food gets stuck in the tonsil

Strep infection

In the past the strep infection was a significant problem due to heart and kidney complications. It was recommended to treat it with antibiotics for no less then 10 days. Now, with the advances of the medical research and understanding of microbiome, most experts advise against antibiotic treatment. Only people in risk groups for the development of heart problems (heart prosthetic devises etc) and kidney problems need antibiotics. 

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Prevention

These types of infections spread easily, so it’s important to try to avoid passing the infection on to others by:

1. 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)
2. Coughing and sneezing into a tissue and disposing of the tissue 
3. Washing hands before eating, after going to the toilet and, if possible, after coughing and sneezing

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Diagnosis

Tonsillitis is such as common problem that any primary care practitioner will be able to diagnose and treat it. If the infection happens too frequently or tonsils are large and unhealthy, a primary care doctor will recommend to see a specialist. ENT and Allergist are the subspecialists who treat chronic or complicated tonsillitis. Sometimes you will need to see both, to see what exactly is causing a problem.

Other systemic viral illnesses may cause tonsillitis. Kawasaki disease, Coxsackie virus, primary HIV, Ebstein-Barr virus, and oral Candidiasis may also present with throat pain.

Throat swab

Because of COVID, everyone is familiar with the throat swab now! This is a simple method to diagnose any infection of the tonsils. A swab is then sent to the laboratory and a viral or bacterial culture will show which specific organism is invading the tonsil. There are also rapid tests for antigens that can give an answer right away, such as COVID-19 Lateral flow test, or Rapid Strep test.

Complete blood cell count (CBC)

Sometimes when there is a very high fever or other systemic problems, a doctor will order a blood analysis – CBC. This test shows if there is a systemic infection, and also will tell if there is a virus or bacteria by elevation of certain white blood cells. There are other components of the blood test that are usually ordered (especially if the situation is unclear or urgent):

• CRP
• Chem panel
• Liver function
• Viral panel (CMV, EBV ect)

Allergy testing

Tonsils may be large due to the allergy without infection. As a part or a workup of chronically enlarged tonsils in adult or child it is important to rule out allergies. The allergy test is simple and fast, and treating allergy may eliminate a lot of chronic issues (ear infections, eczema, asthma and tonsillitis). The blood screening for allergy can be ordered by the primary care provider. If the allergy is found, it is important to schedule an appointment with an Allergist.

As a summary, most cases of tonsillitis are self-resolving and can be managed at home with supportive treatment, if the tonsillitis is nor getting better in a week or comes back too often – it is time to see as medical professional.

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References

Tonsillitis. Anderson J, Paterek E.

Anatomy, Head and Neck, Palatine Tonsil (Faucial Tonsils) Meegalla N, Downs BW. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jun 18, 2021. [PubMed]

Anatomy, Head and Neck, Tonsils. Masters KG, Zezoff D, Lasrado S. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Aug 22, 2020. [PubMed]

Bartlett A, Bola S, Williams R. Acute tonsillitis and its complications: an overview. J R Nav Med Serv. 2015;101(1):69-73. [PubMed]

Tonsillitis. Georgalas CC, Tolley NS, Narula PA.  BMJ Clin Evid. 2014 Jul 22;2014 [PMC free article] [PubMed]

Bacteriology and antibiotic sensitivity of tonsillar diseases in Chinese children. Wang Q, Du J, Jie C, Ouyang H, Luo R, Li W. Eur Arch Otorhinolaryngol. 2017 Aug;274(8):3153-3159. [PubMed]

A case of pharyngeal diphtheria in Germany, June 2015. Berger A, Meinel DM, Schaffer A, Ziegler R, Pitteroff J, Konrad R, Sing A. Infection. 2016 Oct;44(5):673-5. [PubMed]

Gonococcal tonsillar infection–a case report and literature review. Balmelli C, Günthard HF. Infection. 2003 Oct;31(5):362-5. [PubMed]