Causes, Diagnosis, and Treatment of Tonsillitis

We often think of tonsillitis as one of those rites of passages that children go through alongside chickenpox and braces. While the condition does commonly occur during the preschool to middle-teen years, it can happen at any time in life, for a variety of reasons.

The ways tonsillitis is diagnosed and treated have changed considerably in the past 30 years. There are now rapid tests that can help us pinpoint infections more quickly and newer drugs able to overcome resistant bacteria. With that being said, the rate of tonsillectomy (the surgical removal of the tonsils) has actually risen since the 1970s, according to a study from the Mayo Medical School College of Medicine.

Your tonsils are a part of the lymphatic system, which is responsible for eliminating toxins and harmful microorganisms (including viruses and bacteria) from your body. Your tonsils work by trapping inhaled particles and delivering them to the lymphatic system to be neutralized.

There are three pairs of tonsils in your body:

• Pharyngeal tonsils, also known as adenoids, located at the roof of your mouth near where your nose connects to your throat
• Lingual tonsils located behind the tongue
• Palatine tonsils located at the back of the throat

Tonsillitis occurs when a virus or bacteria enters the mouth or nose and becomes trapped by the tonsils. When this happens, the immune system will target and attack the invaders and trigger an inflammatory response, causing fever and swelling.

Tonsillitis is common, with most people experiencing at least one episode before adulthood, and it is highly contagious. It is most often seen in children ages five to 15 but can also occur between the ages of 15 and 25. The risk tends to decline as a person gets older.

The majority of cases of tonsillitis are caused by a virus, while anywhere from five percent to 40 percent are believed to be caused by bacteria.

Some of the more common viral causes include:

• Cold viruses (including rhinoviruses and adenoviruses)
• Infectious mononucleosis
• Cytomegalovirus (CMV)
• Epstein-Barr virus (EBV)
• Herpes simplex virus (HSV)
• Measles

The most common bacterial causes include:

• Staphylococcus aureus (including MRSA)
• Whooping cough (pertussis)
• Bacterial pneumonia
• Streptococcal pyogenes (strep throat)

Non-infectious causes of swollen tonsils are rarer but may include cancer of the tonsils and cryptic tonsils.

Symptoms of tonsillitis tend to appear quickly and resolve within three to 14 days, often without treatment. The signs and symptoms may include:

• Painful swallowing (odynophagia)
• Difficulty swallowing (dysphagia)
• Inflammation and enlargement of the tonsils
• Pockets or patches of white on the tonsils (tonsillar exudates)
• Swollen lymph nodes, mostly around the neck (lymphadenopathy)
• Fever
• Headache
• Fatigue
• Small red or purple spots on the roof of your mouth (petechiae)

The symptoms can vary by the type of virus or bacteria involved, as well as the age and health of the individual. While most cases of tonsillitis are acute—meaning they appear and resolve quickly—they can also be recurrent (relapsing multiple times per year) or chronic (lasting for more than three months).

The diagnosis of tonsillitis is based first on a physical exam and a review of your medical history. In cases where there are symptoms of strep throat (fever, tonsillar exudate, swollen lymph nodes around the neck, and no coughing), the doctor will take a swab of your throat and have it cultured in a lab to confirm the presence of the strep bacteria. Lab results typically take between 24 and 48 hours.

Newer, rapid genetic tests can be used and, while slightly less sensitive than a throat culture, are able to return results in as little as 10 minutes.

The symptoms of tonsillitis tend to be more annoying than serious and usually require little medical intervention.

• If you have viral tonsillitis, the treatment will be focused on relieving pain and fever with over-the-counter pain relievers, such as Tylenol (acetaminophen) or Advil (ibuprofen). Prescription drugs, including antivirals, are typically not prescribed.
• By contrast, bacterial tonsillitis is commonly treated with antibiotics. Penicillin and amoxicillin are the standard, first-line choices, although erythromycin and newer antibiotics like linezolid may be used in cases of drug resistance. Tonsillitis symptoms usually go away within a few 24 hours of starting treatment.

If the tonsils are so large that they interfere with breathing, the doctor may prescribe an oral corticosteroid (steroid) drug to help reduce their size. However, steroids of any sort should be used with caution due to their significant side effects.

If you have chronic or recurrent tonsillitis that is impacting your quality of life, your doctor may recommend a tonsillectomy. There are several methods for performing this surgery, among them ultrasonic scalpels, high-frequency plasma scalpels, electrical cauterization, and traditional "cold knife" surgeries. While tonsillectomies are relatively common and safe, it is important to discuss both the risks and benefits of the surgery with your doctor.

Whether or not you are prescribed treatment, there are home remedies that can greatly alleviate many of the symptoms of tonsillitis. In addition to using an over-the-counter pain reliever, try:

• Sipping warm fluids like teas or broth
• Drinking cold fluids or sucking on popsicles
• Sucking on anesthetic throat lozenges or using a throat spray containing benzocaine
• Gargling with a solution of 1/2 teaspoon of salt combined with eight ounces of warm water
• Placing a cool compress or ice pack on your neck
• Using a cool-mist humidifier

It is important to note that aspirin should be avoided in children with any viral infection due to an increased risk of Reye’s syndrome, a potentially life-threatening inflammation of the brain and liver.

It's important to remember that most cases of tonsillitis resolve on their own without causing lingering problems. However, serious or recurrent cases can lead to complications such as otitis media (middle ear infection) or peritonsillar abscess (the formation of a pus-filled pocket near the tonsils).

The tonsils can sometimes become so swollen that they interfere with breathing and swallowing. This can lead to a more serious condition known as obstructive sleep apnea.

Sleep apnea is a condition where a person stops breathing for brief periods of time while sleeping. This can lead to daytime fatigue, depression, mood swings, and other, more serious health issues such as high blood pressure and heart disease. Obstructive sleep apnea is also a leading indication for tonsillectomies in persons with chronic or recurrent tonsillitis.

If someone in your family has tonsillitis, it is best to isolate that person and keep others, especially children, well away until the symptoms are resolved. If you’re treating a family member, wash your hands after touching them and consider wearing a face mask if there is any coughing or sneezing. Do not allow a child to go to school until she or he is fully recovered and no longer contagious.