Tonsillitis is the inflammation of the pharyngeal tonsils, which are glands located at the back of the throat and visible through the mouth. This inflammation can also affect other areas of the throat, such as the adenoids and lingual tonsils (tissue at the back of the tongue). Tonsillitis can present in several forms: acute, recurrent, chronic, and as a peritonsillar abscess.

The condition is typically caused by viral or bacterial infections, as well as immunological factors. Almost all children in the United States will experience at least one episode of tonsillitis during childhood. Thanks to advancements in medical and surgical treatments, complications related to tonsillitis, including severe outcomes, are now quite rare.

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Who gets tonsillitis?

Tonsillitis primarily affects children, although it is rare in those under two years old. Bacterial tonsillitis, particularly from Streptococcus species, is most common in children aged 5 to 15, while viral tonsillitis tends to occur more frequently in younger children. Peritonsillar abscesses are typically seen in young adults, though they can occasionally occur in children. The patient’s history is often useful in identifying the type of tonsillitis (i.e., acute, recurrent, chronic).

What causes tonsillitis?

Most cases of acute pharyngitis and tonsillitis are caused by the herpes simplex virus, Streptococcus pyogenes (GABHS), Epstein-Barr virus (EBV), cytomegalovirus, adenovirus, and the measles virus. Bacteria account for 15-30% of pharyngotonsillitis cases, with GABHS being the primary cause of bacterial tonsillitis, commonly referred to as “strep throat.”

What are the symptoms of tonsillitis?

Symptoms vary based on the type of tonsillitis:

  • Acute tonsillitis: Patients may experience fever, sore throat, bad breath, dysphagia (difficulty swallowing), odynophagia (painful swallowing), and tender cervical lymph nodes. Swollen tonsils can lead to airway obstruction, resulting in mouth breathing, snoring, nocturnal breathing pauses, or sleep apnea. Lethargy and malaise are also common. Symptoms typically resolve in three to four days but can persist for up to two weeks despite treatment.
  • Recurrent tonsillitis: This diagnosis is made when an individual has several episodes of acute tonsillitis within a year.
  • Chronic tonsillitis: Individuals may experience a chronic sore throat, halitosis, ongoing tonsillitis, and persistently tender cervical nodes.
  • Peritonsillar abscess: Symptoms include severe throat pain, fever, drooling, bad breath, trismus (difficulty opening the mouth), and a muffled voice quality, often described as the “hot potato” voice (as if speaking with a hot potato in the mouth).

What happens during the physician visit?

During the visit, your child will undergo a general examination of the ear, nose, and throat, along with a review of their medical history. A physical exam may reveal:

  • Fever and enlarged, inflamed tonsils covered in pus.
  • GABHS infection (strep throat), possibly indicated by palatal petechiae (tiny spots on the soft palate). Enlarged neck nodes may also be present. A fine red rash could indicate scarlet fever, commonly occurring in children aged 5-15.
  • Open-mouth breathing and a muffled voice due to obstructive tonsillar enlargement, although the voice change is usually less severe than with a peritonsillar abscess.
  • Tender cervical lymph nodes and neck stiffness, often seen in acute tonsillitis.
  • Signs of dehydration, assessed through skin and mucosal examination.
  • The possibility of infectious mononucleosis due to EBV, particularly in adolescents or younger children with acute tonsillitis, especially if they have tender cervical, axillary, or groin nodes. Severe lethargy, malaise, and low-grade fever may accompany the condition.
  • A gray membrane covering the inflamed tonsils in cases of EBV infection, which can be removed without bleeding. Palatal petechiae may also be observed.
  • Red, swollen tonsils that may have small ulcers in individuals with herpes simplex virus (HSV) tonsillitis.
  • Unilateral bulging above and to the side of one tonsil in cases of peritonsillar abscess, potentially accompanied by a stiff jaw, difficulty opening the mouth, and referred ear pain.

Treatment

Tonsillitis is typically treated with antibiotics. Fluid replacement and pain control are crucial. Severe cases, particularly those involving airway obstruction, may require hospitalization. For chronic or recurrent tonsillitis, a surgical procedure to remove the tonsils is often recommended. Peritonsillar abscesses may require urgent drainage treatment.