Tonsillitis – Etiology, Presentation, Types, Complications, Contagious and Treatment

tonsillitis in adults symptoms, pictures, contagious, remedy

What are tonsils?

Tonsil make an important part of the body’s immune system and plays a vital role in guarding against the allergens and pathogens, entering in our body through mouth and nose. Their location at the throat and palate is very convenient for that purpose and allows them to activate the immune system in a timely fashion.

The tonsils are a non-encapsulated (sometimes partially encapsulated) part of lymphoid tissue, located along the oro-pharyngeal track.

A set of lymphoid tissue makes a ring where mouth and nose meets the throat. This ring is called ‘Waldeyer’s tonsillar ring’ and includes adenoid tonsil (pharyngeal tonsil), two tubal tonsils, two palatine tonsils and the lingual tonsil.

Each type of tonsil is named according to its certain location. Adenoids and tubal tonsils are located on the roof of pharynx and lingual tonsils are located behind the tongue.
Palatine tonsils are what layman would refer to as tonsils in general, especially when referring to tonsillitis.

Tonsillitis - Symptoms, Causes, Treatments, Surgery

Palatine Tonsils

Palatine tonsils are soft lymphoid tissues located at the back of the pharynx (throat), one on each side. The lymphoid tissue consists of number of channels, called crypts. There are about 20 crypts reaching the deepest part of the structure. These crypts are lined with squamous epithelium and open on to the surface.

Anatomy of palatine tonsil

The normal adult tonsil weighs around 1.5 gm and measures up to 2.5 cm in length, 2 cm in width and 1.2 cm in thickness.
A palatine tonsil is bounded laterally by the superior constrictor muscle of the pharynx and is embedded between the anterior and posterior pillars made by palatoglossus muscle and palatopharyngeus muscle. The lingual branch of glossopharyngeal nerve passes below the lower border of the tonsil and carries the taste sensations to the posterior part of the tongue.


The epithelium lining of the tonsils is stratified squamous epithelium which is in sync with the oral lining. Below the epithelium lie the lymphoid follicles, and have germinal centers (e.g. lymph nodes) below it. The epithelium engulfs the pathogens when in contact (phagocytosis) and present them to the macrophages. Macrophages then pass them onto the B cells (activated by T cells) and result in antibody production—antigen-antibody reaction.

Lymphoid tissue and a role of tonsil as a lymphoid organ

There are two types of lymphoid tissues, primary and secondary. Both types of tissues are considerably different than the other organ systems, based on cell cycle and proliferation of lymphocytes.

Primary Lymphoid Organs

These include thymus gland and bone marrow—sites where lymphocytes are generated from the immature progenitor cells, such as lymphoblasts. T cells and B cells are born in the bone marrow but only B cells stay. T cells migrate to thymus for maturation.

Secondary Lymphoid Organs

Secondary lymphoid tissue includes tonsils, adenoids, peyer’s patches (in intestine), spleen, lymph nodes and areas associated with MALT (mucosa- associated lymphoid tissue). Their main function is to activate the white blood cells (T cells and B cells) by interacting with the antigens, initiating the adaptive immune response by mature lymphocytes. In addition, they are assigned special tasks, like spleen can filter blood and the tonsils have ability to capture antigens in the upper respiratory tract.
The tonsils contain B cells, a type of white blood cell that fights various infections and T cells help in building up the immunity and destroy cells infected with viruses.

B cells also produce antibodies against polio, streptococcal pneumonia, influenza, and numerous other infections.

how does tonsillitis look
healthy tonsils vs unhealthy


Tonsils are the first line of defense mechanism. This also makes them most susceptible to infections themselves. Since tonsils fight both viruses and bacteria, tonsillitis can be both viral or bacterial.

However, viral tonsillitis is typically most common.

Viral causes of tonsillitis include

Adenovirus, may cause a variety of infections most common of which is common cold, sore throat, bronchitis and pneumonia. Others may include, pink eye(conjunctivitis), diarrhea and bladder infection. Adenovirus rarely cause serious illness, but those with weak immune system or infants might develop severe response to the virus.

Rhinovirus, a most common cause of the common cold.

Influenza, commonly known as flu. Respiratory syncytial virus, which often causes pneumonia and bronchiolitis (inflammation of the small airways in the lung)

Coronavirus, responsible for up to 30% of common cold cases and may cause severe acute respiratory syndrome (SARS).

Less common causes of viral tonsillitis

Epstein-Barr Virus: EBV causes infectious mononucleosis, also called mono or kissing disease. The patient presents with fever, sore throat, enlarged lymph nodes and tonsils

Herpes simplex virus type-1: HSV causes oral herpes and present with raw cracked blisters, not only on the lips and mouth but often on the tonsils too. In addition to that, patient has extreme difficulty

swallowing, sore throat and fever.

Bacterial causes of tonsillitis include

Most common bacteria causing tonsil infection is:

⦁ Streptococcus pyogenes
Other less common bacteria include:
⦁ Staphylococcus aureus
⦁ Mycoplasma pneumonia
⦁ Chlamydia pneumonia
⦁ Neisseria gonorrhoeae
⦁ Bordetella pertussis
⦁ Fusobacterium sp.

Acute tonsillitis with enlarged, red and swollen tonsils

How long does it take to get over viral tonsillitis

Symptoms of tonsillitis

  • Most commonly patients with tonsillitis present with:
  • High temperature.
  • Sore throat
  • Pain when swallowing.
  • Complains of headache, pain in ears or neck, coughing and chills.

On examination, common findings are
⦁ Red and swollen tonsils with pus filled spots.
⦁ Swollen lymph nodes in the neck region.

Other Less common complaints

Fatigue, vomiting, bad breath, furry tongue, changes in the sound of voice, pain with jaw movement and stomach pain.

When to see a doctor?

  • High fever- 103˚F or above
  • Muscle weakness or extreme fatigue
  • Stiff neck Sore throat for over 2 days.

Signs and Symptoms in young children

Since young children are unable to describe, doctors can suspect tonsillitis if they present with:

A sore throat that doesn’t go away for 24-48 hrs.

  • Drooling due to painful swallowing.
  • Not eating much.
  • Unusual fussiness.

Young children need immediate care if

  • Extreme fussiness and drooling.
  • Difficulty in breathing and excessive pain during swallowing.

Two major Risk factors for tonsillitis are, young age and repeated exposure to germs. Bacterial tonsillitis is most common among children ages 5 to 15, while viral tonsillitis is more common in younger children. School going children comes in close contact with germs every day, either through direct contact or through peers.

What to expect on doctor’s visit

Doctors generally start with physically examination, looking into the throat and palpating neck for lymph nodes. Different signs mostly depend on the cause of tonsillitis and help in the correct diagnosis.

Group A beta-hemolytic Streptococcus pyogenes (GABHS) is associated with tiny hemorrhagic spots on soft palate. Neck nodes may be enlarged and a fine rash over body, if present, suggest scarlet fever.

Open mouth breathing and muffled voice may result from the obstructive tonsillar enlargement. The voice change is even more severe with peritonsillar abscess.

In Epstein-Barr virus infection (EBV), a grey membrane may appear on the tonsils. The membrane can be removed without bleeding. Palatal petechiae may also appear.

In Herpes Simplex virus (HSV) tonsillitis, red swollen tonsils along with small ulcers on their surface can be seen.

Unilateral bulging above and to the side of one of the tonsils is a presentation of peritonsillar abscess. A painful, stiff jaw and pain referred to the ear may be present.

Signs of dehydrations, fatigue and tender lymph nodes are common with acute tonsillitis.

Tests for tonsillitis

Throat swab is a simple test, done with a sterile swab. Most of the clinics have rapid in-clinic test, if it comes positive then patient is almost certainly positive for bacterial infection. Most doctors run a confirmatory test of throat culture.

Complete blood count (CBC) is done to evaluate the blood markers. If the strep throat lab test is negative, the CBC may be needed to help determine the cause of tonsillitis.

Treatment options for tonsillitis

Treatment of tonsillitis start with home remedies

Adequate resting ensures fast healing by letting the body use its energy on fighting the infection, instead of on daily activities. Similarly, keeping oneself hydrated is important to prevent dry uncomfortable throat. Warm drinks (caffeine- free) sooth and relieve discomfort for some time. Other things that can relieve discomfort are over-the-counter lozenges, humidifiers, steam baths and pain medications like ibuprofen or acetaminophen. Avoiding irritants like tobacco and smoke is important too.


For bacterial infection, most common antibiotic prescribed is Penicillin. It is recommended to take the full course of antibiotic, even if you get symptom free. Failure to do so might result in spread of the infection—causing rheumatic fever and kidney inflammation.


Tonsillectomy is indicated when the condition is chronic and recurring. If you’ve had at least seven cases of tonsillitis or strep in the last year (or five cases or more over each of the last two years), then you might be the candidate for tonsillectomy.

Some secondary issues requiring tonsillectomy are

Sleep apnea, which is a serious sleep disorder. A person is not able to breathe while sleeping. These breathing pauses may last for a few seconds to minutes. Enlarged tonsil may be the cause of sleep apnea as they block the airway passages. Such patients benefit a lot with tonsillectomy.

Extreme difficulty in swallowing

Spread of an infection from tonsils to other areas or an abscess that is difficult to treat.
Tonsil cancer.

Bleeding of the tonsils

One common method for tonsillectomy is “Cold knife dissection”. This procedure requires the use of scalpel to remove tonsils. Other procedures are cauterization, lasers, radio waves and ultrasonic vibration. The procedure in done under general anesthesia and removal of tonsils do not make patients prone to more infections.

Recovery after Tonsillectomy

Sipping on cold water or ice popsicles helps staying hydrated post-surgery. During early recovery best is to start with liquid diet like apple sauce and chicken broth. Soft foods are encouraged like ice cream, oatmeal and pudding.

Snoring for the first two weeks after the procedure is normal and expected. Total recovery is expected within two weeks after  tonsillectomy.

Tonsil conditions

1. Acute tonsillitis

An acute tonsillitis presents with a rapid onset disease causing swelling and sore throat, followed by resolution within days. In most of the cases the elimination of infection is carried out by the host immune system itself.
On examination, the tonsil may have gray or white coating (exudate)

2. Chronic Tonsillitis

Sometimes, the infection persists for longer durations or there may be repeated episodes of acute tonsillitis.

3. Peritonsillar abscess

A pocket of pus is formed next to tonsil as a result of extended infection. As the pocket grows it pushes the tonsil towards opposite side. Peritonsillar abscess needs emergent draining.

4. Tonsil Hypertrophy

As a result of an infection, tonsils swell and become enlarged. Repeated or chronic infection is one of the main reason for the tonsil enlargement (hypertrophy). However, family history is important too. Tonsil hypertrophy can occur in anyone but chances are more likely if you have a family history of tonsil hypertrophy. In some cases, allergies might play a role in tonsil enlargement too.

Common symptoms of tonsil hypertrophy

  • Halitosis or bad breath, caused by the infected tonsils.
  • Sleep apnea, snoring and mouth breathing. Large tonsils obstruct the airways and disrupt the normal breathing and sleep cycle. Sleep apnea is a serious condition and can cause pulmonary hypertension and right ventricular hypertrophy.
  • Weight loss and decreased appetite, due to pain when swallowing.
    Chronic ear infections and hearing loss. The enlarged tonsils can block the Eustachian tubes and block the fluid drainage, which then builds up behind the eardrum and cause ear infections.
  • Recurring sinus infections. enlarged tonsil block the drainage of the sinus cavities and cause sinus infections.

Treatment of tonsil hypertrophy

Treatment solely depends on the etiology. If the doctor diagnose tonsil hypertrophy due to infections, then they might subscribe antibiotics to fight the bacteria. If allergies are suspected, then some antihistamines or corticosteroids are prescribed. In cases where the culprit is repeated or chronic infections, tonsillectomy is the treatment of choice.

5. Tonsillar calculi

Tonsil calculi are called tonsil stones or tonsilloliths. Tonsils have uneven crevices, tunnels and crypts, which attract a number of dead cells, mucous, food particles and saliva. As they accumulate into pockets and calcifies, they provide a breeding place for bacteria and viruses —giving a distinct, foul odor (halitosis).

It’s possible to have one tonsil stone or multiple. Tonsil stones range in size from rice to pea size and many people may not know they have it. They are generally small, but in rare cases tonsilloliths have measured 30 centimeters. Large tonsil stones can become symptomatic and are difficult to remove, but they are generally not harmful.
Tonsil stone protruding from the tonsil

Treatment Options for Tonsil Stones

Treatment of tonsil stones depend on the severity of the condition. In most of the cases no treatment is necessary. Many are found to have tonsil stones incidentally on X-rays or CT scans. There are some home remedies that help relieve the symptoms.

Gargle with salt water

Gargling relieves the pain and discomfort due to sore throat and inflamed tonsils. It may even dislodge the stones if gargled vigorously. Mix half a teaspoon of salt in lukewarm water and gargle at least two times a day.

Laser Tonsil Cryptolysis

Cryptolysis is a treatment where the pockets and crevices in the tonsil (where stones are lodged) are smoothed out with the help of a laser. This is a non-invasive procedure, done under local anesthesia and causes minimal pain. Downtime after treatment is also minimal.

Coblation Cryptolysis

This pain free procedure is done under supervision of an ENT doctor. Radio waves are used to change a simple salt solution into charged ions, which cling to the tonsil tissue and cut through it. This removes the crevices on the tonsils and get rid of tonsil stones too.


To treat the underlying bacterial infection antibiotics are prescribed. However, they can’t treat the basic problem causing tonsil stones.


Although not the recommended treatment, but when all other options fail to get rid of the severe symptoms, ENT specialist can opt for tonsillectomy. The removal can be done with scalpel or laser, or even with coblation medical device.

can tonsil stones return after a tonsillectomy
Tonsil stones after surgery

Complications with tonsillitis:

Acute oropharyngeal infections

Untreated or incompletely treated tonsillitis can lead to acute oropharyngeal infections that can spread into the deep neck spaces and then into the mediastinum. This can turn into life threatening condition and may require thoracotomy and cervical drainage. Radiological imaging is required to locate the pockets of infection.

Peritonsillar cellulitis occurs when the inflammation spread beyond the tonsil into the oropharyngeal mucosa. Peritonsillar abscess is the pocket of infection between the tonsillar capsule and lateral pharyngeal wall. The abscess most commonly spreads into the retropharyngeal space. Spread of the infection may result in necrotizing fasciitis which requires the hospital treatment with IV antibiotics and surgical debridement. Toxic shock syndrome is another complication that may arise due to the spread of infection from peritonsillar abscess, possibly treated with IV immunoglobulins.

Rarely, thrombophlebitis of the internal jugular vein is seen secondary to acute tonsillitis, commonly caused by Fusobacterium Necrophorum. CT scanning with contrast is necessary to make the diagnosis. Treatment requires IV antibiotics and may require ligation of the internal jugular vein if multiple septic emboli become evident.

Group A beta-hemolytic Streptococcus pyogenes (GABHS) complications

Tonsillitis caused by group A streptococcus or another strain of streptococcal bacteria requires complete course of treatment. If left untreated they may give rise to conditions like rheumatic fever, kidney inflammation etc.

Rheumatic fever: It is an inflammatory disorder that affects the heart, joints and other tissues. In heart, they cause vegetations on the mitral and tricuspid valves, leading to murmurs and valvular stenosis. Persistent relapsing fever usually accompanies. For the right diagnosis, throat swab is not enough, because a positive result indicate colonization rather than pathogenicity. The right diagnosis requires the elevated titer levels of anti-streptolysin antibodies, anti DNA-ase beta or anti-hyaluronidase.

Septic arthritis: Patient presents with painful septic joints and require arthrocentesis for the diagnosis and partial therapeutics. Treatment involves IV antibiotics for 6 weeks’ time.

Post-streptococcal glomerulonephritis: It is an inflammatory disorder of the kidneys. Urinalysis helps to detect subclinical renal injury for persons with recurrent tonsillitis.

Some Frequently asked questions regarding tonsillitis:

Why tonsillitis is more common in children and rare in adults?

The tonsil is the body’s first defense mechanism against pathogens entering through mouth. This function makes them more prone to infections. However, this function of tonsils starts to decline after puberty and that is why tonsillitis is more common in kids than adults.

Is tonsillitis contagious?

Viral tonsillitis is contagious for 7-10 days while bacterial tonsillitis can remain contagious for about two weeks. Those who are taking antibiotics for bacterial tonsillitis are considered non-contagious after approximately 24-48 hours of appropriate therapy.  How long does it take to recover from tonsillitis?
In four out of ten people, symptoms only last for three days and most people get better within a week.

Can tonsillitis be prevented?

Key is to take care of hygiene. Wash hands thoroughly with soap, avoid close contact with infected individuals and avoid sharing belongings like towels, drinking cups etc.


What is azotemia? Can dehydration cause azotemia?

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