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Tonsillitis causes, symptoms, treatment, FAQs

What are palatine tonsils and their function?
They are two masses of lymph tissue located at either sides of the back of the pharynx (the throat).
The lymph tissue of both tosils is covered with pink mucous layer like that of the adjacent mouth lining.
tonsillitis

Tonsils are part of the body's immune system and are the first line of defence in fighting infections.

When bacteria or viruses enter the body, The tonsils act as "filters" engulfing the foreign organisms in white blood cells. 
Tonsils prevent germs from entering the airways and causing infections.
normal-tonsils

What is meant by tonsillitis?

Acute tonsillitis is non specific inflammation of palatine tonsils.
It occurs when bacterial or viral infection affects the tonsils, and cuases them to swell and may develop "exudate" which is a gray or white coating.

Chronic tonsillitis is persistent inflammation of the tonsils due to repeated acute infections.

Peritonsillar abscess (Quinsy): Collection of pus between fibrous capsule of the tonsil, usually at its upper pole, & the superior constrictor muscle.
Peritonsillar abscess must be drained urgently.

Strep throat: this is when Streptococcus aureus bacteria causes infection of the tonsils and throat. The patient may feel neck pain and fever in addition to sore throat.

Tonsilloliths (tonsil stones): this is when some debris are trapped and they become calcified and hardened. 

What causes tonsillitis?

a. Predisposing factors:

  • Recurrent URT infection 
  • Bad hygiene
  • Low body resistance.

b. Causative organisms:

Tonsillitis may be caused by viruses or bacteria, which are:
  • Group A beta haemolytic streptococci
  • Rhinovirus
  • Adenoviruses
  • Epstein-Barr virus: this viruse causes infectious mononucleosis, tonsillitis usually develops as a secondary infection 
  • Influenza virus
  • Parainfluenza viruses
  • Enteroviruses
  • Herpes simplex virus
  • Hepatitis A virus

c. Incidence:

Tonsillitis occurs at any age, but it is more common in children espicially at the age from preschool through mid-teens.
Tonsillitis can recur many times in a short priod of time.

Almost every child will probably get tonsillitis at least once.

What are the symptoms of Tonsillitis?

Symptoms of tonsillitis may include:
  • High fever 39-40
  • Headache, malaise, anorexia & myalgia
  • Sore throat & odynophagia (painful swallowing) and painful ulcers
  • Referred otalgia (ear pain)
  • Fetor oris (bod mouth smell)
  • Swollen glands (lymph ndes) in the neck or jaw
  • Hot potato voice if huge tonsils
  • Swollen congested tonsils, oropharynx is red & edematous
  • Stiff neck
  • Yellow white spots may be seen, yellow white membrane on the surface (doctor examination).
picture-of-tonsillitis

Symptoms of tonsillitis in Children

  • Vomiting
  • Stomach upset
  • No desire to eat
  • Increased drooling
  • Pain in the abdomen (belly)
Signs (Doctor examination):
General: Fever & proportionate tachycardia, patient looks ill.

Local
  • Swollen congested tonsils, oropharynx is red & edematous.
  • Yellow white spots may be seen, yellow white membrane on the surface.
  • Edema of soft palate & foetor oris.
  • Enlarged tender UDCLN (jugulo digastric).

Investigations and tests to confirm Tonsillitis diagnosis

  • Throat swab for culture and sensitivity: which is taken from the back of the pharynx. It takes a couple of days in the laboratory to get the results.
  • Complete blood count (CBC): usually reveals leucocytosis (increased number of white blood cells).
  • Erythocyte sedimentation rate (ESR): usually high

Is tonsillitis contagious?

Yes it is. A patient with tonsillitis can be contagious even before he develops any symptoms (24-48 hours before symptoms).
A patient with tonsillitis remains contagious untils he starts antibitic treatment.

After 24 hours of starting antibiotic treatment, the patient becomes less contagiuos.

How is infection transported?

Tonsillitis is transported via droplet infection i.e:
  • If a patient with tonsillitis sneezes or coughs near you and you breathe in those droplets
  • If you touch or hold contaminated objects then you touch your mouth or nose
  • Being in a place where many people gather can spread the infection from the patient to many contacts, this explains why tonsillitis is widely spread among school-age children.
The incubation period of the disease is 2 to 4 days meaning that it takes 2 to 4 days to develop symptoms after being exposed to a patient with tonsillitis.

Complications of Tonsillitis

Mostly complications occur with bacterial tonsillitis. Possible complications include:
  • Otitis media (middle ear infection)
  • Peritonsillar abscess "Quinsy" (a collection of pus around the tonsils as described above)
  • Obstructive sleep apnea 
  • Parapharyngeal abscess
  • Retropharyngeal abscess 
  • Laryngitis, and bronchitis  
With inadequate treatment for streptococcal infection, the patient may develop more serious conditions, such as:
  • Rheumatic fever
  • Sinusitis
  • Scarlet fever
  • Glomerulonephritis (kidney infection)
  • tonsillar cellulitis: spread of infection to other parts of the body

Differential diagnosis (DD) of Tonsillitis:

Tonsillitis should be differentiated from other diseases that cause membrane over tonsil, which are:
  • Scarlet fever
  • Erythematous rash
  • Hypertrophy of posterior pharyngeal wall 

How to prevent Tonsillitis?

There are some measures that may decrease the risk of having tonsillitis infection:
  • Avoid contact with patients who have active infections
  • If you are infected with tonsillitis, avoid contact with others until you get cured
  • Wash your hands regularlyc espicially if you had contact with a person who is coughing or sneezing

How to treat Tonsillitis?

a. General measures

  • Have rest
  • Light diet with smooth foods
  • Adequate warm fluids
  • Gargle with warm salt water

b. Medication

  • Antibiotics: you may start by I.M Penicillin & continue on oral e.g -Amoxycillin – Amoxycillin clavulinate, Cephalosporins, & macrolids.
  • Analgesics, antipyretics, anti-septic mouth wash.
  • For viral tonsillitis: Antibiotics do not help, and the above-mentioned general measures are enough to help the body resist the infection, you can take lozenges and OTC analgesics also.

c. Tonsillectomy surgery

Tonsillectomy is the best treatment for recurrent and chronic tonsillitis.
It can be considered an outpatient procedure, as the patient doesn't have to stay in the hospital after the surgical operation.
Most propably, patients go home few hours after surgery.

Most patients usually recover within 7-10 days after the surgery.

Answers to Frequently Asked Questions (FAQs)

How long does tonsillitis last?
In most cases, Tonsillitis lasts 4-10 days. 
If it is caused by viral infection, it recovers spontaneosly with simple general measures within 4-10 days.
Bacterial tonsillitis, if left without treatment, persists for up to a couple of weeks.
Medications may make it last about 3-5 days, in bacterial infections.

How do you get tonsillitis?
Tonsillitis is transported from person to person via "droplet infections" as described above.

What does tonsillitis look like?
When the E.N.T specialist examines your pharynx through your mouth, he sees two almond-shaped masses on both sides of the pharynx, red & edematous as in that image below.
What-does-tonsillitis-look-like

How long is tonsillitis contagious?
Tonsillitis is contagious from the beginning of the infection even if no symptoms appear.
A patient with tonsillitis becomes contagious 24-48 hours before he develops symptoms, and he stays contagious 1-2 days after starting treatment.

How to prevent tonsillitis?
Many measures can protect you from getting infected with tonsillitis, such as:
  • Hand washing is very important and crucial in preventing organisms that cause tonsillitis
  • Avoid contact with any person who has coughing, sneezing or sore throat until he starts medical treatment (1-2 days after starting)
  • Tonsillectomy is the final solution to prevent repeated tonsillitis in children
How long does viral tonsillitis last?
With adequate general measures as mentioned above, viral tonsillitis lasts for 4-10 days mostly.

What does tonsillitis feel like?
A patient with tonsillitis feels pain in his throat with difficulty in swallowing, a scratchy-sounding voice and he my feel like something closing his throat
In addition, he may have high temperature and chills with the rest of symptoms mentioned above.

What to eat with tonsillitis?
  • Hydration is essential in treatment of tonsillitis to avoid dehydration. Take warm fluids and avoid hot beverages that may further irritate your sore throat.
  • Avoid highly acidic juices like grapefruit juice, lemonade and orange juice.
  • Decrease coffee and tea.
  • Take soft foods like pudding, applesauce and yogurt, plain pasta, rice, mashed potatoes, winter squash.
  • Fruit juices like Pomegranate, bananas help to improve your condition.
Why do I keep getting tonsillitis?
There are some theories that explains the causes of repeated tonsillitis (Recurrent).
  • Some recent studies shown a genetic predisposition to developing repeated tonsillitis
  • Evolving of resistant strains of the bacteria. Research from 2018 suggests that chronic and recurrent tonsillitis may be caused by biofilms in the folds of the tonsils. Biofilms are communities of microorganisms with increased antibiotic resistance that can cause repeated infections.
  • Weak body immunity
  • You are in contact with someone who is a strep carrier
How do you know if you have tonsillitis?
If you have one or more of the above mentioned symptoms and it doesn't respond to home treatment, you should visit an ENT specialist.

How long do antibiotics take to work for tonsillitis?
A patient with tonsillitis feels improvement about 48-72 hours from starting antibiotic treatment provided that he takes the proper type and proper doses.

How to cure tonsillitis without antibiotics?
This question should be answered by your ENT specialist, because he can decide if it is viral or bacterial tonsillitis after taking throat swab.
If it is viral tonsillitis, you can recover within a week with proper diet and rest and the above mentioned precautions.
If it is bacterial tonsillitis, you will have to take antibiotic course as determined by your doctor.

When does tonsillitis stop being contagious?
A patient with tonsillitis is able to spread the illness until he is no longer sick, but if he takes antibiotics for bacterial tonsillitis, he should stop being contagious after 24 hours.

Can Tonsillitis be dangerous for a Pregnant woman?

Tonsillitis with pregnancy may give a warning that the pregnant woman has low immunity for some reason, and that she may be vulnerable to other infections and disorders up to miscarriage.

Having entered your body, infection could be transferred to the fetus and jeopardise his health with hazards like Intrauterine infection, premature birth, and weak labour activity espicially during the second trimester of pregnancy.

If tonsillitis progresses to the chronic stage, this adds other risks to your health including immunity deficiency. Most propably those women have delivery via caesarean sections.

What are the safe treatments for tonsillitis during pregnancy?

Taking medications during pregnancy is not desirable.
If Tonsillitis is caused by viral infection, the pregnant woman will not have to take medication.
If tonsillitis is bacterial, she will be required to take antibiotics, under supervision of her doctor.

Safe medication for tonsillitis with pregnancy


  • Cleansing the tonsils with an antiseptic
  • Herbal infusions for washing the tonsils 
  • Disinfecting solutions on the tonsils
  • Anti-inflammatory sprays could be used
  • Using biologically active additives (BBA) to strengthen the immune system and speed up the healing process


Contraindicated treatments for tonsillitis with pregnancy


  • Use of medicines with anti-histaminic drugs
  • Physiotherapy
  • Use of antibiotics except if there is a probable threat to the growing foetus from streptococcus bacteria tonsillitis in the third trimester of your pregnancy.

References:
Scott-Brown 7th edition: Volume 2, Part 15, chapter 119; Mucoceles Scott-Brown 7th edition: Volume 2, Part 16 chapter 172 Sinha V et al. 2005 Proptosis through eyes of ENT surgeon. Indian J Otolaryngol Head Neck Surg 57(3):207–209. Surgical Anatomy of the Head and Neck. 2001. 1- James Paul Dworkin, Laryngitis: Types, Causes, and Treatments, Otolaryngologic Clinics of North America, Volume 41, Issue 2, 2008, Pages 419-436

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