Introduction

Sore throats can have a range of causes. They usually result from an inflammation of the throat caused by cold viruses. This can also affect the palatine tonsils. Often simply referred to as "tonsils," these are the visible lumps of tissue on the left and right sides at the back of the throat. Bacterial infections of the tonsils are less common. But it isn’t easy to tell what kind of germs are responsible for the infection. Children and teenagers are much more susceptible to tonsillitis (inflammation of the tonsils) than adults are.

Tonsillitis starts suddenly and is painful, but it usually goes away within one to two weeks. But it may also return several times. Although that can be unpleasant, it only rarely results in complications.

It is important to distinguish between tonsillitis and enlarged tonsils. These are two separate medical conditions. In enlarged tonsils, the adenoids may be affected as well.

At a glance

• The typical symptoms of tonsillitis include a sore throat, fever and swollen tonsils with a yellowish coating.
• It is caused by bacteria or viruses that spread through droplets.
• Tonsillitis usually goes away within one to two weeks. Complications are rare.
• Painkillers are available to relieve the symptoms. Antibiotics are sometimes used to treat bacterial infections.
• Surgery may be considered if the tonsillitis keeps coming back.

Symptoms

The typical symptoms of acute tonsillitis include the following:

• Sore throat
• Swollen and very red tonsils with a yellowish coating
• Difficulty swallowing
• Swollen and painful lymph nodes in the neck
• Fever over 38°C (100.4°F)
• Headache
• Fatigue and tiredness
• Loss of appetite
• Bad breath

If it is a viral infection, typical cold symptoms such as a cough or a stuffy nose are likely too.

The throat is often inflamed (pharyngitis) as well, not only the tonsils. It is considered to be tonsillitis if the inflammation mostly affects the tonsils.

Tonsillitis can also cause atypical symptoms, especially in children. These may include stomach ache, nausea or vomiting.

Inside the mouth: Swollen, inflamed tonsils with pus-filled spots

Causes

Bacteria and viruses may be spread through tiny droplets – in other words, when someone who is infected talks or sneezes, droplets containing the germs are released into the air. They can then come into contact with other people‘s mucous membranes, where they start multiplying.

Bacterial tonsillitis is typically caused by certain types of streptococcus bacteria. But not everyone who has these bacteria in their body also ends up getting tonsillitis.

Sometimes tonsillitis occurs as a result of scarlet fever, which is also caused by bacteria. Viral infections like mononucleosis (also called “mono” or glandular fever) can lead to tonsillitis too.

Outlook

Acute tonsillitis symptoms like sore throat and fever will usually go away within one to two weeks. The fever often goes away somewhat before the sore throat does. But it may take longer for the swelling of the tonsils to go down.

Effects

Complications are rare. The most common complication is a build-up of pus around the tonsils – known as a peritonsillar abscess or quinsy. This may develop if the tonsillitis is caused by bacteria, and can get better again without treatment. But there is a risk of the infection spreading to nearby tissue in the throat and chest area or of septicemia (blood poisoning) developing. This can lead to serious complications, so it's very important to get treatment. The following symptoms may be signs of quinsy:

• A very severe sore throat on only one side of the throat and difficulty swallowing
• General physical weakness and fever
• Earache (especially in only one ear)
• The feeling that there is a lump in your throat when speaking
• Trouble opening your mouth

It is estimated that quinsy arises in no more than 1 to 10 out of 1,000 people who see a doctor because they have a sore throat. It is just as rare for tonsillitis to lead to a middle ear infection.

Rheumatic fever is a very rare complication of tonsillitis. This involves painful inflammation in several joints and in the heart muscle and valves. Rheumatic fever only occurs after infection with particular types of streptococcus bacteria. It is estimated that less than 1 out of every 100,000 children in Germany get rheumatic fever each year. Nephritis (kidney inflammation) is also a very rare complication of certain kinds of streptococcal infections. An estimated 6 out of every 100,000 children in Germany are affected each year.

Diagnosis

When you have a sore throat, a doctor can examine you to try to answer the following questions:

• Is tonsillitis causing the symptoms?
• How severe is the inflammation?
• Is it bacterial tonsillitis?
• Is it likely to go away quickly without antibiotics?
• Is there a high risk of complications?
• Is treatment with antibiotics needed?

The doctor examines the throat and asks about the exact symptoms. It is likely to be bacterial tonsillitis if the tonsils are swollen and coated, with a fever but no cough.

A rapid test can be done too. Statutory health insurers in Germany cover the costs of this test for children under the age of 16 years. The test involves using a throat swab to get a sample of secretions from your tonsils. The sample is checked for streptococcal bacteria. It provides results within a few minutes, but they're not always correct. You can get more accurate results by sending the sample to a lab, but it takes one or two days for the results to come back.

Blood tests are only rarely done, for instance in order to rule out other medical conditions.

Treatment

The main goal of treatment is to relieve the symptoms and prevent complications. The following medicines can be used to treat acute tonsillitis:

• Medication for relieving pain and lowering fever, like ibuprofen or acetaminophen (paracetamol)
• Antibiotics (for bacterial tonsillitis only)

Antibiotics can make the tonsillitis go away a little sooner. Also, people who take antibiotics for tonsillitis stop being contagious within 24 hours after starting the treatment. Antibiotics can also lower the risk of developing complications – even though these are rare anyway. Because antibiotics have side effects and only help a little against the symptoms, you can often do without them.

Some people relieve their symptoms by sucking on throat lozenges, or using home remedies such as a neck wrap or gargling with salt water or tea.

Recurrent tonsillitis can also be treated with painkillers or antibiotics. The surgical removal of tonsils is another treatment option for people who frequently get tonsillitis.

Our decision aids on tonsillitis in children and on tonsillitis in adults may help when deciding whether or not to have surgery. They summarize the main advantages and disadvantages of the various treatment options.

Further information

When people are ill or need medical advice, they usually go to see their family doctor first. In our topic "Health care in Germany" you can read about how to find the right doctor – and our list of questions can help you to prepare for your appointment.

Sources

• Deutsche Gesellschaft für Allgemeinmedizin und Familienmedizin (DEGAM). Halsschmerzen. DEGAM-Leitlinie Nr. 14 (S3-Leitlinie). AWMF-Registernr.: 053-010. 2020.
• Georgalas CC, Tolley NS, Narula PA. Tonsillitis. BMJ Clin Evid 2014: pii: 0503. [PMC free article: PMC4106232] [PubMed: 25051184]
• Kenealy T. Sore throat. BMJ Clin Evid 2014: pii: 1509. [PMC free article: PMC3948435] [PubMed: 24589314]

• IQWiG health information is written with the aim of helping people understand the advantages and disadvantages of the main treatment options and health care services.

  Because IQWiG is a German institute, some of the information provided here is specific to the German health care system. The suitability of any of the described options in an individual case can be determined by talking to a doctor. informedhealth.org can provide support for talks with doctors and other medical professionals, but cannot replace them. We do not offer individual consultations.

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