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Tonsillitis (Swollen Tonsils)

  • What is tonsillitis?

    Tonsillitis is a condition where the tonsils are inflamed, resulting in swelling and inflammation. It may be classified as acute, recurrent (acute) or chronic.

    Types of tonsillitis

    • Acute tonsillitis – This is the most common type experienced by patients, and the symptoms usually improve over 1 – 2 weeks.
    • Recurrent tonsillitis – The symptoms resolve after an attack but attacks occur frequently, eg. >4 times per year.
    • Chronic tonsillitis – Inflammation does not completely resolve after an initial acute attack.


    What are tonsils?

    The tonsils and adenoids are part of a ring of lymphatic tissue in the throat, known as Waldeyer’s ring. This ring includes the:

    • palatine tonsils (usually referred to as “the tonsils” because these are the only tonsils that can be seen through the mouth)
    • adenoids located at the uppermost part of the throat (pharynx) at the back of the nose
    • lingual tonsils located on the surface of the back of the tongue (the tongue base)
  • Tonsillitis is often caused by viral infections of the upper respiratory tract.

    More symptomatic infections of the tonsils are often due to bacterial infections especially involving the Streptococcus bacteria. In infections related to Epstein-Barr virus (EBV), the tonsils (and nearby lymph nodes of the neck) may remain inflamed for weeks.

  • The symptoms of tonsillitis include:

    • Sore throat
    • Difficulty and pain with swallowing
    • Fever and chills
    • Aching in the ears
    • Exudates / white spots on the tonsils

    There may also be associated symptoms such as:

    • Headaches and body aches
    • Hoarseness
    • Swollen lymph nodes of the neck (especially with EBV infection)
    • Fatigue
    • Snoring and/or noisy breathing (especially in children)
  • If you experience symptoms of tonsillitis, your doctor will likely recommend the following tests:

    Physical exam

    Tonsillitis is usually diagnosed based on the history of symptoms and the findings on examination. This may include:

    • An examination your throat directly to look for the signs and severity of tonsillitis
    • Examination of the ears and nose for associated signs of infection
    • Gentle palpation of your neck (for enlarged lymph nodes)
    • Listening to your breathing with a stethoscope (for other signs of upper respiratory tract infection)

    Your doctor may also advise other tests in the assessment of tonsillitis:

    • Nasopharyngoscopy – This may be important if there are features to suspect associated infection and/or enlargement of the adenoids, especially if there is nose block, noisy breathing or abnormalities on examination of the ear.
    • Blood tests – Your doctor may order blood tests to assess the level of infection and to help to identify the cause of infection.
    • Throat swab – In a throat swab procedure, a sample of the exudates is obtained from the tonsils using a sterile swab. Various types of laboratory tests (culture, antigen identification and polymerase chain reaction – PCR) may be used to identify specific bacteria or viruses that might be the cause of the infection.
  • Non-surgical treatment

    In acute tonsillitis, the main treatment modality are medications:

    • Anti-inflammatory medications – These reduce inflammation and consequently the duration and severity of pain, fever and aches. Examples include Paracetamol and non-steroidal anti-inflammatory drugs (NSAIDS).
    • Opioid analgesics – For more severe pain, these medications are available on prescription. However, more caution is advised due to possible severe side effects.
    • Throat gargles, sprays and lozenges
    • Antibiotics – For severe symptoms, or when a bacterial cause is suspected or shown from a test result

    In most cases, treatment can be given by oral medications. However, your doctor may advise hospitalisation if condition is more severe, for example, if:

    • Severe symptoms are not responding to oral medications, and therefore treatment with intravenous medications are advised
    • Poor oral intake with dehydration, especially in young children or elderly patients
    • Complications of tonsillitis

    Surgical treatment

    Tonsillectomy is a surgical operation where the tonsils are removed. It is one of the most common ENT operations performed, both in adults and children.

    Apart from recurrent or chronic tonsillitis, other reasons your doctor may advise you to consider tonsillectomy include:

    • Recurrent peritonsillar abscess (quinsy)
    • Snoring and obstructive sleep apnea (OSA)

    The operation is performed entirely through the mouth under general anaesthesia, so there are no external scars. A variety of techniques can be used to remove the tonsils including electrocautery (most common), “cold steel” (surgical knife) or Coblation.

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  • Although tonsillitis is not a life-threatening condition, it may lead to some serious health complications such as:

    Obstructive sleep apnoea (OSA)

    Chronic or recurrent inflammation of the tonsils may lead to progressive enlargement of the tonsils. This may cause obstructive sleep apnoea (OSA), a condition characterised by disruptions in breathing while you sleep. This can cause increased daytime sleepiness, headaches and reduced concentration. In the long term, OSA increases the risk of high blood pressure and heart disease.

    Peritonsillar and deep neck abscesses

    Tonsillitis can cause peritonsillar abscess, an infection that results in a collection of pus around or behind the tonsil. The symptoms are severe with swelling of the throat, pain and difficulty opening the mouth and possibly difficulty breathing. Rarely, the infection can spread to other parts of the neck. When an abscess occurs, emergency surgery to drain the pus from the abscess is usually required.

    Immune-related injury to organs in other parts of the body

    Infections caused by group A Streptococcus bacteria, including streptococcal tonsillitis, may rarely result in immune-mediated inflammation and injury to distant organs. These include rheumatic fever (which can affect the skin, heart, brain and joints) and glomerulonephritis (which results in damage to the tissues of the kidneys).

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