OVERVIEW

What is tonsillitis?

Tonsillitis is an inflammation caused by pathogens (such as viruses and bacteria) invading the tonsils and multiplying rapidly when the body's resistance declines^[1]. Common symptoms include sore throat, fever, and cough.

Treatment varies depending on the type of tonsillitis. Acute tonsillitis requires a tailored treatment plan, primarily involving antibiotic therapy. Chronic tonsillitis is initially managed with conservative treatments, such as topical medication, crypt irrigation, cryotherapy, or laser therapy. If conservative treatments fail or systemic complications arise, surgical removal of the affected tissue may be necessary.

Is tonsillitis common?

Tonsillitis is a prevalent throat disorder, particularly among children and adolescents, though unified epidemiological data is currently lacking.

What are the types of tonsillitis?

Based on disease progression, tonsillitis is classified into acute and chronic forms^[1].

• Acute tonsillitis has a sudden onset with pronounced symptoms, often accompanied by fever and throat pain.
• Chronic tonsillitis involves persistent throat discomfort, primarily a sensation of a foreign body in the throat.

Which department should I visit for tonsillitis?

Patients should consult otolaryngology (ENT), while pediatric cases may visit pediatrics. For uncertainty about the specific department, general internal medicine, infectious diseases, or family medicine are also appropriate options.

SYMPTOMS

What are the common symptoms of acute tonsillitis?

Acute tonsillitis is mainly divided into acute catarrhal tonsillitis, acute suppurative tonsillitis, and acute cryptogenic tonsillitis. Although symptoms may vary slightly among these types, they generally share the following common features:

• Systemic symptoms: Chills (feeling cold), loss of appetite, fatigue, constipation, fever, etc. Children, in particular, may experience convulsions or lethargy due to high fever (39.1°C–40°C)^[1].
• Local symptoms: Severe sore throat, which may radiate to the ears and cause ear pain. Children may cry and become restless due to pain when swallowing caused by swollen tonsils, and they may also experience difficulty breathing.

What are the symptoms and manifestations of chronic tonsillitis?

• Tonsil enlargement: May lead to difficulty swallowing, slurred speech, breathing difficulties, or snoring during sleep.
• Throat discomfort: Sensation of swelling or pain in the throat, especially noticeable when swallowing food.
• Foreign body sensation in the throat: Feeling as if there is something stuck in the throat when swallowing saliva.
• Irritating cough: Coughing may occur due to throat discomfort.
• Bad breath: Caused by the accumulation of anaerobic bacteria or caseous secretions in the tonsillar crypts, leading to foul odor when speaking or exhaling, which does not improve after brushing teeth.

In addition to the above symptoms, some patients with chronic tonsillitis may not experience noticeable symptoms.

What complications can tonsillitis cause?

Local complications:

• Peritonsillar abscess: Also known as "quinsy," occurs when inflammation spreads to the surrounding tissues, leading to suppurative inflammation and abscess formation.
• Retropharyngeal abscess and parapharyngeal abscess.
• Acute otitis media: Pathogens from the affected area may spread to the middle ear via the Eustachian tube, causing acute otitis media.

Systemic complications: Generally believed to result from allergic reactions triggered by the infecting pathogens affecting other organs.

• Acute arthritis: Often affects the shoulders, elbows, and knees.
• Kidney diseases: Such as glomerulonephritis, IgA nephropathy, acute urethritis, acute orchitis, and epididymitis.
• Rheumatic fever.
• Circulatory system diseases: Acute pericarditis, acute endocarditis, and acute myocarditis.

Others: Septicemia, subacute thyroiditis, acute peritonitis, acute appendicitis, or acute cholecystitis.

However, there is no need to worry excessively, as acute tonsillitis can usually improve quickly with timely treatment.

What diseases can recurrent tonsillitis lead to?

Due to prolonged exposure to bacteria and toxins in the tonsillar crypts, allergic reactions may occur, leading to various complications such as rheumatoid arthritis, rheumatic fever, heart disease, nephritis, and persistent low-grade fever.

Therefore, if you have tonsillitis, it should be treated promptly to prevent the development of chronic inflammation and recurrent episodes.

CAUSES

What Causes Tonsillitis?

1. Infectious Factors:

   • Acute tonsillitis: The main pathogen is group A β-hemolytic streptococcus. Non-hemolytic streptococcus, staphylococcus, pneumococcus, Haemophilus influenzae, certain viruses (adenovirus, influenza virus, etc.), and parasites (e.g., Toxoplasma gondii) can also cause the disease. Mixed bacterial and viral infections are relatively common. In recent years, cases involving anaerobic bacteria and Gram-negative bacteria have also been reported.
   • Chronic tonsillitis: The main pathogens are streptococcus and staphylococcus. Recurrent acute tonsillitis leads to epithelial necrosis in the crypts, where bacteria and inflammatory exudates accumulate. Poor drainage of the crypts contributes to the onset and progression of the disease. It can also occur secondary to scarlet fever, diphtheria, influenza, measles, or nasal and sinus infections.

2. Immune Factors: Certain triggers (e.g., cold exposure, excessive fatigue, heavy smoking or drinking, harmful gas exposure, or HIV infection) can weaken systemic or local immunity. Bacteria and viruses hidden in the tonsillar crypts may then invade the body, or existing pathogens may multiply excessively, leading to the disease.

Is Tonsillitis Contagious?

Acute tonsillitis is contagious, as its pathogens can spread through droplets, food, or direct contact.

Chronic tonsillitis is generally not contagious.

Is Tonsillitis Hereditary?

Tonsillitis is an inflammatory response caused by infection and is unrelated to genetics. Therefore, tonsillitis is not hereditary.

DIAGNOSIS

What tests are needed for tonsillitis?

If tonsillitis is suspected, the doctor will perform a simple throat examination and necessary laboratory tests to differentiate the condition.

• Physical examination: The doctor will visually inspect for significant tonsil swelling, visible white secretions or spots in the crypts, and redness/swelling of both tonsils.
• Complete blood count (CBC): Helps determine whether inflammation is caused by a bacterial infection. Tests may include blood analysis, white blood cell count, erythrocyte sedimentation rate (ESR), elevated C-reactive protein (CRP), antistreptolysin O (ASO), and serum mucoprotein.
• Tonsil secretion bacterial culture: A sample of tonsil secretions is sent for testing to identify the pathogen, aiding diagnosis and treatment selection.
• Epstein-Barr virus (EBV) test: Used to rule out EBV infection. If the doctor suspects infectious mononucleosis as the cause of tonsillitis symptoms, this test helps confirm the diagnosis.

Which diseases are easily confused with tonsillitis? How to differentiate them?

Infectious mononucleosis: Symptoms like sore throat, swollen/red tonsils, and high fever resemble tonsillitis, leading to confusion. Blood tests to rule out EBV infection are necessary for differentiation.

TREATMENT

How to treat tonsillitis?

The treatment methods for patients with acute tonsillitis and chronic tonsillitis are not entirely the same.

• Patients with acute tonsillitis are mainly treated with oral antibiotics and glucocorticoids. During the illness, they should drink plenty of water, rest more, eat nutritious foods, and maintain smooth bowel movements. If high fever occurs, antipyretics can be taken^[1].
• For patients with chronic tonsillitis, physical exercise to enhance immunity and immunotherapy can be considered first. Only for patients with irreversible lesions or systemic complications will doctors consider performing a tonsillectomy^[1].

Under what circumstances is surgery required for tonsillitis?

If any of the following conditions exist, a tonsillectomy is recommended:

• Recurrent acute episodes of chronic tonsillitis (more than 4–5 times per year) or multiple occurrences of peritonsillar abscess;
• Excessive hypertrophy of the tonsils, obstructing swallowing, breathing, or causing slurred speech;
• Chronic tonsillitis leading to diseases such as rheumatic fever, nephritis, arthritis, or rheumatic heart disease, or causing adjacent organ diseases in the nose, ears, or throat;
• Unexplained long-term low-grade fever with chronic tonsillitis;
• Tonsillar keratosis or diphtheria carriers who do not respond to drug treatment.

If none of the above conditions exist, surgery is unnecessary for simple tonsillar hypertrophy without local or systemic symptoms.

Under what circumstances should a tonsillectomy be avoided?

• Patients with acute tonsillitis or other acute illnesses, such as colds or epidemics. It is best to perform the surgery 2–3 weeks after inflammation subsides.
• Patients with certain blood disorders, refractory hypertension, heart disease, active tuberculosis, etc., should avoid surgery.
• Patients with dry or atrophic pharyngitis should avoid surgery unless absolutely necessary, as symptoms may worsen postoperatively.
• Surgery is not recommended during pregnancy.
• Other situations where the doctor deems the risks outweigh the benefits.

Can pediatric patients with tonsillitis undergo tonsillectomy?

Yes, but a doctor's evaluation is required.

Tonsils play a certain immune role in children. When children catch a cold, tonsillitis or swelling may occur. Whether or when to perform a tonsillectomy depends on the doctor's assessment of risks and benefits based on the condition.

Under what circumstances should pediatric patients undergo tonsillectomy?

• Recurrent tonsillitis requiring long-term antibiotic treatment, affecting the child's growth and development;
• Grade II tonsillar hypertrophy (where one tonsil extends beyond the midline of the throat), obstructing breathing, swallowing, or causing slurred speech;
• Snoring, mouth breathing, or apnea during sleep, with nocturnal oxygen desaturation detected in tests.

If these conditions exist, tonsillectomy should be considered.

What are the effects of tonsillectomy on pediatric patients?

It may cause some degree of immune decline, though this is not yet fully understood.

Tonsils are the largest lymphoid tissue in the pharynx and play an active immune role in children, especially between ages 2 and 5. Removal may reduce immunity, so the decision to perform a tonsillectomy should be carefully evaluated^[1].

What preparations are needed before a tonsillectomy?

Patients should provide their medical history and undergo physical examinations, with special attention to bleeding history and coagulation tests. Common tests include:

• Blood, urine, stool tests, biochemical panels, coagulation tests, pre-transfusion tests, and immune function tests.
• Nasopharyngeal X-ray, chest X-ray, and ECG. For general anesthesia, liver and kidney function tests are required, and fasting is necessary. For local anesthesia, minimal food intake or fasting is advised.

Sedatives may be given if the patient is overly anxious.

What surgical methods are currently used for tonsillitis?

Traditional methods include dissection and guillotine techniques, but the latter is rarely used due to residual tonsils or scarring. Dissection is more common^[1].

Newer methods like coblation tonsillectomy are recommended for their convenience, shorter surgery and recovery times, and minimal tissue damage. This method is now widely used.

How long does recovery take after a tonsillectomy?

Pseudomembranes form in the tonsillar fossa within 24–48 hours post-surgery. The protective white membrane typically sheds around day 7, causing mild pain and slight bleeding. Most patients fully recover in 2 weeks, though some may take 3–5 days longer.

What complications may arise from a tonsillectomy?

Tonsillectomy is a minor surgery, but risks exist. Experienced surgeons and proper postoperative care can minimize complications, which may include:

• Bleeding: Primary bleeding occurs within 24 hours (often within 6 hours). Secondary bleeding usually happens 5–6 days post-surgery^[1].
• Infection: Typically occurs within 3 days, often with fever, especially in patients with low immunity or bleeding^[1].
• Scarring: Surgeons aim to minimize damage to muscles and mucosa.
• Other complications: Subcutaneous emphysema, sepsis, referred ear pain, lung abscess, pneumonia, atelectasis, deep neck abscess, or foreign body aspiration^[1].

Why do some people still experience throat discomfort after tonsillectomy?

Some patients may still have throat discomfort or pain post-surgery because they had both tonsillitis and chronic pharyngitis. In such cases, symptomatic treatment for chronic pharyngitis is needed. Gastroesophageal reflux should also be ruled out, and acid-suppressing drugs may be required.

DIET & LIFESTYLE

What should tonsillitis patients pay attention to in their diet after surgery?

Within 24 hours after surgery, a gray-white pseudomembrane will form on the wound to cover it. Before the pseudomembrane forms, the diet should consist of light, nutritious liquids, such as rice soup or thin lotus root starch, which should not be too hot. After the pseudomembrane forms, the diet should include light, nutritious semi-liquid foods, such as porridge, soft noodles, steamed eggs, light chicken soup, lean meat soup, or vegetable soup.

One week after surgery, the pseudomembrane begins to shed. Avoid fried, spicy foods (chili peppers, barbecue, pepper, etc.), overly hard foods (walnuts, melon seeds, chestnuts), and acidic foods (beef, bread, crackers, etc.) to prevent bleeding.

Are there other precautions for tonsillitis patients after surgery?

• Avoid infection at the surgical site by rinsing the mouth after eating.
• Monitor for fever or bleeding at the surgical site. Report these symptoms to a doctor immediately for prompt treatment.
• Avoid strenuous exercise before the pseudomembrane has completely shed.
• Avoid oral anticoagulant medications.
• Follow-up: Schedule check-ups one week and two weeks after surgery. The doctor will examine the surgical site for bleeding, infection, pseudomembrane growth/shedding, and symptom improvement (e.g., swallowing pain).

How soon can pediatric tonsillitis patients return to school after surgery?

After a tonsillectomy, the condition stabilizes in about two weeks, allowing the child to return to school without issues. Since chronic illness is resolved, the child’s overall health often improves, benefiting their learning and growth.

PREVENTION

How to prevent tonsillitis?

• Adjust clothing according to seasonal changes to avoid catching cold and weakening immunity.
• Eat more fruits rich in vitamins.
• Use air purifiers at home and wear masks outdoors to filter harmful gases and reduce respiratory irritation.
• Children with weak immunity should improve resistance through moderate exercise and a balanced diet. Outdoor activities like hiking or rope skipping are recommended (at least twice weekly, 30 minutes per session). Additionally, flu vaccination helps prevent viral infections.
• If a family member has tonsillitis, seek prompt treatment, manage the condition, and avoid close contact with others.
• Patients with acute tonsillitis should wear masks both outdoors and at home, and avoid sharing utensils.