Swollen Tonsils: Causes, Treatment and When to See an ENT

01Role

What are tonsils and why do they swell?

The tonsils are two masses of lymphoid tissue at the back of the throat, one on each side, that help recognise germs entering through the mouth and nose. They are largest in childhood and shrink in adolescence. When they meet a virus or bacteria, they swell and may become red, painful and covered with white or yellow spots. Swelling can also appear without infection.

02Causes

Causes of swollen tonsils

• Viral tonsillitis: common cold viruses, adenovirus, flu, Epstein–Barr virus and others; the majority of cases.
• Bacterial tonsillitis: group A Streptococcus (strep throat) is the most important cause; it accounts for about 5–15% of adult and 20–30% of child sore throats.
• Glandular fever (infectious mononucleosis): very large tonsils with exudate, marked fatigue and swollen neck glands, mostly in teenagers and young adults.
• Tonsil stones (tonsilloliths): white or yellow lumps trapped in crypts, causing bad breath and a feeling of something stuck.
• Allergy, reflux and irritants can contribute to chronic enlargement.
• Peritonsillar abscess: a complication of tonsillitis with a pocket of pus beside the tonsil.
• Rarely, a tumour or lymphoma, which usually causes one tonsil to be much larger than the other without infection.

03Symptoms

Symptoms

• Sore throat and pain on swallowing.
• Red, enlarged tonsils, sometimes with white or yellow patches.
• Fever, headache, tiredness and bad breath.
• Tender swollen glands in the neck.
• Muffled or changed voice.
• Snoring or noisy breathing at night if the tonsils are very large.
• In young children: refusal to eat, drooling or stomach ache.

04Viral or strep

Viral or bacterial?

It is hard to tell by appearance alone. A cough, runny nose, hoarseness and mouth ulcers suggest a viral cause. Fever above 38 °C, white patches on the tonsils, tender front neck glands and no cough suggest strep throat (the Centor criteria). A rapid antigen test or throat swab can confirm strep, and your doctor will decide whether you need antibiotics. See also anginas (Spanish) and throat with white patches.

05Treatment

Treatment and home care

• Pain relief: paracetamol (acetaminophen) or ibuprofen as directed.
• Fluids and soft foods: cool or warm, not very hot or acidic.
• Rest while you have a fever.
• Saltwater gargles (half a teaspoon in a glass of warm water) for older children and adults.
• Lozenges for adults and children over six.
• Antibiotics (usually penicillin or amoxicillin) only for confirmed or strongly suspected strep throat; finish the course.
• Steroids in selected severe cases at the doctor’s discretion.

06Contagion

Contagion

Tonsillitis spreads through droplets and close contact. Wash hands, avoid sharing cups and cutlery, and stay home while you have a fever. With strep throat, you are generally considered non-contagious about 24 hours after starting an antibiotic.

07Enlarged

Chronically enlarged tonsils

Tonsils can stay large without being infected, especially in children, and may cause loud snoring, mouth breathing, restless sleep and pauses in breathing (obstructive sleep apnoea). In these cases an ENT assessment is advised, and removal of the tonsils (and adenoids) can help. An adult with one tonsil clearly larger than the other, a firm lump, bleeding or persistent throat pain on one side must be examined promptly.

08Surgery

When is tonsillectomy considered?

The AAO-HNSF guideline suggests that surgery may be an option for children with at least 7 well-documented episodes of throat infection in one year, 5 episodes per year for two years, or 3 per year for three years, with other qualifying symptoms, and for children with sleep-disordered breathing due to enlarged tonsils. In adults it is considered after repeated infections, abscesses or obstruction. Tonsillectomy is common and safe but causes one to two weeks of significant throat pain and carries a risk of bleeding, so decisions should be individual.

10Cases

Three common situations

Adult with sore throat, cough and runny nose: almost certainly viral; fluids, rest and pain relief, with review if no improvement in a week.

Child with fever, white-spotted tonsils and no cough: see a doctor for a strep test.

Child who snores loudly with enlarged tonsils: ask for an ENT assessment for sleep-disordered breathing.

11Summary

Key points to remember

Most swollen tonsils are viral and settle with care at home. Seek testing for strep when the pattern fits, watch for warning signs, and consider ENT review for recurrent infections, tonsil stones or obstructive symptoms.

This guide is for general information and does not replace an assessment by your own doctor or ENT specialist.