Introduction

You might have heard the terms strep throat and tonsillitis used interchangeably however, this is inaccurate as you can have tonsillitis without having strep throat. Both conditions affect the tonsils located on either side of the throat. The main function of the tonsils is to act as an initial defence against ingested or inhaled pathogens (organisms that cause disease).

Tonsillitis is simply an inflammation of the tonsils usually as the result of a bacterial infection or more commonly a viral infection.¹ The most common viral causes are adenoviruses, coronaviruses, or rhinoviruses which usually lead to uncomplicated tonsillitis that presents as a sore throat.^2,3 Bacterial pathogens, such as the ones responsible for causing strep throat also known as streptococcal pharyngitis, group A Streptococcus lead to bacterial tonsillitis.⁴ With bacterial tonsillitis, there are shared symptoms with acute tonsilitis but people will also present with additional symptoms unique to the bacterial infection, in this case, strep throat.¹ 

This article will break down the key differences in symptoms, diagnosis, and treatment options for these two separate conditions.

Risk factors

Risk factors for tonsillitis and strep throat are similar.⁵

Tonsillitis 

• Age: tonsillitis mostly affects children
• Frequent germ exposure: people in close contact with school children are more often exposed to viruses and bacteria that cause tonsillitis¹

Strep throat

• Age: it is more common in children aged 5-15 years old and rare in children under  3 years old
• Close contact: this is the most common risk factor for illness. Adults with strep throat are often parents of school-aged kids or adults who work or are in close contact with children such as those that work in daycares and schools. 

Other settings where people may be at an increased risk of catching the infection due to close contact include homeless shelters, detention centres, and military training facilities.⁴

Symptoms

Tonsillitis 

Often, because tonsillitis is caused by viruses that cause the common cold, tonsillitis feels like a bad flu/cold. Visually, the tonsils located in the lateral oropharynx (sides of the throat), will look red and swollen. Most people, both adult and children, will present with the following mild symptoms:^1,2,3

• Sore throat
• Trouble swallowing
• High temperatures
• Headache
• Earache
• General discomfort
• Fatigue
• Coughing

In more severe cases, you may notice these additional symptoms:

• White spots filled with pus on your tonsils
• Halitosis (bad breath) 
• Swollen glands in your neck creating a protruding lump that you can see/feel

If these symptoms do not go away within 7 days, or you keep getting throat infections, it may be signs of bacterial tonsillitis and you will need to contact your GP for further help.

Strep throat

It is important to note that people with strep throat may notice a lack of cold-like symptoms and a sudden onset of sore throat and high fever. Individuals with strep throat may also notice the following additional symptoms:⁴

• Small red spots on the roof of the mouth
• Body aches
• Scarlet fever (rash)
• Vomiting or nausea, commonly in children
• A higher fever than those with tonsillitis

Diagnosis

On average, acute tonsillitis symptoms will go away on their own after 3 to 4 days if the underlying cause is a viral infection; diagnosis of tonsillitis involves a medical history check and a physical exam of the oropharynx (the middle part of the throat).¹

Healthcare professionals may also consider rapid antigen testing and/or throat culture swabs alongside physical examination. This is suggested to understand if a bacterial infection is the cause of the tonsilitis and if treatment with antibiotics is necessary. It’s recommended that lab testing is done for confirmation in all cases where viral causes are not expected due to the broad overlapping of symptoms between strep throat and viral tonsillitis.⁴

Treatment

Usually, symptoms of acute tonsillitis go away on their own after a few days however there are some at home remedies that you can do to manage the symptoms:^1,6

• Gargle with salty warm water
• Take NSAIDs such as ibuprofen or painkillers such as paracetamol
• Drink cooling drinks to soothe the throat
• Get lots of rest 

You may also want to visit a pharmacist as they can suggest other treatments such as:

• Throat lozenges to soothe inflammation
• Throat sprays to soothe inflammation
• Antiseptic solutions

With strep throat, the main goal of treatment is to reduce the severity and longevity of symptoms, prevent complications and limit the spread of infection to others. It is usually treated with penicillin or amoxicillin. If you are allergic to penicillin, your doctor may prescribe clindamycin, clarithromycin or azithromycin. Often, you may also be prescribed an NSAID for the pain associated with inflamed tonsils or to control fever.^4,7

Following treatment with antibiotics, patients’ often see their symptoms clear up in 1-3 days.

If you are prone to recurrent tonsillitis, you may be recommended for surgery to have the tonsils removed, this is only offered in very severe cases of tonsillitis.¹

Complications

Tonsillitis is frequently managed with great clinical outcomes and no acute or delayed complications in cases of viral infection, however,  though rarely, complications can occur in tonsillitis caused by strep throat. Some of these complications include:⁴

• Rheumatic fever: an inflammatory disease commonly found in strep throat patients aged 5-18 years old that affects multiple organ systems. It often manifests as arthritis in large joints. It can also affect the heart, brain, and skin¹
• Abscesses: these are pockets of pus seen in the neck or around the tonsils. Smokers are at higher risk of developing this complication though it is most commonly seen in younger adults and adolescents. These abscesses are treated through a combination of steroids and antibiotics as well as drainage of the abcesses. 
• Ear infections
• Sinus infections
• Post-streptococcal glomerulonephritis: this generally happens in people infected with nephritogenic strains of Group A Streptococcus. Patients living in overcrowded areas and children in developing countries are the most at risk of developing this complication. In most cases, a spontaneous resolution of the illness will occur and normal renal function will be restored; however, prognosis is worse in elderly patients. Individuals with this illness present with the following:¹
  • Oedema
  • Hypertension
  • Urine sediment abnormalities
  • Hypoproteinemia
  • Elevated inflammatory markers
  • Low complement levels

Prevention

As the risk factors for both tonsillitis and strep throat are similar, the measures that can be taken to prevent contracting viral or bacterial pathogens that lead to these illnesses are the same; it is recommended that anyone in contact with the most at risk groups frequently wash their hands and once an individual has been confirmed to have tonsillitis or strep throat, that they are quarantined until they have began treatment or symptoms have subsided. 

Summary

While tonsillitis and strep throat are often used interchangeably, there are key differences in their causes and thus their treatment. It is important to understand these differences to appropriately manage either condition and avoid acute or delayed complications that may result from improper treatment. 

Tonsillitis is simply the inflammation of the tonsils and can have a number of causes from viral to bacterial pathogens. One such bacterial pathogen are group A Streptococcus, the most common cause for strep throat; thus you can have tonsillitis without having strep throat but a symptom of strep throat is tonsillitis.

Strep throat is differentiated and diagnosed from viral tonsillitis and other bacterial tonsillitis via physical examination and laboratory tests, because symptomatically they present very similarly aside from added symptoms associated with strep throat such as scarlet fever, higher temperatures, nausea and vomiting, and red dots on the back of the throat. Once a bacterial infection with group A streptococcus is confirmed via testing, patients are prescribed antibiotics and NSAIDs. 

The treatment for viral causes of tonsillitis is at home remedies that can be accompanied by lozenges and antiseptic throat sprays. Tonsillitis symptoms often go away on their own over a short period of time. However, in strep throat patients, without antibiotic treatment, there may be complications that develop such as the formation of abscesses, ear infections, sinus infections, rheumatic fever, and post-streptococcal glomerulonephritis.