Introduction

Tonsillitis is a disease which involves inflammation of the tonsils most commonly as a result of a pathogenic infection. The causative pathogens vary between different bacteria and viruses and differentiation between the two is crucial for appropriate treatment. Most often, tonsillitis presents as an acute infection; in other words, it is an illness which goes away once it has run its course and does not come back soon after. In some cases, people may develop chronic tonsillitis, which is long lasting and does not go away as usual tonsillitis should.  

Definition and Causes

Acute Tonsillitis

Acute tonsillitis tends to occur as a sudden onset, short term infection which lasts around a week. It may be caused either by bacteria or viruses, with virally-caused tonsillitis being most common. For viruses, the most common cause for tonsillitis are viruses, which cause the common cold or flu, including rhinovirus, adenovirus, or respiratory syncytial virus. For bacteria, Streptococcus pyogenes is the most common cause, hence the name ‘strep throat’, which in some cases is used interchangeably with tonsillitis. It is key to clear up, however, that although the name ‘strep throat’ is also used to refer to tonsillitis by some, it is not technically correct. The two terms do differ as strep throat refers to an infection of the throat by the specific Streptococcal bacteria whilst tonsillitis refers to general tonsil inflammation.¹

Chronic Tonsillitis

Chronic tonsillitis may be used to either refer to a long-lasting case of tonsillitis or recurrent tonsil inflammation over a period of time. Some causes include persistent infection. These types of infections may ‘resist’ the action of the immune system or treatment and hence are able to survive for longer, causing a longer term infection. This is why chronic tonsillitis is more common in immunocompromised individuals as they do not have the means to ‘fight off’ the infection properly. Chronic tonsillitis may also refer to repeating acute tonsillitis infections, although a better term for something like this would be recurrent tonsillitis.   

Symptoms

Acute Tonsillitis

The first symptom most people experience when developing tonsillitis is a sore throat. The throat may also appear red and cause difficulty swallowing. In the case of bacterial infection, the tonsils may also have white patches or spots on them. This sore throat would also likely be accompanied by systemic symptoms like a fever, headache, or body pain. Some people may also have enlarged lymph nodes in the neck or may experience vomiting. 

Chronic Tonsillitis

Those suffering from chronic tonsillitis will experience a sore throat which is persistent and causes continuous discomfort. The tonsils would also be chronically enlarged as would the lymph nodes in the neck. Another symptom is bad breath that occurs due to bacteria collecting in the inflamed tonsils along with food, dead cells, and saliva. People with chronic tonsillitis may also feel fatigued and therefore sometimes irritable. 

Duration and Frequency

Acute Tonsillitis

This type of tonsillitis is short lasting and tends to go away after one or two weeks. Once it goes away, it is unlikely to come back again unless exposed to another tonsillitis-causing pathogen.

Chronic Tonsillitis

This type of tonsillitis may last for several weeks and be non-responsive to treatment. It may also be that the infection is recurrent and occurs multiple times within a year. 

Diagnosis

Diagnosis is similar for both types of tonsillitis. A doctor will take a look at the tonsils and throat and ask about the experienced symptoms. Based on this information, they may be able to determine if the illness is tonsillitis. Next, they must determine whether the tonsillitis is viral or bacterial. They may do this by observing for distinguishing symptoms or by doing a throat swab. The throat swab will be sent to a laboratory for diagnosis via a rapid strep test or by doing a bacterial culture. If the test or the culture are negative for the suspected bacteria, then they may determine the infection is viral. The doctor will determine whether the tonsillitis is chronic by finding out how long the symptoms have persisted or by finding out how many times the tonsillitis has occurred within a certain time frame.

Treatment

Acute Tonsillitis

Treatment will depend on whether the infection is bacterial or viral. If the infection is viral, it is recommended to rest and stay hydrated. Some medication may also be taken for symptom relief such as painkillers for the sore throat. If the infection is bacterial, the doctor may prescribe antibiotics. 

Chronic Tonsillitis

For chronic tonsillitis, the treatment will usually be more intensive. In the case of ongoing bacterial tonsillitis, a doctor may recommend long term antibiotic use. Furthermore, a tonsillectomy may be recommended, which involves surgically removing the tonsils.^1,2 

Complications

Peritonsillar abscess

This is most commonly a complication of bacterial tonsillitis where a pocket of pus forms between the tonsils and the wall of the throat. This will cause swelling of the mouth and throat, impacting functions like speaking, swallowing, and, most importantly breathing. Therefore, it may constitute a medical emergency where the abscess needs to be slit and drained. For someone who has chronic tonsillitis, it may lead to recurrent peritonsillar abscesses. 

Tonsil stones

Tonsil stones form rigid, white or yellow spots on the tonsils. Although they are not too dangerous, they do trap food, bacteria, saliva, and more, which in turn will give off a pungent odour. This type of complication tends to be more common in chronic tonsillitis compared to acute. 

Sleep apnea

As the tonsils are inflamed, their larger size may lead to obstruction of the airway. This will lead to breathing difficulties during the day and night. It will also cause sleep apnea, which is defined as a partial or complete obstruction of the airways during sleep.³ 

Bacterial spread

Bacterial caused tonsillitis carries the risk of the bacteria spreading to other organs in the body. This could lead to illnesses like rheumatic fever, which may lead to the inflammation of many tissues like the heart, joints, or brain. The bacterial spread may also lead to scarlet fever, which causes a skin rash and flu-like symptoms.⁴ If the bacteria manages to enter the blood, it may also cause sepsis, which could lead to death.

Prevention

The pathogens causing tonsillitis are usually spread via direct contact with infected individuals or by sharing water bottles or cutlery. The illness may also be spread via the airborne route where someone becomes infected by inhaling contaminated droplets produced by an infected individual sneezing or coughing. If these droplets settle on a surface and then someone touches their nose or mouth after coming into contact with the contaminated surface, they may also become infected. Therefore, the best preventative practices for both acute and chronic tonsillitis are good hygiene practices. These include washing hands with warm water and soap before eating or before touching the face. If warm water and soap are not available, then using 70% alcohol content sanitiser is a viable option. It is also key to avoid sharing any drinks or utensils with infected individuals. If sick, people should isolate themselves until better and sneeze or cough into a tissue, and dispose of it safely. Another prevention strategy for chronic tonsillitis would be a tonsillectomy to prevent recurrent infection.^1,2

Summary

Tonsillitis is the inflammation of the tonsils caused by either bacteria or viruses. The illness may be acute (where it lasts a short period of time and does not reoccur often within a set period of time), or chronic (where it will be long lasting and an individual may experience a high rate of reinfection). It is important to distinguish between the two to undertake better tailored treatment. Well-suited treatment is key in preventing the development of any more serious complications as well as in efficiently removing the illness to improve quality of life. Key preventative measures include practising good hygiene, self-isolating, and not sharing objects such as utensils with infected individuals.