What are the symptoms of tonsillitis?

The main symptoms of tonsillitis

If you have tonsillitis it can feel like a bad cold or flu. The main symptoms of tonsillitis in children and adults are:

• Sore throat.
• Coughing or sneezing.
• High temperature above 38⁰C (fever).
• Feeling sick (nausea).
• Feeling tired.
• Pain when swallowing.
• Swollen, red tonsils.
• Earache

Sometimes the symptoms may be more severe and include:

• Swollen painful glands (lymph nodes) in the neck.
• White spots (pus) on the tonsils.
• bad breath.

If you think you or your child has tonsillitis find out what to do next by clicking here. This will tell you if you need to see a doctor and how to treat it.

The rest of this feature will take a in-depth look at the symptoms of tonsillitis as, at Patient, we know our readers sometimes want to have a deep dive into certain topics.

In this series of articles centred around tonsillitis, you can read about the causes of tonsillitis, symptoms of tonsillitis and treatments for tonsillitis - all written by one of our GP experts.

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Symptoms of tonsillitis

There are several symptoms of acute tonsillitis which people with tonsillitis may have some or all of. Some symptoms are more common with viral infections, and others with bacterial infections. Healthcare professionals can use tools such as the Centor score or FeverPAIN to estimate how likely a bacterial infection is, based on the signs and symptoms.

Throat photo showing large, red tonsils with yellow pus ('exudates')

By Michaelbladon at English Wikipedia, Public domain, via Wikimedia Commons

Sore throat

Most people will have a sore throat with tonsillitis. The pain is often worse on swallowing.

Fever

Some people will also have a fever where the body temperature is above 38.0°C-100.4°F. Having a fever with tonsillitis makes a bacterial infection more likely, although lots of people with viral infections will also have fevers.

Swollen tonsils

The tonsils are the two red lumps at the back of the throat, either side of the uvula - the dangling bit at the centre of the back of the throat. These will be red and swollen in people with tonsillitis.

Throat photo showing enlarged tonsils

By Klem, CC BY 3.0, via Wikimedia Commons

White or yellow spots (exudates) on tonsils

Some people will develop spots of white or yellow pus (exudates) on the tonsils - these make a bacterial infection more likely.

Swollen lymph nodes in the neck

Some people develop swollen glands - lymph nodes - in the neck which are usually uncomfortable or painful to touch. The medical term for this is 'cervical lymphadenopathy' - and having this makes a bacterial infection more likely.

Swollen lymph node in the neck

By Coronation Dental Specialty Group, CC BY-SA 4.0, via Wikimedia Commons

Cough

Some people have a cough with tonsillitis which might be dry, or bring up sputum (phlegm). Having a cough makes it more likely that there is a viral infection.

Runny nose/blocked nose

Having a runny nose or a blocked nose makes a viral infection more likely.

Muscle aches and pains

Having muscle aches and pains during an episode of tonsillitis makes a viral infection more likely.

Earache

People with tonsillitis, especially children, can have earache. This is usually because pain in the tonsils can be felt in the ear - due to the way the nerves are set up. Sometimes, in bacterial tonsillitis, ear pain can indicate that a middle ear infection has developed.

Bad breath

Tonsillitis can cause bad breath due to inflammation of the tonsils. Whilst some types of bacteria produce foul smells, having this symptom doesn't mean that the tonsillitis is due to a bacterial infection.

Feeling generally unwell and tired

Like with most infections, people with tonsillitis will often feel generally unwell and tired. Children may be less active and playful than usual.

Symptoms of serious problems from tonsillitis

Tonsillitis almost always gets better with time, and very rarely causes complications and serious illness. However, here are some rare complications of tonsillitis:

Quinsy

Bacterial tonsillitis can, rarely, cause an abscess - a ball of pus - to form in the back of the throat. This usually needs to be drained in hospital and, if not treated, can cause further serious problems. Symptoms of a quinsy include:

• A severely painful sore throat, worse on one side, especially if the pain has suddenly got worse.
• Difficulty opening the mouth fully - trismus.
• Changes in the voice - a 'hot potato voice' where speech is muffled.
• Being unable to swallow, including being unable to swallow saliva, which may lead to dribbling.
• Difficulty breathing.

Scarlet fever

One type of bacteria that causes tonsillitis (Group A streptococcus, or strep throat) can also cause scarlet fever in children. Scarlet fever doesn't usually cause serious problems in children, but should be treated with antibiotics to prevent it spreading. Symptoms of scarlet fever are:

• A widespread rough rash - this feels like sandpaper. In lighter-skinned children, this rash is red or pink. In people with darker skin tones, it's often difficult to see the red or pink rash, but the rough texture of the skin can still be easily felt.
• Strawberry tongue - a bright red tongue with white spots.

Rheumatic fever

Group A strep can also cause rheumatic fever. However, this has almost completely disappeared in the UK, though it is still present in some other countries. Symptoms of rheumatic fever usually appear about one to five weeks after the bacterial throat infection. Rheumatic fever symptoms include:

• High fever.
• Multiple joint redness.
• Pain and swelling
• A rash that is pinky red on your tummy and arms (erythema marginatum).
• Bumps under the skin (subcutaneous nodules).
• There may also be jerky body movements (chorea).
• Infection can affect the heart and cause heart damage.

Post-streptococcal glomerulonephritis

This is a rare autoimmune condition, affecting the kidneys, that can occur after Group A streptococcus infection.

Post-streptococcal glomerulonephritis symptoms include:

• Dark reddish-brown pee - may be blood.
• Swelling (oedema).
• Not peeing as often as usual.
• Fatigue.

If you have any of the above symptoms, you must go to the emergency department at your local hospital immediately.

Can tonsillitis symptoms come and go?

Once tonsillitis has started, symptoms usually remain for about four to seven days and usually get better by the end of that time. During an episode of tonsillitis, symptoms might vary throughout the day, particularly if painkillers are used - pain should improve after taking them, but may come back as they wear off.

Some types of infections, such as Epstein-Barr virus (glandular fever/infectious mononucleosis) can take longer to recover from - the sore throat in EBV infection may last several weeks.

Some people get repeated episodes of tonsillitis (recurrent tonsillitis) or tonsillitis that never fully clears (chronic tonsillitis). These people may have symptoms of tonsillitis that return after weeks or months.

How long does it take for tonsillitis symptoms to show?

Lots of different infections can cause tonsillitis, all of which have different times between first getting infected, and tonsillitis symptoms developing. For bacterial infections such as strep throat the time between infection and symptoms is about two to five days. Viral infections can take between one to five days to show symptoms.

When to see a doctor for tonsillitis symptoms

Most cases of tonsillitis are caused by viral infections, and can be managed at home without seeing a doctor for treatment.

If there are other symptoms that suggest a viral infection, such as a cough, runny nose, blocked nose, or muscle aches and pains, it's unlikely that antibiotics will help, and they may cause harm.

See a doctor if:

• Tonsillitis symptoms are particularly severe - for example, if treatment from a pharmacy isn't controlling the symptoms, or it's difficult to eat or drink due to pain from the throat.
• Symptoms of tonsillitis aren't getting better, or are getting worse, after four days.
• There are symptoms of scarlet fever (see above).

Seek urgent medical advice - get an urgent same-day appointment from your GP, call 111 in the UK, or attend the nearest emergency department - if you have symptoms of a quinsy (see above).

It's very rare for children or adults to become seriously unwell with tonsillitis. Fever in Children (High Temperature) and Sepsis (Septicaemia) give more detail about symptoms and signs of serious illness and when you should seek urgent medical advice.

How is tonsillitis diagnosed?

Tonsillitis is diagnosed based on the presence of typical signs and symptoms. Clinical risk scores such as the modified Centor criteria and FeverPAIN can be used to determine how likely it is that someone's symptoms are due to a viral or bacterial infection. Tests aren't usually needed.

Sometimes, swab tests looking for Group A strep are used. Most tests take several days to return, but there are rapid Strep tests available, particularly in the USA.

These tests can be useful in ruling out strep throat in people who seem like they might have a bacterial throat infection. However, tests may not add much beyond clinical assessment if a bacterial throat infection is thought to be very likely.

In addition, testing is not helpful in people with a low likelihood of having a bacterial throat infection. Up to 20% of healthy children carry Group A streptococcus in their throat. These children can get viral throat infections as well. Tests for streptococcus cannot tell the difference between bacteria that is causing an infection, and bacteria that is living in the throat but not causing any symptoms.

Testing for streptococcus in people who are very likely to have a viral throat infection is therefore more likely to pick up bacteria that are living in the throat but not causing an infection, leading to overuse of antibiotics.

If glandular fever/infectious mononucleosis (Epstein-Barr virus infection) is suspected, blood tests can be used to help confirm the diagnosis.

Sexually transmitted infections can sometimes cause tonsillitis and can be tested for with throat swabs and sometimes blood tests.

What else could it be?

Tonsillitis is usually easy to diagnose. Infections of other parts of the throat (pharyngitis) can also cause a sore throat. Other conditions that are much rarer, and can cause some similar symptoms to tonsillitis, include:

• Epiglottitis - a serious condition where the airway, just behind the tongue, becomes inflamed and swollen. Vaccination against Haemophilus influenzae type B infection has made this much less common.
• Infections of the deep tissues of the neck - such as retropharyngeal abscesses.
• Quinsy (peritonsillar abscess).
• Ludwig's angina - a rare and serious infection where the soft tissue under the tongue and floor of the mouth becomes infected.

Further reading

• FeverPAIN Clinical Score.
• Georgalas CC, Tolley NS, Narula PA; Tonsillitis. BMJ Clin Evid. 2014 Jul 22;2014:0503.
• Roos K; The diagnostic value of symptoms and signs in acute tonsillitis in children over the age of 10 and in adults. Scand J Infect Dis. 1985;17(3):259-67. doi: 10.3109/inf.1985.17.issue-3.04.