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With increasing one-sided throat swelling, muffled ("hot potato") speech and difficulty opening the mouth, or with shortness of breath and constant drooling, you need immediate medical help — when in doubt, call the emergency number 112.
Tonsillitis is an acute inflammation of the palatine tonsils — the two oval pads of lymphatic tissue that sit on the left and right at the back of the throat. The tonsils are part of the body's defences and belong to the lymphatic ring of the throat. Precisely because they sit at the entrance to the mouth and throat, they are constantly in contact with pathogens and therefore become inflamed easily. Colloquially the condition is often simply called angina — not to be confused with angina pectoris affecting the heart, with which it has nothing to do.
Typical signs are severe sore throat that gets worse on swallowing, reddened and swollen tonsils and often fever. The good news: in the vast majority of cases tonsillitis is harmless and clears up on its own — especially when viruses are the cause. The real art lies less in elaborate treatment than in recognising the few cases in which an antibiotic or a medical assessment is genuinely needed.
Medically, a distinction is made between acute tonsillitis (a single, suddenly occurring infection), the recurrent form with several bouts per year, and chronic tonsillitis, in which the tonsils remain permanently inflamed. This classification matters because it helps determine whether and when surgery is considered — more on that later.
The most important question with tonsillitis is not "how bad", but "viral or bacterial?". Because that determines whether an antibiotic makes any sense at all. And the answer surprises many people: the largest share of all tonsil and throat infections — well over half in adults, and even more in young children — is triggered by viruses. Antibiotics fundamentally do not work against viruses.¹
Among the bacterial forms, group A streptococci (more precisely: beta-haemolytic streptococci of group A) are chiefly responsible. These bacteria are the actual reason why antibiotics play any role at all with sore throats — in rare cases they can cause complications and can be treated well with penicillin.
| Feature | More likely viral | More likely bacterial (streptococci) |
|---|---|---|
| Cough & runny nose | often present | usually absent |
| Hoarseness | common | rare |
| Fever | rather moderate | often above 38 °C |
| Coating on the tonsils | possible, rather slight | often purulent spots/coatings |
| Lymph nodes in the neck | slightly swollen | clearly swollen, tender to pressure |
| Typical age | everyone, including small children | especially 3–15 years |
Important: these features are clues, not proof. No single sign — not even pus on the tonsils — reliably proves a bacterial infection, and many viral infections look deceptively similar to a streptococcal angina. That is precisely why a simple points-based score is used in practice to estimate the probability (see the Diagnosis chapter). As a rough rule of thumb: the more classic cold signs such as cough, runny nose and hoarseness are present, the more likely it is viral — and the less likely an antibiotic is to help.
Acute tonsillitis usually starts suddenly. The main feature is discomfort in the throat, often accompanied by a general feeling of illness. Typical signs are:
If cough, runny nose and hoarseness are also present, this points more to a viral infection, in which the tonsils are affected as part of a general cold. If these cold signs are absent and high fever, purulent coatings and thickly swollen neck lymph nodes dominate, a bacterial cause becomes more likely.
The symptoms usually peak after two to three days and then improve step by step. Uncomplicated tonsillitis is generally over after about a week. If the symptoms last considerably longer, worsen again or occur very much on one side, this should be assessed by a doctor.
Tonsillitis arises from pathogens that reach the throat through the air we breathe or by contact. The pathogens are transmitted by droplet infection — that is, when coughing, sneezing or speaking — as well as via the hands and shared objects such as glasses or cutlery.¹
Tonsillitis is encouraged by anything that challenges the immune system or brings many people together in a confined space: the cold season, spending time in nurseries and schools, a weakened immune system, as well as smoking and dry heated air, which irritate the mucous membranes.
On transmission: as long as fever persists, the risk of infecting others is highest. With bacterial (streptococcal) tonsillitis, a person is usually no longer contagious about 24 hours after starting an effective antibiotic therapy — before that: keep your distance, cough into your elbow and wash your hands. Without an antibiotic, the ability to infect others can last longer. Children should only return to childcare once they are free of fever and feel fit again.
The doctor first makes the diagnosis by looking and feeling: a glance into the reddened throat, assessing the tonsils and their coatings, feeling the neck lymph nodes and measuring the fever. From these observations it is possible to estimate how likely streptococci are as the cause — and simple points-based scores were developed for exactly this.¹,²
The best known is the Centor score; for children it is extended by age as the McIsaac score. The idea behind it: four easily checked criteria are each awarded one point. The more points, the more likely bacteria are behind it.
With the McIsaac score, age is added: children from 3 to 14 years receive an additional point, while for adults aged 45 and over one point is deducted. This gives a rough way to classify the probability:
| Points | Streptococci likely? | Usual approach |
|---|---|---|
| 0–1 | unlikely | usually just self-care, no antibiotic |
| 2–3 | possible | weigh up, possibly a rapid streptococcal test |
| 4 and more | more likely | an antibiotic may make sense |
Important to understand: even with a high score, an antibiotic is not automatic. Current guidelines stress that sore throats — including those caused by streptococci — usually heal on their own and that an antibiotic only shortens the course by about a day. That is why the score is weighed up together with the overall picture and your symptoms, rather than treating sore throats with antibiotics across the board.
In unclear cases, a rapid streptococcal test via a throat swab can help. However, it is not always necessary and not always meaningful: streptococci can also be detected in healthy carriers without causing the symptoms. A blood test or a more detailed examination is added when there is suspicion of glandular fever or a complication.
Because most cases of tonsillitis are caused by viruses and clear up on their own, almost every treatment focuses on relieving the symptoms — regardless of whether an antibiotic is added in the end. The aim is that, despite the sore throat, you can drink, eat and sleep while your body fights the infection itself.¹
Well proven and easy to put into practice are, above all, consistent pain relief and enough fluids. Many of the well-known home remedies feel additionally soothing, even if they do not shorten the illness — they make the days until recovery more bearable.
The most common misconception with tonsillitis is the expectation that "with a sore throat this severe" an antibiotic must be needed. In reality, an antibiotic only makes sense if a bacterial cause (streptococci) is likely — and even then it shortens the course by only about a day on average. Against the far more common viral forms it does not work at all.¹,²
So why treat at all? With a proven streptococcal angina, an antibiotic can relieve symptoms a little faster, shorten the contagious period and, in rare cases, make certain complications less likely. This possible benefit is weighed against side effects and the promotion of antibiotic resistance. That is why the principle applies: as targeted as possible, as rarely as necessary.
Side effects such as gastrointestinal complaints are not a reason to stop on your own — often a conversation with the practice or pharmacy already helps. If you take several medicines at the same time, it is worth looking at possible drug interactions.
brite reminds you of every antibiotic and painkiller dose and documents your course without gaps — ready for your next conversation with the doctor.
A particularly important distinction is glandular fever (infectious mononucleosis), caused by the Epstein-Barr virus. It can look confusingly similar to bacterial tonsillitis — with thickly swollen, coated tonsils and a severe sore throat. But because it is viral, no antibiotic works, and this is exactly where misjudgements happen.¹
A few features make glandular fever more likely:
The suspicion can be confirmed by a blood test. Treatment is purely symptomatic — rest, painkillers, fluids. An important practical point: if you are mistakenly given Amoxicillin for glandular fever, a pronounced skin rash can develop. And because the spleen may be enlarged, you should avoid contact sports and heavy physical exertion for a few weeks to prevent injury to the spleen.
Document every episode in brite with date, fever and treatment — the best basis for talking to your ENT practice about recurring tonsillitis.
Most cases of tonsillitis heal without consequences. In certain situations, however, surgery on the tonsils is considered, and in rare cases complications can occur that require prompt action.
When is tonsil surgery an option? Not for a single bout of tonsillitis. An operation is discussed above all with frequently recurring infections. As a rough guide, this means several medically documented episodes per year, treated with antibiotics, over a longer period. A distinction is made between complete removal of the tonsils (tonsillectomy) and partial reduction (tonsillotomy), which plays a role above all in children with greatly enlarged tonsils and breathing or swallowing problems. The decision is always an individual weighing of benefits and risks together with an ENT practice — a frequent reason for an operation is a repeated tonsillar abscess.
Possible complications are rare, but important to know:
Tonsillitis is treated over several days — with painkillers, often on a fixed rhythm, sometimes additionally with an antibiotic for the full duration. The treatment only works if it runs reliably and you keep an eye on the course. That is exactly what brite supports.
