Chronic Tonsillitis

Chronic vs recurrent vs acute tonsillitis

Symptoms

• sore throat that keeps coming back or never fully goes
• persistent bad breath (halitosis)
• tonsil stones: small white or yellow lumps in the tonsil crypts with a foul smell
• red, enlarged or scarred tonsils
• tender, swollen lymph nodes in the neck
• a bad taste in the mouth
• discomfort when swallowing, sometimes ear pain
• in children with large tonsils: snoring, mouth breathing and restless sleep

Causes

The tonsils are lymph tissue at the back of the throat that help fight infection. Their surface has deep pits (crypts) that can trap bacteria, food debris and dead cells. Repeated infections, often with group A Streptococcus (strep throat) or viruses, can lead to persistent low-grade inflammation and bacterial "biofilms" that are hard for antibiotics to clear.

Risk factors include:

• ages 5 to 15 and young adulthood
• close contact settings such as schools and dormitories
• frequent exposure to strep
• smoking and secondhand smoke

Diagnosis

A doctor examines the throat, tonsils and neck and reviews how many episodes you have had, how severe they were and whether they were confirmed with a strep test. Keeping a record of each episode, including dates, fever, and test results, helps with decisions about surgery. Additional tests may include a throat swab, blood tests for mononucleosis, and in adults with one enlarged tonsil, a biopsy or tonsillectomy to rule out lymphoma or cancer.

Treatment

Managing flare-ups

• Strep throat is treated with antibiotics, usually penicillin or amoxicillin, for the full course.
• Viral tonsillitis does not need antibiotics.
• Pain relief: acetaminophen (paracetamol) or ibuprofen, following the label dose. No aspirin for children or teenagers.
• Fluids, rest, throat lozenges for older children and adults.

Ongoing care

• warm salt-water gargles
• brushing teeth and tongue, and staying hydrated
• gently removing tonsil stones with a water flosser on a low setting
• stopping smoking

Tonsillectomy

Surgical removal of the tonsils is considered when infections are frequent and well documented. Commonly used thresholds (the Paradise criteria) are:

• 7 or more episodes in the past year, or
• 5 or more episodes per year in each of the past 2 years, or
• 3 or more episodes per year in each of the past 3 years

Each episode should include features such as fever, pus on the tonsils, tender neck glands or a positive strep test. Other reasons include a peritonsillar abscess, sleep-disordered breathing from large tonsils, and persistent symptoms that do not respond to treatment.

Recovery after tonsillectomy

• Expect throat pain for 7 to 14 days, often worse around days 5 to 7.
• Drink plenty of fluids and eat soft foods.
• Take pain relief as advised. Ibuprofen is usually allowed; codeine must not be given to children.
• Bleeding risk is highest in the first 24 hours and around 5 to 10 days after surgery. Any bleeding from the mouth needs urgent assessment.

Complications

• peritonsillar abscess (quinsy)
• recurrent missed school or work
• sleep apnea in children with very large tonsils
• rarely, rheumatic fever or kidney inflammation after untreated strep

Frequently asked questions

What are the symptoms of chronic tonsillitis?

Common symptoms are a sore throat that keeps returning or never fully resolves, persistent bad breath, tonsil stones, swollen and red tonsils, tender neck glands, a bad taste, and discomfort when swallowing. Children may also snore and sleep poorly.

Can chronic tonsillitis go away without surgery?

Sometimes. Episodes often become less frequent as children grow older. Good oral hygiene and treating each strep infection can help. If infections remain frequent and disruptive, tonsillectomy is the most effective long-term solution.

How many times do you need tonsillitis before removal?

Doctors commonly consider tonsillectomy after 7 or more documented episodes in one year, 5 or more a year for 2 years, or 3 or more a year for 3 years. Other factors, such as abscesses or sleep problems, may also be reasons for surgery.

Does chronic tonsillitis cause bad breath?

Yes. Bacteria and debris trapped in the tonsil crypts produce sulfur compounds that cause bad breath, and can form tonsil stones. Gargling, good oral hygiene and treating the tonsil inflammation often help.