Tonsillitis and Antibiotics

Dr Suresh is a GP and skin cancer doctor in Brisbane, and patients can book with him at this link

This is a very common condition that patients come in with, or at least they think they might have tonsillitis. After the initial opening spiel from the patient, it’s usually followed up with ‘and do I need antibiotics?’

So let’s start with what the tonsils are. They are 2 small areas of lymphoid tissue at the back of the throat. They are part of the immune system and grow with age as the body develops. Some people have quite small tonsils, others can have quite large tonsils.

Tonsillitis is when the tonsils become inflamed (and usually infected)

So let’s start with the symptoms. What are the symptoms of tonsillitis?

Well typically the main symptom will be sore throat. Often accompanied by sore glands. There may be a fever. You may feel unwell with body aches, or flu like symptoms. There may be a cough. Your symptoms could be very mild, or quite marked . You may also swollen or red tonsils, and there may be pus (exudate) on them too.

What about other issues with the tonsils?

The tonsils can have other issues, and a common issue may be a tonsillar stone which is often confused for tonsillitis. This is where debris is stuck within the crypts in the tonsils and can form a stone (which can in fact be picked out if you are keen to do so).

So back to infection. How do we know whether it is viral or bacterial?

Well it is difficult to tell as the features can overlap, but some features which may make the infection more likely to be bacterial will be a high temperature, absence of a cough, sore painful glands, and pus on the tonsils. This is what we call the CENTOR score. This may be used by your doctor to determine whether it is bacterial or not. They may also suggest doing a swab for the bacteria, usually streptococcus, which can sometimes help, although realistically it doesn’t tell you whether the bacteria is causing an infection, or merely sitting there in the throat not doing anything harmful (a commensal).

I heard tonsillitis can become an abscess?

Yes that’s true. Signs of an abscess include severe pain, high fevers, neck pain, or an obvious abscess on clinical examination from your doctor, or something we call trismus which is the inability to open your jaw normally. If you suspect this you must see your doctor immediately.

So what treatment is there?

For viral tonsillitis, the main treatment is what we call supportive care, which I’ve written about before. Rest, paracetamol, ibuprofen and plenty of fluids, and of course the one thing we never want to give – time. Usually the symptoms will resolve within 5-7 days.

For suspected bacterial tonsillitis your doctor may suggest antibiotic therapy. Local guidelines may differ, so please check with your local doctor or GP, but generally it is penicillin based treatment (usually phenoxymethylpenicillin). This can help to treat the infection, although interestingly the symptoms won’t always improve with this.

If severe, your doctor may even suggest a short course of steroids to help ease the symptoms.

Typically if there is no improvement in your symptoms after 72 hours of the antibiotics, or of course if you are getting worse, then you should see your doctor again to review you.

It is very important that if you start antibiotics that you finish the full course, as stopping early can increase the chance of developing resistance to those antibiotics, but untreated tonsillitis can cause issues down the line (see post on scarlet fever too).

Ok great, so we have treated the tonsillitis, but it keeps coming back. Do we need them taken out? If so what’s the criteria for it?

If tonsillitis is a recurrent problem, then you may benefit from having them removed. It is best to speak to your GP about this. Criteria will depend on your local guidelines, so speak to your doctor, but generally it is not recommended to remove the tonsils unless the issue is recurrent.

There is typically no set criteria nowadays for removing the tontils. The pendulum seems to swing every few years between removing and leaving them in, and previously we used to recommend removal the tonsils (tonsillectomy) if you have had more than 5 episodes in a year requiring antibiotics, or 7 episodes in 2 years. However this guidance is somewhat outdated now and typically we will suggest removing now if they are causing a big issue. Realistically what this means is if you get recurrent tonsillitis, but it is mild, and you aren’t very impaired by it, then there may not be much benefit in tonsillectomy. However if you get it a few times a year but are off school/day care / work / uni for 2 weeks at a time, or fall behind at school or work, then this may be a good reason to have them removed. If in doubt please speak to your local GP and ask for a referral to an ENT doctor if they agree.

Dr Suresh is a GP and skin cancer doctor in Brisbane, and patients can book with him at this link