Recurrent tonsillitis: why it keeps coming back and when surgery is considered

The tonsils are two lumps of tissue at the sides of the back of the throat. The NHS describes tonsillitis as an infection of the tonsils, a common childhood illness that teenagers and adults can get too. The tonsils become red and swollen, and the usual symptoms include a sore throat, problems swallowing, a high temperature, cough, headache, feeling or being sick, earache and tiredness.

Recurrent tonsillitis simply means that this happens again and again. Some people have a run of infections in one winter and then settle; others have frequent episodes for years. The pattern matters, because it affects whether a specialist opinion is worthwhile and because it can help your GP tell a true recurrent pattern from a series of ordinary colds.

Between attacks the tonsils may look normal, or they may remain slightly enlarged. People often notice bad breath and a sense of something stuck in the throat, but those symptoms can also come from other problems, so they should be assessed rather than assumed to be tonsillitis.

The NHS says tonsillitis is usually caused by a virus, such as a cold, though it can also be due to a bacterial infection such as strep throat. NICE Clinical Knowledge Summaries lists common causes of sore throat in primary care as the common cold, influenza, streptococcal infection and infectious mononucleosis (glandular fever), and notes that acute throat infections most commonly occur in people aged 5 to 24 years.

Because so many different viruses can cause tonsillitis, repeated attacks do not necessarily mean the same infection is returning. Close contact with other people, for example at school, nursery or in a busy workplace, increases exposure. Nobody can say for certain why some people seem to have more infections than others, and the sources used for this guide do not give a single explanation.

The NHS says tonsillitis itself is not contagious, but most of the infections that cause it are, for example colds and flu. If you or your child have a high temperature or do not feel well enough to do usual activities, it suggests staying at home and avoiding contact with other people until you feel better, using tissues for coughs and sneezes and washing hands afterwards.

The NHS says a doctor can usually tell if it is tonsillitis by asking about your symptoms and looking in your throat. You may also need a swab test, in which a cotton bud is wiped at the back of the throat to see if bacteria are causing it, and a blood test for glandular fever if symptoms are severe or will not go away. The NHS says a GP will usually wait for the test results to tell which type you have.

NICE Clinical Knowledge Summaries says that FeverPAIN and Centor clinical prediction scores should be used to help decide whether to prescribe an antibiotic. These scores weigh features such as fever, the look of the tonsils and the presence of cough, which is why a GP may examine the throat even if the diagnosis seems obvious.

For people with repeated attacks, keeping a simple diary of the dates, the doctor consulted and any treatment given is useful. A GP can then see whether the frequency meets the thresholds for a specialist assessment.

The NHS says tonsillitis usually gets better on its own after a few days but can last longer. To ease symptoms it suggests getting plenty of rest, drinking cool drinks, taking paracetamol or ibuprofen (aspirin is not given to children under 16) and gargling with warm salty water, which children should not do. A pharmacist can suggest lozenges with a local anaesthetic, antiseptic or anti-inflammatory, antiseptic solutions and throat sprays, although the NHS notes that there is little proof sprays help.

NICE says symptoms of a sore throat resolve within 3 days in 40% of people and within 1 week in 85%, irrespective of whether it is due to streptococcal infection. That is why antibiotics are not routine for every episode.

The NHS advises seeing a GP if symptoms of tonsillitis do not go away within 1 week or if you keep getting throat infections. It advises getting help from NHS 111 now if you have pus-filled spots on your tonsils or a sore throat so painful that it is difficult to eat or drink.

Call 999 or go to A&E if you have a severe sore throat that quickly gets worse, swelling inside the mouth and throat, difficulty speaking, being unable to swallow, difficulty breathing or difficulty opening your mouth. The NHS describes these as signs of quinsy, an abscess filled with pus between the tonsil and the wall of the throat. NICE lists peri-tonsillar abscess (quinsy), parapharyngeal abscess and middle ear infection among the complications of throat infection.

The NHS says it is very rare that someone needs their tonsils taken out and that it is usually only done if you have severe tonsillitis that keeps coming back. NICE Clinical Knowledge Summaries says that people with recurrent tonsillitis, defined as more than 7 episodes per year for one year, 5 per year for 2 years, or 3 per year for 3 years, should have a specialist assessment as they may benefit from tonsillectomy.

Meeting the numbers does not mean surgery is automatic. A specialist considers how severe each episode was, how much it affects daily life and what the risks of an operation are. The decision is made together with you or, for a child, with the family.

On the NHS the route is GP, then an ENT outpatient assessment if the pattern meets the criteria, then a decision about surgery. Waiting times for ENT vary by area. Some people choose to see a private ENT surgeon to shorten the wait; the same criteria and risks apply, and a thoughtful surgeon will ask for the record of earlier episodes. Your GP can supply this whichever route you choose.