Throat, tonsil and adenoid | Prof. Dr. Alper Tunga Derin

General education only; not a substitute for examination or diagnosis.

What this area covers

The pharynx is a muscular channel running from the back of the nose down to the food pipe and voice box, and it is described in three parts: behind the nose (nasopharynx), behind the mouth (oropharynx) and around the voice box (hypopharynx). The palatine tonsils sit on either side of the back of the mouth, the adenoids at the back of the nose and the lingual tonsil at the base of the tongue. This lymphoid tissue helps the body defend against germs, especially in childhood.

Acute sore throat: pharyngitis and tonsillitis, most of which are viral and some bacterial.
Abscess next to the tonsil (peritonsillar abscess, quinsy).
Recurrent and chronic tonsillitis.
Tonsil stones (tonsilloliths): white-yellow debris collecting in tonsil crypts that can cause bad breath.
Snoring and sleep-disordered breathing caused by enlarged tonsils and adenoids.
One-sided tonsil enlargement or a non-healing ulcer in an adult, which needs assessment for cancer.

Symptoms

Sore throat, pain on swallowing, fever, tiredness and tender lymph glands in the neck.
Red, swollen tonsils or white-yellow spots of pus.
Cough, runny nose and hoarseness point more towards a viral infection.
Severe, increasing pain on one side, pain spreading to the ear, difficulty opening the mouth, a muffled voice and drooling may suggest a peritonsillar abscess.
Bad breath, a feeling of something stuck in the throat and foul-smelling debris coming from the tonsils.
One-sided throat or ear pain that does not settle for weeks, a neck lump, difficulty swallowing and unexplained weight loss.

When to see a doctor

Situations that need urgent care

Difficulty breathing, being unable to swallow saliva or drooling: call emergency services (112).
Rapidly worsening one-sided sore throat, inability to open the mouth, a muffled voice or swelling in the mouth or neck.
Being unable to drink at all, marked weakness or confusion together with high fever.
Any bleeding from the mouth or nose after tonsil surgery, however small; if bleeding is heavy, call 112.

Situations for a planned appointment

A sore throat that has not started to improve within a week.
Tonsillitis that recurs several times a year and affects school or work.
Troublesome tonsil stones or persistent bad breath.
In an adult, one-sided tonsil enlargement lasting more than a few weeks, a non-healing ulcer or white or red patch on the tonsil, or a neck lump.

Most sore throats settle on their own, but some signs may point to a more serious cause. A definite diagnosis and treatment decision can only be made after examination.

How it is diagnosed

History and examination: the mouth, tonsils, pharynx and neck lymph glands are examined, and the frequency and severity of episodes are recorded.
Clinical scores: the NICE NG84 guideline uses FeverPAIN (fever in the past 24 hours, pus on the tonsils, attending within three days of symptom onset, severely inflamed tonsils, no cough or cold symptoms) or Centor (tonsillar exudate, tender front neck glands, history of fever over 38 °C, absence of cough) to judge who is likely to benefit from antibiotics.
Throat swab or rapid strep test when needed, and a blood test for glandular fever (infectious mononucleosis).
Ultrasound or contrast-enhanced CT when a peritonsillar abscess is suspected, and needle aspiration for both diagnosis and treatment.
Flexible endoscopy to examine the tongue base, lower pharynx and voice box.
When cancer is suspected: biopsy (sometimes a diagnostic tonsillectomy), neck ultrasound with fine-needle aspiration, and MRI, CT or PET-CT; in oropharyngeal cancer the link with HPV is also assessed.

Throat examination (stock, illustrative).

Treatment options

Watchful waiting and self-care

According to NICE, acute sore throat is usually self-limiting; symptoms can last around a week, and most people get better within that time without antibiotics, whether the cause is bacterial or viral. Pain and fever control with paracetamol or, if suitable, ibuprofen and adequate fluids are advised. For tonsil stones, oral hygiene and gargling are often enough.

Medicines

With a FeverPAIN score of 0–1 or a Centor score of 0–2, antibiotics are not recommended.
With a FeverPAIN score of 2–3, no antibiotic or a back-up prescription to use if symptoms do not improve is considered.
With a FeverPAIN score of 4–5 or a Centor score of 3–4, an immediate or back-up antibiotic is considered; people who are systemically very unwell are given antibiotics immediately.
The type and length of antibiotic are decided by the doctor, bearing in mind that antibiotics shorten symptoms only slightly and can cause side effects such as diarrhoea.

Procedures and surgery

Peritonsillar abscess: needle aspiration or drainage through a small incision with antibiotics; tonsillectomy may be considered in severe or recurrent cases.
Tonsillectomy for recurrent tonsillitis: for children, the 2019 AAO-HNSF guideline sets thresholds based on documented episodes (at least seven in the past year, at least five per year for two years or at least three per year for three years). In adults, the decision is likewise based on how often episodes occur, how severe they are and how they affect quality of life.
For long-standing troublesome tonsil stones and chronic tonsillitis, tonsillectomy may be considered in selected patients when other measures fail.
For one-sided tonsil enlargement or a non-healing ulcer in an adult, biopsy or tonsillectomy may be performed to establish the diagnosis.

Before and after surgery

Before surgery, general health, bleeding tendency and medicines are reviewed and an anaesthetic assessment is carried out. Blood thinners should only be stopped or adjusted on the advice of the treating physician.

Sore throat is expected after tonsillectomy; adults often feel it more than children, and it may spread to the ears. Recovery usually takes about two weeks. Regular painkillers, plenty of fluids and soft foods that are easy to swallow are advised. The time to return to work or school depends on the person and the type of work.

Bleeding after tonsillectomy can occur within the first 24 hours (primary bleeding) or later (secondary bleeding). Secondary bleeding is most common between days 5 and 10 after surgery.
Any bleeding from the mouth or nose, even a small amount, should be assessed in hospital straight away; if bleeding is heavy, call 112.
High fever, being unable to drink or steadily increasing pain should also be reported to the doctor.

Follow-up

In acute sore throat, reassessment is needed if symptoms worsen rapidly, have not started to improve within a week or the person becomes very unwell.
After tonsillectomy, healing is checked and the pathology result of the removed tissue is discussed with the patient.
For patients who had a diagnostic operation or biopsy, next steps are planned according to the pathology result.
People who have had a peritonsillar abscess should seek care early if similar symptoms return, as the abscess can recur.

Frequently asked questions

No. Most sore throats are caused by viruses and get better without antibiotics. NICE recommends deciding whether an antibiotic is needed using the FeverPAIN or Centor score. Unnecessary antibiotics can cause side effects and encourage resistance.

Tonsil stones are usually harmless but can cause bad breath and a feeling of something stuck in the throat. Oral hygiene and gargling are often enough. An examination is advised if they are a constant nuisance or come with one-sided tonsil enlargement or pain.

Yes. Tonsillectomy may be considered in adults with frequent tonsillitis, recurrent peritonsillar abscess, sleep-disordered breathing or a tonsil change that needs a diagnosis. Pain after surgery is usually more marked in adults. The decision is made together after discussing the expected benefits and risks.

Usually not; tonsils can naturally differ in size. However, in an adult a new or growing one-sided tonsil, a non-healing ulcer, one-sided throat or ear pain or a neck lump means cancer must be ruled out. In that case an ENT examination and, if needed, a biopsy are arranged.

Any bleeding from the mouth or nose, even a small amount, should be assessed in hospital straight away; if bleeding is heavy, call 112. Secondary bleeding is most common between days 5 and 10 after surgery, so take care throughout the first two weeks. Waiting and hoping it stops on its own is not the right approach.

Yes, it can recur in some patients. If there is a history of recurrent abscess or frequent tonsillitis, tonsillectomy may be discussed as an option. Seeking care early is important if similar symptoms return.

Sources

The general information on this page is based on the guideline and institutional sources below. Individual diagnosis and treatment decisions require an examination.

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