Painful, usually viral, and worth documenting properly if it keeps coming back.
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Tonsillitis is inflammation of the tonsils — the two pads of tissue at the back of the throat. Most cases are viral, most settle within about a week, and most need pain relief rather than antibiotics. Our sore throat page covers the general assessment; this one is about the tonsils specifically.
Four things worth knowing:
1. The emergency signs are about swallowing and breathing, not pain. Difficulty swallowing your own saliva, drooling, difficulty opening your mouth, a muffled voice, or severe one-sided pain with the uvula pushed across — that is a quinsy or a deep neck infection, and it needs immediate assessment.
2. Tonsillectomy depends on documented episodes, not on how bad it feels. Referral criteria are numerical — broadly seven episodes in a year, five a year for two years, or three a year for three years. Which means keeping a written record of dates and treatments is what actually gets you referred. People lose years to not having done that.
3. Tonsil stones are harmless and extremely common. Small white lumps in the tonsil crypts causing bad breath and a foreign-body sensation. They are not infection, they do not need antibiotics, and almost nobody has them explained.
4. One tonsil persistently larger than the other, without infection, needs looking at. Asymmetry is the one appearance that is not reassuring.
An abscess forming beside the tonsil. It needs draining, and it will not clear on antibiotics alone:
Small hard white or yellow lumps sitting in the pits of the tonsil. They cause persistent bad breath, a sensation of something stuck, and occasionally a mild sore throat — with no fever and no illness. Harmless, common, and frequently mistaken for chronic infection and treated with repeated antibiotics.
One tonsil persistently and noticeably larger than the other, when you are not currently infected — particularly with a neck lump, weight loss or night sweats. Asymmetry needs an ENT opinion rather than watchful waiting.
Common cold viruses, influenza, adenovirus, COVID. Glandular fever is a particularly important cause in teenagers and young adults, producing very large tonsils, heavy exudate, glands at the back of the neck, and profound fatigue lasting weeks.
Group A streptococcus is the main one, more common in children aged 5 to 15, and the organism behind scarlet fever.
Debris, dead cells and bacteria collect in the natural crevices of the tonsil and calcify. People with deeper crypts — often after repeated tonsillitis — get them more. They are a mechanical issue rather than an infection, which is why antibiotics do nothing for them.
Tonsils are naturally large in childhood and shrink through the teens. That is normal. What matters is whether they are obstructing breathing at night — snoring, restless sleep, pauses in breathing, mouth breathing, or daytime irritability and poor concentration. That is a reason for referral in its own right, quite separate from infection.
Diagnosed clinically, and a video consultation covers it well — you can show us your throat, which is genuinely useful here and something a telephone call cannot do.
We use FeverPAIN or Centor to decide about antibiotics — structured scores based on fever, pus, rapid onset, inflamed tonsils and absence of cough. It turns a judgement call into a defensible decision.
Where the score suggests streptococcal infection, or someone is significantly unwell, immunosuppressed or deteriorating. Penicillin V for a full ten days — the longer course matters for strep. A back-up prescription is often the sensible middle path.
Do not use amoxicillin or ampicillin where glandular fever is possible. It causes a dramatic widespread rash in the great majority of people with glandular fever — not dangerous, but alarming, and routinely misrecorded as a lifelong penicillin allergy that then limits antibiotic options for decades.
Not treatable remotely and not curable with antibiotics alone — it needs draining. If the picture fits, we will send you to hospital rather than prescribe.
No antibiotics needed. Gargling, gentle dislodging with a cotton bud, and a water flosser on a low setting all help — do not dig at them with anything sharp. Where they are persistent and genuinely troublesome, ENT can offer treatment.
We can refer where the documented frequency meets the criteria, or for quinsy, obstructive sleep symptoms, or persistent asymmetry. What makes the referral succeed is the written record — dates, symptoms, whether antibiotics were given, and days lost to work or school.
Call 999 or go to A&E for:
Seek same-day medical advice for:
Book an appointment for:
If you get recurrent tonsillitis, write down every episode: the date, the symptoms, whether you saw anyone, whether antibiotics were given, and how many days you lost.
Referral for tonsillectomy depends on documented frequency — broadly seven episodes in a year, five a year for two years, or three a year for three years. Without a record, the conversation stalls, and people spend years going round in circles because nobody told them to keep one. A note on your phone is enough.
Avoid contact sport, rugby, martial arts and heavy lifting for at least four to six weeks, because the spleen may be enlarged and can rupture. This is the single most important instruction, and it is too often given in passing. Avoid alcohol while the liver is inflamed, and expect fatigue to take weeks to months — which is normal, not a sign of something missed.
Large tonsils in childhood are normal and shrink with age. What matters is sleep: if your child snores heavily, seems to stop breathing at night, sleeps restlessly, or is irritable and struggling to concentrate by day, mention it specifically — that is a reason for referral in its own right.
Most tonsillitis is viral and settles within a week without antibiotics. Regular paracetamol and ibuprofen, salt water gargles, Difflam spray and cold drinks do more for the pain than a prescription does, and all are available over the counter cheaply.
Pharmacy First now covers acute sore throat and tonsillitis — free, same-day, no appointment, using the same FeverPAIN scoring a GP would apply. That is the right first stop.
Where a private consultation earns its fee is documentation and recurrence. If you get tonsillitis repeatedly, the number of documented episodes is what determines whether you qualify for NHS tonsillectomy — typically seven in one year, five a year for two years, or three a year for three years. Episodes you managed at home without seeing anyone do not count towards that, and people frequently discover this only when they finally ask about surgery.
Having each episode properly recorded is therefore genuinely valuable, and it is a reason to be seen even when you know what it is.
What needs urgent in-person care: difficulty breathing, inability to swallow saliva, drooling, a muffled voice, or inability to open your mouth fully. Those suggest quinsy — an abscess needing drainage — and antibiotics alone frequently will not resolve it.
NICE NG84, Sore throat (acute): antimicrobial prescribing, governs treatment. It recommends FeverPAIN or Centor scoring to identify likely streptococcal infection, no antibiotic or a back-up prescription for most people, and phenoxymethylpenicillin where treatment is indicated.
NICE Clinical Knowledge Summary, Sore throat — acute, covers assessment, self-care and complications.
ENT UK and NHS commissioning guidance for tonsillectomy define the documented-episode thresholds set out above — the SIGN criteria of seven episodes in one year, five per year for two years, or three per year for three years — which is why documentation matters.
NG84 and CKS both identify peritonsillar abscess as requiring same-day hospital assessment, underpinning the urgent features listed.
Guidance also advises avoiding amoxicillin where glandular fever is possible, given the characteristic florid rash it produces.
Usually not — most tonsillitis is viral, and even for streptococcal infection antibiotics shorten it by around a day. Cough, a runny nose and hoarseness point to a virus. Fever, pus on the tonsils, tender neck glands and no cough point the other way, and that is when we would consider a prescription or offer a back-up one.
With a written record. The criteria are numerical — broadly seven episodes in a year, five a year for two years, or three a year for three years — and referral depends on documented episodes rather than how bad it has felt. Start noting dates, symptoms, treatment and days lost now, even if you are not sure yet. It is the single thing that unblocks this.
Tonsil stones — debris that collects and hardens in the natural pits of the tonsil. They are harmless, extremely common, not an infection, and antibiotics do nothing for them. Gargling, a water flosser on a low setting, or gentle pressure with a cotton bud will shift them. Do not use anything sharp. They are a leading cause of otherwise unexplained bad breath, and almost nobody has them explained.
It is worth getting looked at rather than watched. Persistent asymmetry when you are not infected — particularly with a neck lump, weight loss or night sweats — needs an ENT opinion. Most turn out to be nothing, but it is the one tonsil appearance that should not simply be reassured away.
Only where glandular fever is possible — which in a teenager or young adult with a prolonged severe sore throat is a real possibility. It causes a widespread dramatic rash in most people with glandular fever, and that rash is routinely written into records as a lifelong penicillin allergy, narrowing your antibiotic options for the rest of your life.
When the fever has settled and they feel well enough to take part. For confirmed strep throat or scarlet fever, 24 hours after starting antibiotics. There is no fixed exclusion period for ordinary viral tonsillitis.
Large tonsils are normal in childhood and shrink with age — but heavy snoring, restless sleep, pauses in breathing, or daytime irritability and poor concentration are a separate matter and a reason for referral in their own right, quite apart from how often they get infections. Mention the sleep specifically; it is often the more important half of the story.
August 23, 2026
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It means the diagnosis can usually be made from your history and photographs, and that treatment can be arranged safely without examining you. Where a condition is not marked treatable online, it is because examination is the diagnosis — listening to a chest, feeling an abdomen, examining an ear or a joint — or because a procedure or device is needed.
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If your problem turns out to be genuinely outside what we can do remotely, the doctor will tell you straight away, point you to the right service, and refund your fee in full. We would rather do that than fill twenty minutes to justify the charge.
Call 999 or go to A&E — do not book an online appointment and do not wait for a reply to an email. For urgent problems that are not emergencies, NHS 111 is available 24 hours a day, online or by phone, and can direct you to the right service.
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