Tonsillitis and Pharyngitis

Tonsillitis is a word used to describe inflammation of the tissue that sits at the back of the throat. Other words that describe a similar illness include pharyngitis or simply an infected throat. Tonsillitis is usually viral in infants and toddlers. Older children can get bacterial tonsillitis such as ‘strep throat’.


Infants, toddler and children all will have sore throats from time to time. In many cases they are part of a ‘cold’, a simple viral illness that will settle with time.  However occasionally bacteria will be the cause and antibiotics will be necessary. Determining whether viral or bacterial is difficult for clinicians, but there are a few clues.

Viral tonsillitis – toddlers  

In infants and toddlers nearly all infections of the throat are viral. For reasons that are unclear the bacteria streptococcus does not often cause problems in these age groups. Usually the sore throat will be accompanied by runny nose, cough, watery eyes, gastrointestinal symptoms and fever. Parents usually present to their doctor worried about fever, poor appetite and interrupted sleep.  When examined the throat will be inflamed and their maybe ‘white’ areas on the tonsils. This does not necessarily mean a bacterial throat infection.

Throat infections caused by viruses, are common and  antibiotics will be of no benefit. After infection the child is ‘immune’ to that particular viral strain.

  • Adenovirus – this will often be associated with watery inflamed eyes, runny nose, cough and diarrhoea.
    Epstein Barr Virus - Glandular fever

    Epstein Barr Virus – Glandular fever

  • Enteroviruses such as coxsackie virus. There are a number of types and they result in high fevers and ulcers. See ulcers sore throat and fever in toddlers.  This group include hand foot and mouth disease.
  • EBV – glandular fever – In young children this virus can cause quite a nasty febrile tonsillitis.The tonsils will have ‘white areas’ and it is often misdiagnosed as ‘strep throat’.  The will also be a slight runny nose. large inflamed neck ‘glands’ and sometimes a mild rash. The fever is quite high. The good news is that this illness settles quickly in toddlers (days).
  • Other viruses that cause sore throats include those that cause the common cold, influenza viruses, viruses that cause croupy coughs in some children and wheezing in others.


Being viral antibiotics will have no benefit. Offer cold fluids, ice-blocks, even some yoghurt or ice cream. Often the toddler will take just enough to prevent dehydration.  Panadol or nurofen can be used when particularly miserable or when going to sleep.


  • Being viral, often there will be a hacking cough, runny nose and this can result in a middle ear infection or wheezy illness.
  • Some toddlers seem to get recurrent inflamed throats. They can get 8 – 10 per year  which is very frustrating. Parents will often be looking for an ‘answer’ as to why this is occurring. Often these children will be put on multiple antibiotics though bacteria are rarely ever to blame. This group of children eventually grow out of this though sometimes the infections are so bad that removing the tonsils and adenoids is the only option. It is advisable to either see a paediatrician if concerned.

Bacterial tonsillitis in children – Strep throat

What is a streptococcus throat infection ?

Strep throat

Strep throat

The most common bacteria causing throat infections is streptococcus. It is rare under the age of 4 years for reasons that are unclear. It is more common in late winter and spring. The child with a ‘strep throat’ will usually complain of headache, abdominal pain and fever. The sore throat may not be as severe as the abdominal pain. The child will not features of a cold, such as runny nose, or cough and will look quite unwell. Often the fever is 39 to 40 degrees. There can be a large swollen neck gland on one side under the jaw. The throat and tonsils will be inflamed and sometimes there are distinct spots on the pharynx which are a clue to strep throat.

Streptococcus is an interesting bacteria. It can produce toxins that can cause a variety of rashes including a rash called scarlet fever. This is a rough sandpapery rash on the trunk that is slightly pink in nature. In the past streptococcus and scarlet fever were quite serious but nowadays for some reason this is not the case with notable exceptions. There are some rare and some serious complications associated with streptococcus which is one of the reasons antibiotics are still used. The best antiobiotic is penicillin as streptococcus is still sensitive to this.

Recurrent streptococcus throat infection

This can be difficult to manage. There are a number of reasons. Firstly some bacteria live so deep in the crevices of the tonsils that the antibiotics simply do not reach levels enough to eradicate them. So when the time is right they start to cause infection again. Sometimes other family members have streptococcus this arises to the so called ping pong infections that can occur. Eradicating streptococcus can be difficult. Sometimes children just simply ‘grow out of infections’ which simply means the body’s own defences become aggressive enough to prevent infection, but sometimes the tonsils need to be removed. This operation used to be common place but is now only done for infections that occur nearly every month for a year.

Once penicillin is started for streptococcus the child will feel significantly better within 12 to 24 hours and can return to normal activities and school. The penicillin can be given twice per day – which is more convenient than the old fashioned four times per day.

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