Angina, tonsillitis: what causes and symptoms does it have?

Angina, tonsillitis: what causes and symptoms does it have?
Photo source: Getty images

Angina is an infectious disease characterized by inflammation of the tonsils, mostly the palatine tonsils. The inflammation is accompanied by swelling of their structures and pain in the throat. Angina occurs mainly in children. It is one of the most common causes of visits to the doctor. What are its symptoms? How can we distinguish it from other upper respiratory tract diseases?


Angina is the established name for an inflammatory disease of the tonsils. Angina is most often caused by a pathogen of viral, bacterial or fungal origin.

The term tonsillitis comes from the Latin word "angere", which translates as choking - a feeling typical of angina.

The name comes from Latin: "tonsila" = tonsils, "itis" = inflammation.

In the majority of the population, tonsillitis is perceived as inflammation of the palatine (throat) tonsils, visible at the sides of the back of the mouth. This type of inflammation is the most common. However, the disease is not limited to the palatine tonsils.

In addition to the palatine tonsils, inflammation can also affect the lingual tonsils, nasopharyngeal tonsils or tubular tonsils.

In some cases, pharyngitis can also be associated with inflammation of the tonsils. This is known professionally as pharyngitis. The combination of pharyngitis and tonsillitis is then called tonsillopharyngitis.

For a proper understanding of the issue, it is useful to explain the functioning and connection of the tonsils and pharynx.

The tonsils and pharynx are closely related. The pharynx is a muscular tube that forms a connection between the nasal cavity, oral cavity, larynx and oesophagus.

It is also referred to as the so-called connection between the respiratory and digestive systems. It plays an important role in breathing and swallowing.

One of the components of the pharynx are the tonsils. They are oval-shaped formations made up of lymphatic tissue. They are the simplest lymphatic organs in the body.

Specifically, these are the following parts:

  • The paired palatine (throat) tonsils - These are the largest. They are visible on the sides at the back of the oral cavity. Of all the tonsils, they are most at risk of infection and inflammation.
  • Pharyngeal (nasal) tonsils - Located in the vault of the pharynx.
  • Tongue tonsils - Located at the root of the tongue.
  • Paired tube tonsils - Located at the exit of the auditory tube.

These 4 types of tonsils are arranged in a circle around the entrance to the pharynx and form the so-called gateway to the respiratory and digestive systems. The circular arrangement of the tonsils, together with the walls of the pharynx and larynx, form the Waldeyer's lymphatic circuit.

The function of the tonsils as an entrance barrier is primarily to protect the body. They are made up of lymphatic tissue. This enables them to trap pathogens that enter the body through inhaled air and ingested food.

The protective function of the tonsils is enhanced by the fact that they are shaped into protrusions on their surface. The protrusions significantly increase the area of contact with pathogens.

As a primary immunological barrier, almonds contribute significantly to the functioning of the immune system.

Infection and subsequent inflammation of the lymphoid tissue and surface epithelium of the tonsils is called tonsillitis.

In terms of course, there are two types of tonsillitis - acute (short-term) and chronic (long-term).

Tonsillitis can occur and recur several times a year. In this case, we speak of recurrent tonsillitis.

1. Acute tonsillitis

Acute tonsillitis is one of the most common diseases of the upper respiratory tract. It arises suddenly and persists for about 1-2 weeks.

It predominantly occurs in the winter months or early spring. However, it can occur at any time of the year.

The course of acute tonsillitis can be unpleasant. However, with proper treatment it rarely leads to serious health complications.

It most commonly affects children and adolescents aged 5-18 years and young adults up to 25 years. It is not excluded in other age groups.

Bacterial angina is more common in school-age children, while viral angina is more common in children under 5. Angina is very rare in children under 2 years of age.

It affects both sexes without significant differences.

Almost every child comes into contact with acute tonsillitis at least once in their lifetime.

It can be transmitted mainly by close physical contact, during which viruses or bacteria causing infection and inflammation (droplet infection) are spread.

Inflammation of the palatine or pharyngeal tonsils is much more common in acute tonsillitis, and less common in the lingual or tubular tonsils.

The infection may be bilateral (i.e. affecting both paired tonsils) or unilateral only. If both tonsils are affected, the involvement is usually asymmetrical.

2. Chronic tonsillitis (inflammation of the tonsils)

Chronic tonsillitis is characterised by persistent inflammation of the tonsils over a prolonged period of time.

It may develop from repeated attacks of acute tonsillitis or arise from the persistent presence of infection, in which the inflammation develops slowly and more or less unnoticed.

The infectious agents are able to survive and settle in the tonsillar tissue for long periods of time. This is mainly because the natural cleansing and draining capacity of the infected tonsils is impaired.

The ability to remove and kill pathogens and their toxins is reduced due to swollen tonsils that are clogged with cellular waste and products of the pathogens present. The ability to kill pathogens is also reduced due to recurrent inflammation that damages and alters the original structure of the tonsil tissue.

Chronic and recurrent tonsillitis significantly affects the patient's quality of life.

An outbreak of infection may be localized only in certain areas of the tonsils, but the infection can spread to other tonsillar tissues or enter the bloodstream, spread throughout the body and create outbreaks of infection in more distant locations.

As in acute tonsillitis, the palatine and pharyngeal tonsils are much more often affected by inflammation in chronic tonsillitis. Very often chronic pharyngitis is added.

Chronic tonsillitis is more common in adults than in children. Pharyngitis is predominantly found in the paediatric population and is rarer in adults (due to the evolutionary shrinkage of the pharyngeal tonsils after puberty).

This type of tonsillitis affects both sexes without significant differences.

Angina - inflammation of the tonsils
Angina is an infectious disease characterized by inflammation of the tonsils, mostly palatine, accompanied by swelling of their structures and associated sore throat. Source: Getty Images


Angina can have several different provoking causes.

Usually it arises as a result of an infection that is caused by a viral or bacterial pathogen. To a lesser extent, it is provoked by fungi or other factors.

Viral angina is caused by rhinoviruses, influenza viruses, coronaviruses, echoviruses, enteroviruses, adenoviruses or respiratory syncytial viruses. These viruses rarely cause serious complications.

They can also be herpes simplex viruses, Coxsackie virus, Epstein-Barr virus, cytomegaloviruses, hepatitis viruses or rubella viruses.

Some of these viruses are also involved in other upper respiratory tract illnesses such as the common cold or flu.

Many of these viruses are a natural part of the microflora in the mouth and throat.

Streptococcus pyogenes, Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae, Mycoplasma pneumoniae, Fusobacterium, Moraxella catarrhalis and other bacteria are mainly involved in the development of bacterial tonsillitis.

The onset and development of bacterial tonsillitis is very often preceded by a pre-existing and well-developed viral infection of the tonsils.

Bacterial tonsillitis can be caused by a single species of bacteria, most commonly Streptococcus pyogenes. However, it is usually polymicrobial in nature, meaning that it is caused by some bacteria from the external environment, but also by bacteria naturally present in the mouth and throat.

Bacterial infection most commonly affects the palatine tonsils.

Other causes of tonsillitis include fungi, such as Candida albicans, or actinomycetes.

Tonsillitis can also arise secondary to another, already developed disease. For example, we speak of secondary tonsillitis in patients with sexually transmitted diseases - HIV infection, syphilis, gonorrhoea, chlamydial infection - or in patients with tuberculosis or diphtheria.

A specific cause of tonsillitis is the coating of tonsil tissue with strong acids or alkalis.

Risk factors that increase the likelihood of developing tonsillitis include:

  • Age - In general, tonsillitis is more common in children, especially those of school age.
  • Frequent exposure to pathogens - Spending a lot of time in a group of children increases the risk of spreading the infection not only among the children themselves, but also among adults in the children's group (e.g. teachers).
  • Patients with weakened immune systems - Chronically ill patients, patients with bone marrow disorders, patients with poor white blood cell function, etc.


Typical symptoms of acute angina include:

  • Sore throat.
  • Swelling and redness of the tonsils
  • Difficulty and pain when swallowing
  • Fever, usually above 38 °C (38 °F)
  • Plaque on the tonsils (its nature depends on the type of tonsillitis)
  • Swelling and soreness of the throat nodes
  • Headache
  • Pain in the ears
  • Fatigue
  • Loss of appetite
  • Change in voice
  • Trouble breathing

Children may also have atypical symptoms such as excessive salivation, abdominal pain, nausea and vomiting.

In viral tonsillitis, cough, runny nose, muscle and joint pain are common. Bacterial tonsillitis is characterized by the presence of exudates (sometimes purulent) on the tonsils.

The distinction between viral and bacterial tonsillitis is quite difficult based on the assessment of symptoms.

There are several types of tonsillitis. Each type of tonsillitis is characterised by the presence of specific symptoms.

Catarrhal angina is characterised by sore throat, swelling, redness or blueness of the tonsils.

Laconic tonsillitis is manifested by bilateral sore throat, earache, fever and fatigue. There are purulent yellowish plaques on the tonsils, which may smell.

In follicular tonsillitis, the symptoms are similar to those of lacunar tonsillitis, with yellowish oozing abscesses on the surface of the tonsils.

More severe types of tonsillitis include pseudomembranous tonsillitis, in which the tonsils are covered with a firm and adherent pseudomembrane. This pseudomembrane is formed as a result of damage to the superficial tissue of the tonsils. When it is torn off, bleeding occurs.

A rarer type is ulcerative tonsillitis, which is characterised by the formation of ulcers on the surface of the tonsils associated with bleeding.

In chronic tonsillitis, there are repeated episodes of purulent tonsillitis. Its manifestations are the same as in acute tonsillitis.

In some cases of chronic tonsillitis, non-specific symptoms are present for a long time, such as scratching in the throat, a tingling or tingling sensation in the throat, a feeling of pressure in the tonsils or a feeling of a foreign body in the throat. These symptoms alternate with periods of absence of symptoms.

In these patients, halitosis is also present.


The diagnosis of angina is made in several steps, starting with a clinical examination, followed by microbiological examination, blood count, inflammatory markers and, if necessary, urinalysis.

The clinical examination consists of taking a medical history (history of the patient's illnesses, medications taken, etc.) and a physical examination.

The physician observes the condition of the tonsils - the presence of redness and mucous discharge, swelling, plaque or sores on the tonsils. If plaque is present, its colouration and adherence to the surface of the tonsils is observed.

The presence of swelling and soreness of the nodes in the neck is also observed. The nose, eyes and ears are also examined for signs of infection.

The presence of fever, cough, nasal congestion, impaired breathing, possible skin rash and abdominal pain is noted.

The basis of the diagnostic examination is to correctly distinguish whether the angina is of viral, bacterial or other origin. This then plays an important role in determining treatment.

The CRP (C-reactive protein) test can be used to detect the presence of bacteria. It is often performed in the doctor's office and gives a quick result.

A more accurate result, or determination of the specific type of bacteria, is provided by laboratory examination of the swab (culture test). The doctor will take a swab directly from the affected infected area on the tonsils.

Diagnosis of streptococcal infections is very important in tonsillitis because streptococci are the cause of many complications and serious consequences.

Blood tests are also used in the diagnosis. Especially in chronic tonsillitis, an increased number of white blood cells and increased sedimentation can be observed in the blood count.

Another test is the ASLO test (antibodies to streptococcus O). The test determines whether the patient has had a streptococcal infection.

Liver function tests or a check for splenic enlargement may also be performed to indicate infectious mononucleosis.

Diagnosis of angina
Several methods are used in the diagnosis of angina. One of the most important steps is to correctly distinguish whether angina is of viral or bacterial origin. Source: Getty Images


Angina can occur in the human body either as a separate disease or as a consequence of another disease (diphtheria, mononucleosis, venereal diseases, etc.).

The severity and the course of angina itself always depend on the state and function of the immune system of the patient concerned. It also depends on the strength and aggressiveness of the provoking cause.

1. The course of acute angina

Acute angina usually manifests itself from the very first days with the above typical symptoms (appearing 2-4 days after exposure).

Inflammation occurs in the lymphoepithelial tissue of the tonsils. The inflammation is often exudative (inflammatory fluid is secreted). The nature of the exudate and plaque forming on the surface of the tonsils may indicate a type of tonsillitis.

In people with a well-functioning immune system, no serious complications are expected in acute tonsillitis. Recovery is uneventful.

With proper treatment, the disease lasts 7-10 days.

More severe forms of tonsillitis, such as pseudomembranous or ulcerative tonsillitis, can develop in people with weakened immune systems and in children whose immune systems are still developing.

2. Complications of acute angina

In some cases, acute angina can become complicated and lead to the development of local or systemic problems and diseases. This applies, for example, to untreated or improperly treated angina.

Local complications include enlargement of the pharyngeal (nasal) tonsils, which leads to reduced patency in the nasal area and breathing difficulties.

Furthermore, it may be the accumulation of inflammatory exudate (pus). This exudate is not adequately removed from the inflamed tonsillar tissue.

The accumulated pus also reaches the surrounding tissues adjacent to the tonsils and a peritonsillar abscess (a circumscribed purulent inflammation of the tissues around the tonsils) is formed.

Peritonsillar abscess occurs in bacterial tonsillitis and is more common in adults and adolescents.

There is also a risk of the infection spreading from the tonsils to the tissues of the throat or to a more distant area of the chest.

Systemic complications include a condition in which inflammatory involvement of the tonsil tissue transmits the infection into the bloodstream. We speak of bacteremia (presence of bacteria in the blood) to sepsis (popularly blood poisoning).

Very dangerous streptococcal infections of the blood or other tissues and organs can also result from the passage of streptococcal bacteria into the blood. They have very unpleasant health consequences.

The consequences of streptococcal infections can be:

  • Rheumatic fever is a painful inflammation of the joints, heart muscle, heart tissues and valves. It leads to limited mobility and heart problems. It is a very rare complication. It occurs approximately 10 to 20 days after a streptococcal infection. The causative agent is Streptococcus pyogenes.
  • Glomerulonephritis is an inflammatory disease of the kidneys. It can lead to kidney failure.
  • Scarlet fever is an infectious disease manifested by fever and a characteristic red skin rash on the lower abdomen, inner thighs, groin or armpits.
  • Inflammation of the middle ear

Repeated episodes of acute tonsillitis can develop into chronic tonsillitis.

3. Course of chronic angina

Chronic tonsillitis develops from recurrent attacks of acute tonsillitis or arises due to the persistent presence of infection in the tissues of the tonsils.

Pathogens are able to survive in the tonsillar tissue primarily due to inadequate cleaning and drainage of the prominences (crypts) on the surface of the tonsils.

The crypts accumulate mass. It is made up of the products of the bacteria present and cellular waste. The crypts become clogged. This mass is also a breeding ground for bacteria. The bacteria can survive for long periods of time and are a source of long-term inflammation of the tonsils.

Abscesses (suppurative) form in the tonsil crypts. The natural structure of the tonsillar tissue gradually changes. This contributes to the deterioration of the self-cleaning capacity.

Repeated inflammatory processes lead to atrophy of the tonsillar tissue (shrinking, stunting).

From the infectious foci in the crypts of the tonsils, the infection can spread to other tonsillar tissues and gradually invade their entire structures.

The spread of infection from the foci to other sites is already considered a complication of chronic tonsillitis.

4. Complications of chronic tonsillitis

Like acute tonsillitis, chronic tonsillitis is characterized by local and systemic complications.

In local complications, the infection spreads to the surrounding tissues adjacent to the tonsils. A peritonsillar abscess or pharyngeal abscesses may form.

After inflammation, post-inflammatory adhesions may form between the tonsil capsule and the surrounding area.

If the pharyngeal (nasal) tonsils are also affected by chronic inflammation, a chronic form of rhinitis, sinusitis, otitis media, sleep apnoea and even chronic hypoxia (oxygen deficiency) develop.

Chronic tonsillitis may also cause night-time snoring or sleep problems.

Systemic complications include the spread of infection from the lesions to the bloodstream and then to distant tissues and organs.

This can lead to serious consequences such as the development of rheumatic fever, glomerulonephritis, inflammation of the skin, inflammation of the heart tissues or inflammation of the ovaries and fallopian tubes.

One of the complications of chronic tonsillitis is the formation of stones in the tonsils. These are hardened calcified remnants of bacteria and waste products that are localized in the crypts of the tonsils.

How it is treated: Angina tonsillitis

Treatment of tonsillitis: medication (when antibiotics?) and topical + surgery

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Interesting resources

  • - Tonsillitis and sore throat in children, Klaus Stelter
  • - Tonsillitis, Acute, Lukas Plank
  • - Tonsillitis, chronic, Lukas Plank
  • - Clinical practice guideline: tonsillitis I. Diagnosis and nonsurgical treatment, Jochen P Windfuhr, Nicole Toepfner, Gregor Steffen, Frank Waldfahrer, Reinhard Berner
  • - Clinical practice guideline: tonsillitis II. Non-surgical treatment, Jochen P Windfuhr, Nicole Toepfner, Gregor Steffen, Frank Waldfahrer, Reinhard Berner
  • - Tonsillitis
  • - Diagnosis and treatment of tonsillitis in children, doc. MUDr. Pavel Kominek, Ph.D., MBA
  • - CHRONIC TONSILITIS, Irina Šebová , Anna Valentová , Ján Siváček
  • - Lymphatic system, Petr Ornst, M.D.