Tonsillitis and sore throat: swollen tonsils, when you need antibiotics, and what helps

What is tonsillitis?

The tonsils are two pads of tissue at the back of the throat, one on each side, that help fight infection. Tonsillitis is when they become infected and inflamed. It often comes together with a sore throat (pharyngitis), and the two are treated in the same way.

Symptoms include a sore throat, pain when swallowing, a fever, red and swollen tonsils, sometimes with white patches or pus, tender swollen glands in the neck, bad breath and earache. Children may also have a tummy ache, vomit or refuse to eat. Most cases get better within 3 to 7 days.

Virus or bacteria? Do you need antibiotics?

Viruses cause most sore throats, including those from colds and flu. Antibiotics don’t work on viruses. The main bacterial cause is group A streptococcus (“strep throat”), which causes about 20–30% of sore throats in children (most often aged 5 to 15) and 5–15% in adults.

Doctors use simple scores to judge the chance of strep. The Centor score gives one point each for:

• white patches or pus on the tonsils
• tender, swollen glands at the front of the neck
• a fever above 38°C
• no cough

Malaysia’s National Antimicrobial Guideline (2024) advises that adults scoring under 3 don’t need antibiotics, only pain and fever relief. A higher score suggests strep, and the doctor may prescribe penicillin or amoxicillin (or another antibiotic if you are allergic) for 5 to 10 days. Children with confirmed strep are usually given a full 10-day course, which also helps prevent rare complications such as rheumatic fever.

What helps a sore throat (ubat sakit tekak)

• Paracetamol or ibuprofen for pain and fever. Don’t give aspirin to anyone under 16.
• Drink plenty of fluids, especially if you have a fever. Cool or warm drinks and soft foods are easier to swallow.
• Rest.
• Salt-water gargles for adults and older children who can gargle safely: half a teaspoon of salt in a glass of warm water.
• Medicated lozenges and throat sprays from a pharmacy (with a local anaesthetic, anti-inflammatory or antiseptic) may reduce pain slightly. Ordinary sweets and mouthwashes have no proven benefit.

Most people feel better within a week. See a doctor if symptoms last longer than a week, keep coming back, or you have a weakened immune system.

When a sore throat is an emergency

See a doctor the same day if you have severe pain with swelling on one side of the throat or roof of the mouth, difficulty opening your mouth or speaking, or a fever with a rash. These can be signs of quinsy (a peritonsillar abscess), a pocket of pus beside the tonsil that needs draining and antibiotics in hospital.

Other conditions to know about:

• Scarlet fever: caused by strep, mainly in young children. A rough “sandpaper” rash appears 12 to 48 hours after the sore throat and fever, often with a red “strawberry” tongue. It is treated with antibiotics, and children should stay home until 24 hours after starting them.
• Glandular fever (caused by the Epstein–Barr virus): mostly in people aged 15 to 24. It causes a severe sore throat, very swollen glands and tiredness that can last weeks. Antibiotics don’t help.

Tonsil grading system: what the grades mean

Doctors describe tonsil size using the Brodsky grading scale, based on how much of the space at the back of the throat the tonsils take up:

Large tonsils (grade 3 or 4) don’t always cause problems. They matter if they cause snoring with pauses in breathing during sleep, difficulty swallowing, or frequent infections.

Tonsil stones (batu tonsil)

Tonsil stones are small, hard, whitish-yellow lumps of trapped food, dead cells and bacteria that harden in the pits of the tonsils. They are harmless, but often cause bad breath and a feeling that something is stuck in the throat.

• Gargle with salt water, brush your teeth and tongue, and drink plenty of water.
• Many stones come out on their own with coughing or gargling. A water flosser on a low setting can help.
• Avoid poking at your tonsils with sharp objects or pressing repeatedly, which can cause bleeding and inflammation.

Surgery is rarely needed for tonsil stones alone.

When are tonsils removed?

Removing the tonsils (tonsillectomy) is considered for frequent, severe tonsillitis that disrupts school or work, usually when there have been:

• 7 or more episodes in 1 year, or
• 5 or more episodes a year for 2 years, or
• 3 or more episodes a year for 3 years.

It may also be offered for repeated quinsy, or for large tonsils causing breathing problems during sleep. Recovery usually takes about 2 weeks off school or work. Bleeding can happen up to 2 weeks after surgery, and any bleeding needs urgent medical attention.

Where to see a doctor about a sore throat

A GP can examine your throat, decide whether you need antibiotics, and refer you to an ear, nose and throat (ENT) specialist for repeated tonsillitis. Our directory lists GP clinics across Kuala Lumpur, Selangor and other states, including clinics open in the evening, at weekends and 24 hours.

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Frequently asked questions