Symptoms of Acute Tonsillitis
Acute bacterial tonsillitis presents with sudden-onset sore throat, fever (101-104°F), tonsillar exudates, tender anterior cervical lymphadenopathy, and notably the absence of cough. 1
Core Clinical Features
The hallmark presentation includes:
- Sudden onset of sore throat with tonsillopharyngeal erythema, often with tonsillar exudates 2, 1
- High fever ranging from 38°C to 40°C (101-104°F) 3, 1
- Tender and enlarged anterior cervical lymph nodes 3, 1
- Absence of cough - this is a critical distinguishing feature from viral causes 3, 1
The American Heart Association emphasizes that the absence of cough is particularly important for differentiating bacterial from viral tonsillitis 1. When cough, coryza, hoarseness, conjunctivitis, or diarrhea are present, viral etiology is much more likely 1.
Additional Common Symptoms
Beyond the core features, patients may experience:
- Headache, abdominal pain, nausea, and vomiting - especially common in children 1
- Soft palate petechiae and beefy red, swollen uvula 1
- Difficulty swallowing due to tonsillar inflammation and pain 4
Age-Specific Considerations
The presentation varies by age group:
- School-aged children (5-15 years) are the primary affected population, with Group A streptococcus accounting for 15-30% of cases 1
- Children under 3 years may present with less specific findings, such as excoriated nares or purulent nasal discharge 1
- Teenagers and adults often have atypical presentations 2
Red Flag Symptoms Requiring Urgent Evaluation
Certain symptoms warrant immediate assessment for life-threatening complications:
- Difficulty swallowing or drooling 3, 1
- Neck tenderness or swelling 3, 1
- Persistent fever with rigors and night sweats 1
- Signs of airway obstruction 1
These symptoms may indicate peritonsillar abscess, parapharyngeal abscess, epiglottitis, or Lemierre syndrome 3.
Critical Diagnostic Pitfall
No single symptom is specific enough to diagnose bacterial tonsillitis without microbiological confirmation. 1 The American Heart Association and multiple other societies emphasize that rapid antigen detection testing and/or throat culture for Group A Streptococcus must be performed before initiating antibiotics 3, 5, 1. Initiating antibiotic therapy without confirming GAS infection leads to unnecessary antibiotic use and contributes to resistance 3, 5.
Distinguishing Bacterial from Viral Tonsillitis
Viral tonsillitis typically presents differently:
- Usually without high fever 3
- Often without tonsillar exudate 3
- Frequently without cervical lymphadenopathy 3
- Commonly accompanied by cough, coryza, or conjunctivitis 1
The presence of these viral features should prompt supportive care rather than antibiotics 4.