Why Is There a White Spot on My Tonsils?

White spots on your tonsils can mean many things, the most common of which include tonsillitis, oral thrush, mononucleosis, and strep throat. There are also non-infectious causes, like tonsil stones, that can cause white bumps on your tonsils.

Bacterial causes may need treatment with antibiotics, while fungal causes are effectively resolved with antifungals. Other conditions are allowed to run their course, using saltwater gargles and pain relievers to help ease symptoms. Severe or recurrent tonsillitis may require a tonsillectomy.

This article describes the symptoms and causes of white spots on your tonsils, including what is involved in the diagnosis and treatment of the various conditions.

Symptoms of White on Tonsils

White spots on your tonsils frequently occur with other symptoms, which vary depending on the cause of the spots.

These may include:

• Sore throat
• Scratchy throat
• Red, swollen tonsils
• Swollen lymph nodes in your neck
• Feeling like something is stuck in your throat
• Hoarse voice
• Coughing
• Fever
• Fatigue
• Pain with swallowing
• Body aches
• Loss of taste
• Bad breath

Causes of White Spots on Tonsils

The tonsils are two fleshy masses in the back of your throat (pharynx). They function like lymph nodes, filtering out bacteria and other germs to prevent infection.

Because of their location and function, tonsils are vulnerable to infection and other problems that can cause white spots, lesions, or plaques.

Here are some of the more common reasons:

Tonsillitis

Tonsillitis is inflammation of the tonsils most commonly caused by a viral infection as well as certain bacterial infections. The condition may be acute (sudden and severe) or chronic (persistent).

Tonsillitis is most common in school children and typically occurs during colder autumn or winter months, but it can also affect adults. In rare cases, tonsillitis can also be caused by sexually transmitted infections like chlamydia, gonorrhea, and herpes.

The tonsils are also major sites of infection for COVID-19, especially in children in whom the inflammation may become chronic.

Strep Throat

Strep throat, otherwise known as streptococcal pharyngitis, is a bacterial infection of the pharynx by Streptococcus pyogenes. Tonsillitis is the central feature of strep throat, which typically develops within one to three days of exposure to the bacteria.

Strep throat accounts for up to 40% of sore throats in children and up to 15% of sore throats in adults. Some cases can lead to the breakout of a sandpaper-like rash called scarlet fever.

Strep throat is transmitted by respiratory droplets that are spread when an infected person coughs, sneezes, laughs, or talks. It can also be passed by touching something contaminated with droplets and then touching your mouth, nose, or eyes.

Most cases resolve on their own within a week, but some cases can become severe and require antibiotic treatment.

Oral Thrush

Oral thrush, also known as oral candidiasis, is a fungal infection of the throat commonly caused by Candida albicans (the same fungus that causes vaginal yeast infections). The fungus normally resides in mucus membranes but is usually well-controlled by the immune system.

It is only when the immune system is suppressed that C. albicans can suddenly overgrow, causing whitish plaque in the mouth and back of the throat. For this reason, oral thrush is considered an opportunistic infection rather than something you "catch."

There are many reasons why oral thrush can develop, including:

• Being immunocompromised, which can occur with conditions like HIV, organ transplant recipients, and those undergoing chemotherapy
• Taking broad-spectrum antibiotics, which can eliminate bacteria that otherwise keep Candida under control
• Taking immunosuppressant drugs, including methotrexate and oral or inhaled steroids
• Wearing dentures, which provide an ideal environment for fungal growth if oral hygiene is not maintained
• Having dry mouth (xerostomia), which deprives the mouth of saliva which otherwise suppresses fungal growth
• Heavy smoking, which appears to promote the growth of Candida

Infectious Mononucleosis

Infectious mononucleosis, also known as "mono" or glandular fever, is an infection usually caused by the Epstein-Barr virus (EBV).

Most people are exposed to EBV as children during which the infection produces few, if any, symptoms. If the infection occurs in teens or adults, it can cause fever, swollen lymph nodes, long-lasting fatigue, and symptoms of tonsillitis.

Most adults who get mono will usually recover without treatment within two to four weeks, but the draining fatigue will often last for months.

EBV is mainly spread through saliva and can be passed from person to person through kissing (which is why it is sometimes referred to as the "kissing disease"). It can also be passed through coughs and sneezes or by touching a contaminated object and then your mouth, nose, or eyes.

It can take weeks before symptoms of mono develop, during which you could pass the virus to others without even knowing it.

Tonsil Stones

Tonsil stones, also known as tonsilloliths, are deposits of mineralized debris in the crevices of your tonsils that create visible whitish lumps.

The stones (comprised of bacteria, calcium, and mineral salts) often affect people with recurrent throat infections. During an infection, debris can become trapped in the crevices of the swollen tonsils. Over time, the debris can accumulate and stick together, forming hardened stones.

While generally harmless, larger stones can cause sore throat, bad breath, coughing, and a feeling of something stuck in your throat. In some cases, a tonsil stone can provide a haven for bacteria, leading to a throat infection.

Less Common Causes

There are several uncommon causes of white spots on your tonsils that your healthcare provider may want to investigate, some of which may be serious.

These include:

• Lupus: This is a systemic (whole-body) autoimmune disease that can sometimes cause whitish, disc-shaped lesions in the mouth and throat.
• Behçet's disease: This is a rare autoimmune disease that causes vasculitis (inflammation of blood vessels). In the mouth and throat, it can cause tiny ulcers covered in a whitish film.
• Oral lichen planus: This is an immune-mediated disease that usually affects the skin but can sometimes occur inside the mouth, causing white, lacy patches along with open, red sores.
• Oral leukoplakia: This is a condition closely linked to smoking that causes white patches in the mouth and throat that cannot be wiped away. It is not cancerous but increases the risk of oral cancer by 40-fold.
• Oral cancer: This is a type of head and neck cancer that can cause white or red patches inside the mouth along with non-healing sores and swollen lymph nodes. Oral and throat cancers are the 11th most common cancers in the U.S., with around 58,000 new cases annually.

Diagnosis of White Spots on Tonsils

The diagnosis of white spots on your tonsil starts with a review of your symptoms and medical history, followed by a physical exam.

During the exam, the healthcare provider will look at the back of your throat while feeling behind your ears and around your neck for swollen lymph nodes. (Tonsil infections commonly cause swollen lymph nodes; tonsil stones generally do not.)

The healthcare provider may take a swab of your tonsils, which will be sent to the lab for evaluation. The sample may be submitted to various tests like polymerase chain reaction (PCR), which can identify infectious agents based on their genetic signatures. The cells may also be cultured (grown in the lab) to make a positive identification.

Blood tests can also be performed to identify viruses like EBV or HIV.

Treatment of White Spots on Tonsils

The treatment for white spots on your tonsils varies by the cause. Some conditions need no treatment and only require the management of symptoms. Other conditions need medical intervention and, in severe cases, surgery.

Tonsillitis

Pain management is generally the first course of treatment for tonsillitis. This may involve saltwater gargles, anesthetic throat lozenges, warm liquids, and other-the-counter (OTC) pain relievers like Tylenol (acetaminophen) or Advil (ibuprofen).

If pain is severe, prescription corticosteroids (steroids) may be prescribed to reduce inflammation quickly.

Bacterial causes may benefit from a short course of antibiotics like penicillin (generally reserved for severe cases to reduce the risk of antibiotic resistance). Viral causes are generally not treated and are allowed to run their course.

When tonsillitis is severe or recurs frequently, a tonsillectomy may be recommended to remove both tonsils.

Strep Throat

Strep throat is treated in much the same way as tonsillitis, with home remedies and OTC pain relievers. Most cases of strep throat will resolve on their own without treatment within a few days.

When strep throat is severe, oral antibiotics may be prescribed to resolve the infection and also reduce the risk of scarlet fever. Antibiotics are generally prescribed in three- to five-day courses and may include:

• Penicillin (generally the first-line choice)
• Amoxil (amoxicillin)
• Erythromycin
• Clindamycin
• Cephalosporins

Oral Thrush

Topical antifungals are the mainstay of treatment for oral thrush, available by prescription as lozenges, tablets, or a liquid, Options include:

• Miconazole
• Nystatin
• Amphotericin B
• Gentian violet

The choice of antifungals is based on the severity of the infection as well as the underlying cause.

Not all cases need to be treated. If medications are the cause, a change of treatment may be advised. Improved oral hygiene may resolve infections associated with dentures, while mucosal lubricants and saliva stimulants can help clear fungal infections caused by dry mouth.

If the underlying cause is HIV, the immediate use of antiretroviral drugs can help restore immune function and prevent future episodes.

Infectious Mononucleosis

Mononucleosis caused by EBV is a self-limiting disease that is usually allowed to run its course. The focus of treatment is on symptom relief similar to that of tonsillitis.

Antiviral drugs used to treat some viral infections are generally avoided because there is little evidence that they can change the course of the infection. Furthermore, they can cause unpleasant side effects and increase the risk of antiviral resistance.

Antivirals like acyclovir or valacyclovir may be prescribed for rare but serious complications of mono, such as meningitis (inflammation of the membrane surrounding the brain and spinal cord) and hepatitis (inflammation of the liver).

Tonsil Stones

If tonsil stones are causing no symptoms, medical intervention is usually not needed. The stones can often be dislodged with gargling, a WaterPik, or a cotton swab.

Larger stones may need to be removed by a healthcare provider. This may involve curettage (a simple tool used to scoop out the stone) followed by pressurized irrigation with water to remove any fragments.

Stones that cannot be manually dislodged may require laser cryptolysis. This is a procedure performed under local anesthesia that vaporizes the stone with a carbon dioxide laser.

When to See a Healthcare Provider

You should get medical attention for white spots on your tonsils if accompanied by:

• A severe sore throat
• Swelling in your mouth and throat
• Difficulty speaking, swallowing, breathing, or opening your mouth
• Severe, draining fatigue
  
• Persistent high fever
• Jaundice (yellowing of the skin and whites of the eyes)
• Severe headache with neck pain
• Persistent bad breath despite good oral hygiene
• Symptoms that last longer than 10 days

Summary

White spots on the tonsils are common with tonsillitis, strep throat, mononucleosis, oral thrush, and tonsil stones. To identify the cause, your doctor may review your symptoms, examine your throat, take a swab of your tonsils, and perform blood tests.

The treatment may involve home remedies like saltwater gargles, throat lozenges, and OTC pain relievers to help ease pain and swelling. Antibiotics may be prescribed to treat bacterial infections, while antifungals can usually clear oral thrush. Most viral infections are allowed to run their courses.

Severe or recurrent tonsillitis may require a tonsillectomy to remove your tonsils.