Tonsils, Mono, and Chronic Fatigue

As I was taking out enormous tonsils from a young child yesterday, I was reminded of a young female college student that I treated many years ago who came to see me with severe tonsillitis. She had severe throat pain, difficulty swallowing, diffuse and tender swollen neck glands, and couldn’t sleep at all. Due to the severity of her "infection," I prescribed a course of oral antibiotics, as well as a short course of anti-inflammatory steroids, to get rid of the swelling in her throat. The next day, she reported that she was feeling dramatically better and sleeping better as well. When I saw her three days later, her tonsils were not touching in the midline anymore, and her neck glands were much smaller. Upon further questioning, she did state that she’s always had large tonsils, but they became much bigger with this infection.

 

You may think that the antibiotics helped to fight the infection, but typically, it takes 2-3 days for antibiotics to reach significant concentrations to begin to work. What actually helped her feel better, faster, was the steroids, which begins to work within a few hours.

 

In retrospect, she probably had mono. But because it resolved rather quickly, it would be classified as a routine throat infection that resolved with antibiotics. However, since mononucleosis is a viral infection (the Epstein-Barr virus), antibiotics won’t really make a difference. Had she not been given oral steroids, her symptoms probably would have continued for weeks to months, despite being given multiple rounds of antibiotics. Most of these patients eventually start to feel better after some time, but some never feel better. This is the classic mono condition that you hear about. Some are later diagnosed with chronic fatigue syndrome.

 

The reason for these persistent symptoms is that the Epstein-Barr virus preferentially infects the lymphoid tissues in your body. Since your tonsils are lymphoid tissues, they will swell up. Having larger tonsils all of a sudden will narrow your upper airway, causing frequent obstructions and arousals when in deep sleep due to muscle relaxation.

 

Frequent obstructions also causes stomach juices to be suctioned into the throat, which causes more swelling and inflammation of the tonsils, leading to a vicious cycle.

 

You may be thinking that it’s a good idea to take out your large tonsils, since it’ll prevent this situation from happening the next time you get a cold. For the most part, it should help, but don’t think of it as a cure. Studies performed in children who undergo tonsillectomies showed that only about 2/3 improve significantly. Many of these non-responders will go on to have obstructive sleep apnea later in life. Even the "responders" will have a slightly increased risk of obstructive sleep apnea, since their jaw structures are more narrowed, which lead to enlarged tonsils.

 

Do you have large tonsils and have severe or recurrent throat problems every time you get a cold? If so, please enter your experiences below in the comments box.


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27 thoughts on “Tonsils, Mono, and Chronic Fatigue

  1. I'd swear we'd met before with the history you just gave!  I had mono when I was a junior in college.  They told me that there was really nothing that they could do about it and I'd just have to ride it out.  Talk about miserable.  My tonsills got so big at one point that my uvula was stuck to one.  I felt truly awful.  But I did get better.  Mostly.
    My tonsills are not as big as they were then, but they're definately above average.  And every time I get the slightest infection or cold, they get even bigger.  (I even have a lymph node in my neck that tends to enlarge right before I get sick!)  I get a LOT of tonsil stones, and seem to be more prone to infection than ever in the past.  I never had strep prior to the mono, have had it three times since.  I get more sinus infections.  Maybe some day I'll have to get the buggers out.

  2. I had my tonsils and adenoids removed when I was 12. I did have bad complications — severe bleeding from both sites days after the surgery. Had to be hospitalized for 4 days with nose packing. However, almost every time I get a cold, I do get throat symptoms — often lasting for months. I also used to get chronic middle ear infections — as an adult, which only cleared up after I had my deviated septum repaired.

  3. When I was in grade 12 last year I was very active and got sick quite often after a sports practice my neck and back were so sore and stiff I couldn’t stop crying. I went to the hospital and he was about to send me off thinking I was just complaining when he lifted my shirt to check my heart beat there was a rash. He then took my blood and found out I had mono. I left and from then on I would randomly get hives for no reason id sleep for hours and constantly get severely sick. After that my lymphnodes were constantly swollen and I was still tired so they took my blood again and said I had chronic fatigue syndrome that went on for months and id still constantly get sick. After that went away almost every other week until now I seem to have tonsillitis and have been medicated for it over 38 times. I saw a specialist last month and he let me choose if I wanted to get them out. Im now on the waiting list. Altogether this experience has left me beyond frusterated and run down. Im hoping my health improves soon.

  4. Ivory and whoever else may read this, so I first had mono when I was 12. I got it again when I was 16. Then more recently, I was diagnosed with it a few weeks ago. My first onset of symptoms were over 5 weeks ago. After about 3 weeks I finally started to feel better, I went a little over a week with no sore throat or swollen neck glands, I would just get tired easily. Something happened during that week because one morning I woke up with mono symptoms again. I was very achy, chills, and my tonsils and neck glands were very swollen. After a couple days of feeling this way I took a good look at my tonsils, they are covered in white patches. This morning I woke up, the chills are gone and the achiness is better, but now my throat is very sore again, along with the white patches and they are almost touching so swollen. I have no idea what my doctor will say this week, but should I request to have my tonsils out?? I have no idea what to think about all this. What if I get mono again? What this throat issue never clears up and I continue to battle with tonsilitis?

  5. My tonsils have been swollen since I was diagnosed in having mono when I was 13. They are prone to tonsil stones, they get larger when I’m sick, and I often have a sore throat and post nasal drip. My neck is very tender and causes me a lot of pain but I’m not sure if it is due to the lymph nodes being swollen. I am always tired and never really feel well. I was told I have CFS and now that I’m 29 and getting married and looking to start a family, it really saddens me to think that I have to live in a state of exhaustion and pain and won’t have the energy I would like to raise children. I’m a little confused about this article, however. Dr. Park, are you stating that you would recommend that I take steroids to help my tonsils to go down? I’m only in the first chapter of your book, so I’m still unaware of how I can go about getting more restful sleep. Any input is much appreciated…I am so frustrated with feeling so yucky. :(

  6. Amber,

    Taking steroids is only a short-term fix. I bring up this example to show that anything that significantly shrinks the tonsils can help you breathe better and sleep better. It can be either short-term or long-term, determined by which option you choose. But the tonsils are usually not the only reason for narrowed breathing passageways that interrupts your sleep. You’ll see what I mean as you continue reading the book.

  7. My 9 yr old son was diagnosed with probable mono in Oct/11 after a positive mono test on my 18 yr old son at the same time. My oldest had tonsillitis, peri tonsil abscess and mono, was very ill/ unresponsive to antibiotic/had surgery in Dec. Surgeon mentioned that he removed adenoids because they were very large. By Christmas he had completely recovered from all symptoms. My youngest, who’s only symptoms in Oct/11 were two small white patches on tonsils/ no sore throat/ slight fever and negative strep swab, was kept home for 6 weeks because of the schools concern of probable mono, even though he was fine after a few days. He is now though very ill. Fatigue, pale, lightheaded, vertigo, constant headache, dark circles under eyes, puffy eyes of one that has not slept. Has now been farther diagnosed w/ sinus infection and chronic sinusitis. I have now requested for him to see an ENT and he has had blood work done/ waiting on results. I have been looking into mono, enlarged adenoids and sleep apnea. He snores and/or is very restless in sleep, wets the bed, night sweats, crys easy, angry outbursts, always “tired”, wakes w/headache and saying “I had a bad sleep”, sleeps w/arms outstretched and head arched/forehead on pillow. Has always caught every cold/flu has had pneumonia, bronchitis more than once. Complains of heatwaves/ sweats. Nasal sounding voice, speech therapy for 4 years, but is still having problems. Breathes, eats w/ mouth open, sniffs and clears throat while eating. He is a “gifted” child, very advanced in school, guitar and martial arts, but has had to miss an incredible amount of school, dropped jiu jitsu and yawns during his guitar lessons. He spaces out while being spoken to and has a hard time staying awake. Some of these symptoms come and go, hour by hour, day by day. He goes to school wanting to stay the whole day but his teacher calls because he is having dizzy spells and looks “unwell”. We follow our dr orders, saline rinses and steriod spray, the spray really hurts his nose after awhile, so we stop and then start again. Could this possibly all be mono like our dr thinks? Has anyone else experienced all this with mono?

  8. I had Mono at 20. The fatique a fue months later. with thoat problems off and on.
    I read the article about Mono and Chroic fatique conection with sleep apnea so I got tested and have sleep apnea. I am get a machine. Hoping it will help after 45 years of pain and weakness you see I’m 65 years old still looking for answers. thanks for your help.

  9. Hello, my adult son had glandular fever twice plus many throat infections as a child/adolescent. He had several vaccines in a hurry before going to India on a business trip and was very ill feeling exhausted etc
    3 years ago he was diagnosed with ME and cannot work. He breathes through his mouth and does not sleep well. As a child a school doctor described his tonsils as large but we decided not to have them removed. What treatments work for people with CFS and ME?
    Thanks

  10. Rosemary,

    Years of chronic mouth breathing causes facial changes that narrows the jaws and makes breathing more difficult during the day and during sleep. If he still has large tonsils, you can see an ENT doctor to see if he’s a candidate for surgery. However, the entire airway must be addressed (nose, palate and tongue levels). CFS and ME is a complex condition with a multiple causes. There are neurologic aspects as well. However, anything to improve his breathing at night while sleeping can only help.

  11. i believe i have it now. from drinking behind a friend who had it. ive had it before and every since then my tonsils swell while im sleep.. any suggestions?

  12. İ live in turkey.İm getting trouble with my tonsils. Only this summer i had tonsillitis for 6 times. İnterestingly it occurs always in same crypt. Very big pus. İ remove it with cotton chips. They smells very bad, yellow, 2 milimeters diameter. Sometimes i have postnasal leakage and these pus partices in my mouth. There was no streptoccocus proliferation on my throat culture but i used oral amoks- clavulanate. No response. Tonsillitis improves spontaneously .Also when i have tonsillitis i dont have fever. Only weakness. And also always fatigue. What should i do?is it possible that i had mono before ? And is it risky for my 4 months old daughter?i look forward your answer thanks

  13. In junior high n hugh zchool i believe it was 3pretty times i was diagnosed with mono…one incudent i missed almist a mknth of school abd lost approx 20 lbs, a lot fir me at that age. I graduated at aboit 115lbs and am 5’6″. Ive had strep throat several times as well throughout my lifetime. I akways felt tired but just explained it away to myself saying im not a morning person, and who wouldnt be tired working fulltime and attending college at night (for 10 years). At age 43 I was finally diagnosed with a moderate to severe case of sleep apnea. I am soon to take a 2d sleep test now having used a CPAP for 3 years. Interesting is prior to teleconference w pulmonary doc arranging the test, the pic they took of my throat in an upright sitting position showed my tonsils are no longer even visible!! Sleep ap is so very dangerous and
    diagnosis is critical…only now more is being learned and information being shared witth primary physicians and
    partients. a being learnes n education os same duaawminated. I developed HBP and take meds for same in my early 20s, anxiety by late 20sn and underactive thyrois in early 40s. ALL these cinditions have been linked to sleep apnea!!

  14. Just wanted to thank Dr. Park for his work and aharing of information! I still suffer fatigue and am trying to resolve still! You have given me new information which may ultimately help.me sleep and live with a higher quality if life – thank you.

  15. Irmak,

    In general, tonsils stones can cause tonsils to get bigger, which can aggravate breathing problems at night, leading to poor sleep quality and daytime fatigue. You should talk to an ENT physician about options.

  16. I suffered really badly with glandular fever at University, in retrospect I think I had chronic fatigue, this led to a massive weight increase and obstructive sleep apnea as a result of the extra weight on my neck.
    Once I graduated and got into a more ‘normal’ routine I lost weight and the problems ceased entirely.

    In the past year – 18 months, I’ve gained quite a lot of that weight back and noticed that any time I’m rundown or tired I will get tonsillitis, having had this 3 times in the past 6 months I’m pretty miserable about it. My sleep is becoming more and more disturbed and I’m sure that if I continue in this way I’ll end up where I was a few years ago! Personally I think my problems would be helped with weight loss but its so hard when you have no energy. Does anybody else have similar issues/advice?

  17. Hello I first noticed white tonsil stones on the right side of my throat. It wasn’t very sore at first but just made my breath smell badly. A day or so later my throat started to become sore so I went straight to an ENT and he prescribed me to amoxicillin and some throat wash to gargle 6 times a day. Two days later I noticed the white tonsil stones appearing on my right tonsil and by this point had a full blown sore throat accompanied by chills and hot flashes with slight ear pain. Went to another specialist and he took me off of the amoxicillin and put me on cephalexin antibiotic. Things got worse from there as the next day I began to develop a rash all over my body so I went to my GP and he said it was common for the rash to develop if I had mono. They tested me and sure enough it was positive for mono but not for strep. So he gave me a steroid shot for the rash, put me on Zithromax and also a steroid prednisolone to take. My question is are the tonsil stones a precursor to sickness or was the mono virus already present and the stones were just the first signs to show up? The rash has come down now slightly but it has been a living nightmare the past week and a half.

  18. I was curious to whether Mono in your youth is some way connected to sleep apnea in later years. I had Mono in my late teens….I believe I had sleep apnea in my twenty’s but not diagnosed until my 50’s. I find that my short memory is going….very embarrassing to be listening to someone and about to respond and find that you forget what the topic was about…I have been using a cpap machine now for two years….my body craves it…although my energy level is better then a few years ago…I find that my energy is short lived…and comes in spurts. I get irritable a lot quicker and my patience is short. I’m unable to complete a full days work over extended periods of time. One day i would be able to, then the next day I may not. It is very frustrating. I’m seeing some type of self-employment so that I can go at my own pace. I think all patients with Mono backgrounds should be tested for sleep apnea…If I was treated sooner I don’t believe I would be having these issues. (Yes, I do wake up still during the night….but I sleep better than I have before the cpap machine)

  19. Regarding tonsillectomy: though I don’t that my daughter met all the criteria for ME/CFS, she certainly did meet many of them. The change in her mental and physical function has been so profound following tonsillectomy that I thought it worth mentioning. I will also talk with her pediatrician, with whom I had discussed tonsillectomy several times since Katie didn’t recover from mono 3 years ago…… she was totally against it……she sent us to a well-known pediatric neurologist in our area. After a typical minimal neurological exam and history, he told my daughter that she had chronic multiple migraines and ‘chronic fatigue’ and that she should get massage therapy, acupuncture, take some herbal supplements, exercise for 30 minutes daily, and get Botox injections that are now popular for migraine. My daughter thought this guy was a quack too – haha. I’m not saying that those therapies aren’t appropriate for some conditions, but they were totally inappropriate in this case. And, my daughter has had one migraine in her life and remembers it well….. tonsillectomy was a god-send! no headaches, runs 3-5 miles/day, vastly improved mood, decreased anxiety, better sleep of course. I’ve been in touch with some scientists/clinicians in the ME/CFS field and they are interested in this as a possible issue.

  20. I had tonsillitis in the month of December and I took the medicine as told to
    My right tonsil never returned to normal size and the doctor refused to take them out. Now its January and they are swollen and worse than ever. I went to the emergency room and I found out I have mono which is weird because I am faithful. But I’m wearing a mask. And I’m really scared about it. What if my tonsils do not return to proper size again? They look absolutely gross. Theres puss pockets and a bunch of stuff everywhere. Its horrible. I hate it!!! I’m pushing for my doctors to take them out but they are refusing to which is bs!

  21. My npath believes many obstructive sleep / upper respitory cases are due to a dietary inflammation. I’m just beginning an experiment to cut out all dairy, all flours and sugars. She says in three weeks the snoring will stop. Maybe the above cases are more complicated and maybe mine is too but I’m curious. I’m on day 5 of my abstinence experiment.

    My CFS did come on after I was super sick. I never went to the doctor at the time but had Epstein bar show up in my labs and suspect I had mono. I also has some horrible personal experiences at the time that causes some emotional traumas and I started aching in my legs a lot and needing large amounts of sleep in my mid twenties. Today I’m 40 on SSD. I sleep 10-12 hours most nights. At the peak it was 16-20 for a good year plus. I tried holding down a part time retail job but just standing for a shower often did me in. Left a great career and moved into my parents basement. Fifteen years later still struggling but my very managed lifestyle has helped keep the flair ups to be less impactful.

    I dot have swollen gland complaints but then there’s issues I’m coming to learn I’ve been ignorant of. I do have a narrow mouth, a cross bite braces can’t fix without upper jaw surgery, my tongue doesn’t fit in the roof of my mouth, I have tmj/ tmd issues, just started working with a neck chiropractor (didn’t know my neck has been out) probably all the pillows I sleep on to prop myself up. Just started using a wedge pillow and like it. Good luck everyone finding solutions. Thanks for sharing. Thanks Dr Park for helping us get more understanding.

  22. My 17yo is day 4 post op from tonsillectomy.
    She was hospitalised for 4 days in Feb 15 and tested for everything under the sun until they realised she had mono. Her bloods indicated she had it sometime before that too, however she was asymptomatic. She had been a perfectly healthy, very active kid who was never sick. She had taken panadol maybe 5 times in her entire life up until then.
    Since then she has developed CFS and has missed so much school. She has had to drop out of so many activities she loved due to the insidious fatigue. This kid did everything from clay target shooting to horse riding, choir, debating, skiing, training for her pilots license to struggling to make it through a school day.
    She gets viral infections usually URTI symptoms every 2-3 weks since Feb 15. Some have been given names- adenovirus, influenza B, tonsillitis, but mostly they are general run of the mill community viruses. She spikes temps of 40 degrees plus, elevated HR, sore throat, congested and generally unwell in appearance. Mostly they put her out of action for 2-3 days before she returns to ‘normal’. She had another admission of 4 days in Dec 15.
    Last week she had violent vomiting, CRP of 150, WCC in the 40s and meningitis like symptoms…. Yet she recovered without event within 3 days. Two weeks before that she had her first ever bout of tonsillitis for which she was given IV steroids and Antis (ironic as we had already planned the elective tonsillectomy).
    Her final school exams are a school term away and we are hoping that the advice we have received that tonsillectomy may help is correct. It is horrible watching this poor kid who was a top student and very involved in her life become someone who can not even socialise with her friends due to fatigue and illness. How she has maintained a positive outlook is beyond me! Ill let you know how she gets on. (she has also taken part in a Murdoch Institute CFS research project).

  23. I suffered with EBV when I was a teenager an ever since had problems with my throat and unrefreshed sleep. During the last year or so however, the chronic sore throat episodes have increased and I seem to have a constant coated tongue, dry mouth, tonsil stones and fatigue. It’s having a massive impact on my life and if I do pick up a virus on top I feel terrible. Following my last viral tonsillitis, I seem to have sores in my nose which have yet to dissappear. It’s now been 8 weeks. Please help 😣

  24. Hi Doctor,
    I am a 52 year old male and I was diagnosed with EBV back in June and I hav had all the usual symptoms.In the last month I have experienced several bouts of waking up after 2-3 hours sleep gasping for breath.My GP diagnosed ap apnea and has referred me to an internist and and a new booodtest to check the state of the mono infection.
    My lymph glands have been swolen from day one and my sinuses also inflamed.In the early stages of the infection I went to the ER and the doctor prescribed a 10 day course of 30mg Dacortin-prednisone here in Spain-which I could not understand and did not take( the tablets are still in my first aid box!).
    Now having read your articles on this subject I realise the mistake I made in not taking the prescribed prednisone.Now I have the problem with apnea I would like to ask if it is too late to take the course of prednisone?
    Regards,
    John.