: Differential diagnosis of swolen tonsils with exudates What can be the cause of painless, swollen tonsils with white spots and streaks (exudates) on them? For example, in the example picture below, what might the differential

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In the picture you provided, the tonsils are enlarged and they appear to be cryptic (that is, they have little "caves" where food and bacteria can get trapped and grow.) Cryptic tonsils are common, painless, a common cause of bad breath, and a source of "tonsilliths/tonsilloliths" or tonsil stones.

Below is a picture of a tonsils with tonsilliths.

Exudates are whitish material that appear on tonsils which are inflammed. The cause can be viral or bacterial. Sometimes the exudates are so typical of one or the other that a fairly accurate diagnosis can be made just by looking at the throat. For example, Infectious Mononucleosis is characterized by enlarged tonsils (sometimes so enlarged that they meet in the middle, called "kissing tonsils") and a membraneous-looking exudate, as in the picture below.

Tonsillar ulcers usually occur with viral infections. They look like craters, usually surrounded with redness.

Strep is the most common bacterial infection of the throat. Strep throat can look like anything or even nothing, so I won't include a picture, because the appearance of the throat is usually useless for its diagnosis. Exudates of some kind are common but not necessary. Strep throat is treated with an antibiotic, as is diptheria and gonococcus.

Diptheria is a very serious infection where the tonsild are covered by a membrane somewhat similar to Infectious Mononucleosis, but usually worse. A vaccination program can largely eliminate diptheria except in cases where immunity has worn off or has never "taken".

Candidiasis is a yeast infection common in children, when it is called "thrush". It is treated with antifungals. The exudates are more diffuse, appearing on the uvula, the palate, and sometimes the tongue as well.

There are many viruses that can cause exudates, and antibiotics don't help when a virus is the cause. The most common causes of sore throat with exudates is a virus, not all of which are listed.

It is important to know the cause of an exudate for two reasons: contagiousness (how likely someone you come into contact with can become infected) and other organ systems which may become involved.

Both strep and Infectious Mononucleosis can be diagnosed on an office visit (perhaps two if the first test is equivocal.) Strep is painful; Infectious Mononucleosis can be painful or not, is common in young adults, and is easily spread.

When you see a throat like that pictured in the question, the safest and smartest thing to do is to be seen by your doctor, so that you get treated if needed, and so that you don't unknowingly spread an infection. The doctor can advise you on the precautions necessary and what to look for that means the infection is getting worse.

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