Chronic tonsillitis refers to a chronic inflammation of the tonsils, often resulting from recurrent episodes of acute tonsillitis or due to poor drainage of the tonsillar crypts, which facilitates bacterial and viral colonization and infection.
Etiology
The primary pathogens associated with this condition are streptococci and staphylococci. Recurrent acute tonsillitis can cause epithelial necrosis within the crypts, leading to the accumulation of bacteria and inflammatory exudates. Impaired crypt drainage facilitates the development and progression of the condition. It can also occur secondary to infections such as scarlet fever, diphtheria, influenza, measles, or infections of the nasal passages and sinuses. The specific pathogenesis of chronic tonsillitis remains unclear, although recent research suggests that it may be related to autoimmune mechanisms.
Pathology
Hypertrophic Type
Repeated inflammatory stimulation leads to lymphoid and connective tissue hyperplasia. The tonsils become hypertrophic, soft in texture, and protrude beyond the palatine arches.
Fibrotic Type
Lymphoid tissue and follicles undergo degeneration and atrophy, and are replaced by extensive fibrous tissue. As scarring contracts, the tonsils become smaller, harder, and often adhere to the palatine arches and surrounding tissues. This type is most often associated with focus infections.
Cryptic Type
The crypts of the tonsils accumulate large amounts of desquamated epithelial cells, lymphocytes, leukocytes, and bacteria, forming tonsillar plugs. In some cases, scar tissue at the crypt openings results in the retention of this material, leading to the formation of plugs or cysts, which act as focal points of infection.
Clinical Manifestations
Symptoms often include a history of recurrent sore throat, susceptibility to colds, and episodes of acute tonsillitis. Between episodes, symptoms are usually minimal, but some individuals may experience throat dryness, itching, a foreign body sensation, or mild cough. Halitosis may occur due to the retention of caseous material rich in anaerobic bacteria within the tonsillar crypts. In children, excessive tonsillar hypertrophy may result in breathing difficulty, snoring during sleep, or swallowing and speech resonance disturbances. The swallowing of tonsillar plugs or the absorption of bacterial toxins from the crypts may cause systemic symptoms such as indigestion, headaches, fatigue, and low-grade fever.
Examinations
Chronic tonsillitis typically presents with chronic congestion of the tonsils and palatoglossal arch. The mucosa appears dark red, and the tonsillar crypts occasionally exude yellow or white caseous material when pressure is applied to the palatoglossal arch using a tongue depressor. The size of the tonsils varies. In adults, the tonsils are often reduced in size but exhibit scarring, an irregular surface, and adhesion to surrounding tissues. Submandibular lymph node enlargement is commonly observed.
Diagnosis and Differential Diagnosis
Diagnosis should be based on the patient's medical history and local examination findings. A history of recurrent acute episodes is a key diagnostic criterion. Tonsil size does not reflect the severity of inflammation and should not serve as the sole diagnostic indicator. Differential diagnosis is necessary to distinguish chronic tonsillitis from the following conditions:
Physiological Tonsillar Hypertrophy
This condition is common in children and adolescents and typically presents without symptoms. The tonsils are smooth, pale in color, with clean crypt openings devoid of secretions or retention, and are soft to the touch. There is no history of recurrent inflammation.
Tonsillar Keratosis
This condition may be misdiagnosed as chronic tonsillitis. It results from excessive keratinization of the crypt epithelium, which produces white, sharp, sand-like granules. These granules are hard, firmly attached, and difficult to remove. Forceful removal often leaves bleeding wounds. Similar keratin deposits may also appear on the posterior pharyngeal wall or the base of the tongue.
Tonsillar Tumors
Rapid enlargement of one tonsil or tonsillar swelling with ulceration, often accompanied by ipsilateral cervical lymph node enlargement, raises the possibility of a tumor and requires biopsy for confirmation.
Complications
Chronic tonsillitis can act as a focal infection when triggered by factors such as exposure to cold or damp conditions, reduced immunity, endocrine imbalances, autonomic dysfunction, or poor living and working environments. Such focal infections may lead to hypersensitivity reactions and systemic complications, including rheumatic arthritis, rheumatic fever, heart disease, IgA nephropathy, psoriasis, ankylosing spondylitis, and unexplained prolonged low-grade fever (e.g., periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis syndrome, also known as PFAPA syndrome).
Chronic tonsillitis is considered one of the sources of systemic infection. However, no objective or definitive method currently links focal infection with systemic diseases. The following aspects should be considered when evaluating the condition:
Medical History
Patients with systemic complications due to tonsillitis often have a history of recurrent acute episodes. Focal infection often manifests during acute exacerbations, such as in nephritis patients, who may show significant abnormalities in urine following tonsillar inflammation.
Laboratory Tests
Diagnostic evaluations such as erythrocyte sedimentation rate, anti-streptolysin O titers, serum mucoprotein levels, and electrocardiographic assessments can aid in identifying focal infection cases, as abnormalities are commonly observed in such patients.
Treatment
Non-Surgical Therapy
Treatment should not be limited to antibiotics but should also incorporate immunotherapy or measures against hypersensitivity. This may include the use of desensitizing bacterial products, such as streptococcal allergens or vaccines.
Local therapies, such as the application of topical medication, crypt irrigation, and laser treatments, have been attempted but show limited long-term efficacy.
Physical exercise can help strengthen the body and enhance disease resistance.
Surgical Therapy
In clinical practice, low-temperature plasma knife tonsillectomy is commonly employed.