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• Prerequisites and learning objectives
• Lesson
  • Content
    • 1 - Pathophysiology - General information
    • 2 - Rhinopharyngitis
      • 2.1 - Etiologies
      • 2.2 - Diagnosis
      • 2.3 - Treatment
      • 2.4 - Complications associated with rhinopharyngitis
      • 2.5 - Differential diagnosis
      • 2.6 - Hypertrophy of adenoid vegetations causing recurrent rhinopharyngitis
      • 2.7 - Other factors favoring nasopharyngeal infections
    • 3 - Angina
      • 3.1 - Etiology
      • 3.2 - Clinical diagnosis
      • 3.3 - Bacteriological diagnosis
      • 3.4 - Clinical forms
        • 3 . 4 . 1 - Acute catarrhal angina (or erythematous angina)
        • 3 . 4 . 2 - Angina with purulent exudate (or erythemato-pultaceous angina)
        • 3 . 4 . 3 - Pseudomembranous angina (or false-membrane angina)
        • 3 . 4 . 4 - Ulcerative and necrotic angina
        • 3 . 4 . 5 - Vesicular angina
        • 3 . 4 . 6 - Gangrenous, necrotizing angina
      • 3.5 - Treatment
      • 3.6 - Differential diagnosis of angina
    • 4 - Chronic tonsillitis
      • 4.1 - Chronic tonsillitis in children
      • 4.2 - Chronic tonsillitis in adults
    • 5 - Complications of tonsillar infection
      • 5.1 - Local complications
      • 5.2 - General complications
    • 6 - Tonsillectomy indications
      • 6.1 - Indications
      • 6.2 - Contraindications
  • Key points
  • Teachers version
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• Appendix
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4  -  Chronic tonsillitis

Chronic infection of the palatine tonsils exhibits different manifestations in children and adults.

4 . 1  -  Chronic tonsillitis in children

Chronic tonsillitis in children is secondary to a local immunological disturbance during the first few years of life and can be favored through inappropriate antibiotic treatments.

Chronic tonsillitis in children is clinically manifested by :

• recurrent angina, often associated with white exudates, which are prolonged, with significant adenopathies and long-lasting asthenia;
• persistence of these angina types:
  • inflammatory condition of the tonsils, hard, atrophic or sluggish, releasing a cloudy or purulent fluid when pressure is applied;
  • inflammatory biological syndrome: hyperleukocytosis and raised C-reactive protein (CRP) levels;
  • chronic cervical and sub-angulo-maxillary lymph nodes;
  • lack of efficiency of potential systemic antibiotic therapy.

The evolution is desperately chronic, resulting in height-weight development delay and school retardation through absenteeism, while promoting local and regional complications (nasal sinus area, otitic, and tracheobronchial) or general complications.

Differential diagnosis: chronic tonsillitis should not be confounded with a simple constitutional tonsil hypertrophy or reactive hyperplasia (infectious disease or allergic reactions). These hypertrophies have no functional impact, meaning that no therapeutic sanction is needed (except possibly in cases of breathing discomfort and sleep apnea caused by mechanical obstruction when the hypertrophy is marked).

Treatment of chronic tonsillitis:  tonsillectomy.

4 . 2  -  Chronic tonsillitis in adults

Chronic tonsillitis in adults is characterized by a significant scarring of the tonsils, which adds to the normal regression of the lymphoid tissue.

The symptomology, mainly local, is usually moderate, arising more easily in patients who are anxious, dystonic, and cancer phobic. Symptoms include intermittent unilateral dyphagia with otalgia, bad breath, fetid fragmented sputum, and tickly coughing.  There are no general signs of infection.

Upon examination, the tonsils are small, encrusted in the arcus palatini, with pockets filled with caseum, scar nodules felt on palpation, as well as yellowish cysts due to crypt occlusion.

Evolution is chronic, yet often benign. Search for and therapeutic management of gastro-esophageal reflux disease may improve evolution.

However, local (intra-amygdala abscesses or peritonsillar abscess) or general complications may occur, and it is standard practice to screen for chronic tonsillitis in the context of a check-up for kidney disease or infectious rheumatism.

Differential diagnosis :

• mainly chronic pharyngitis, where inflammation is widespread across the pharynx, especially in relation to a general disease (diabetes, gout, allergies, etc.), digestive disorder, mycosis (after prolonged antibiotic therapy, chemotherapy, etc.), or long-term use of atropinic agents (antihypertensive drugs, tranquilizers, etc.);
• pharyngeal paraesthesia, phobic manifestations relative to the pharyngeal area: sensation of a foreign body or having a "lump in one's throat" (globus hystericus) in a neurotic cancer phobic patient. Local examination is normal.

However, the examination must always be performed very carefully so as not to miss early-stage tonsil cancer, hidden in clefts or behind the arcus palatini. Palpation of the amygdala is an essential gesture.

The treatment consists of minor local means: gargling, surface spraying using a laser, radiofrequency therapy, and cryotherapy. Tonsillectomy is indicated in patients presenting complications.