Chronic tonsillitis often develops from recurrent episodes of acute tonsillitis. It can also occur after acute infectious diseases such as scarlet fever, measles, influenza, diphtheria, etc., or be accompanied by nasal sinus infections. The most common pathogenic bacteria are streptococci and staphylococci.

bubble_chart Etiology

In chronic tonsillitis, the epithelium in the crypts undergoes necrosis and sloughing off, leading to the accumulation of bacteria and inflammatory exudates. The crypts may develop small ulcers and scar formation, resulting in poor drainage, which creates a favorable environment for bacterial growth and reproduction, making the infection difficult to eliminate. Recurrent acute tonsillitis can further weaken the body's resistance or result in incomplete treatment, increasing the likelihood of progression to chronic tonsillitis. The exact pathogenesis of this condition remains unclear, but recent immunological perspectives suggest that autoallergy plays a significant role as a key mechanism in the development of chronic tonsillitis.

bubble_chart Pathological Changes

According to the pathological changes, it can be divided into three types.

1. Hyperplastic type: Commonly seen in children. The lymphoid tissue of the tonsils proliferates, with an increase in lymphoid follicles and connective tissue, leading to chronic congestion and hypertrophy of the tonsils.

2. Fibrous type: Commonly seen in adults. The lymphoid tissue of the tonsils atrophies, fibrous scar tissue proliferates in the stroma, the crypt openings are obstructed, and the tonsils become smaller and tougher.

3. Crypt type: The main lesions are deep within the tonsillar crypts, with lymphoid follicles showing chronic inflammation and lymphoid tissue becoming scarred. Due to obstruction of the crypt openings by scar tissue, drainage is impaired, resulting in significant enlargement of the crypts or the accumulation of large amounts of desquamated epithelium, bacteria, lymphocytes, and leukocytes forming purulent plugs. Because the condition is severe and prone to complications, it is also known as chronic septic tonsillitis.

Patients often have a history of sore throat, susceptibility to common cold, and acute tonsillitis attacks. Usually, there are few subjective symptoms, but there may be throat discomfort, a foreign body sensation, irritating cough, fetid mouth odor, or mild pain. In children with excessively hypertrophic tonsils, symptoms such as difficulty breathing, snoring, slurred speech, and slow eating are common. Due to frequent swallowing of inflammatory secretions, which irritate the gastrointestinal tract, or the absorption of bacteria and toxins from the crypts, systemic reactions may occur, leading to symptoms like indigestion, poor appetite, fatigue, weakness, emaciation, headache, and low-grade fever.

Examination reveals chronic congestion of the palatoglossal arch and tonsils, with the mucous membrane appearing dark red. The tonsils are often inflamed and adherent to the anterior and posterior arches; their surface may be smooth, uneven, or lobulated. Sometimes, linear scars, enlarged crypt openings, and caseous plugs or yellowish-white spots under the mucous membrane can be seen. When the tonsils are pressed with a tongue depressor on the outer side of the palatoglossal arch, secretions may exude from the crypt openings. Enlarged lymph nodes are often palpable below the mandibular angle.

bubble_chart Diagnosis

The diagnosis should be based on medical history combined with the aforementioned symptoms and signs, rather than solely on the size of the tonsils. As age increases, the tonsils gradually shrink. Chronic tonsillitis is classified into three types: hypertrophic, fibrous, and cryptic. Therefore, the size of the tonsils does not indicate the degree of inflammation, and diagnosis should not be made based on this alone.

Currently, surgical removal of the tonsils remains the primary treatment method. However, it is essential to carefully assess the indications to avoid unnecessary removal, which could lead to weakened respiratory tract immunity against infections and impaired immune surveillance. Moreover, surgery is not entirely risk-free and may sometimes result in complications such as dry throat, pain, and discomfort. Surgery should only be considered when the inflammation has become irreversible. From an immunological perspective, chronic tonsillitis is considered an "infection-allergic condition," often caused by streptococcal infections. Therefore, treatment should not be limited to local medication, systemic antibiotics, or surgical removal alone. Immunotherapy and anti-allergic measures should also be incorporated, including the use of bacterial products with desensitizing effects (such as streptococcal allergens and vaccines for desensitization) and various immune-boosting medications, such as injections of placental globulin or transfer factors.

bubble_chart Complications

Chronic tonsillitis not only can cause infections in adjacent organs due to the spread of inflammation, such as otitis media, sinusitis, laryngitis, tracheitis, and bronchitis, but more importantly, it serves as one of the common infectious foci in the human body, closely related to conditions like acute nephritis, wind-dampness arthritis, wind-dampness fever, heart disease, and chronic low-grade fever. There is currently no specific diagnostic method for identifying focal tonsillitis. Clinically, it is often believed that complications arise due to allergic reactions triggered by bacteria and toxins in the tonsillar crypts. Such complications typically occur 1–3 months after an episode of tonsillitis, and the progression or exacerbation of the condition is often linked to recurrent tonsillitis. Focal tonsillitis is predominantly characterized by fibrotic changes, often accompanied by retained secretions in the crypts and swollen submandibular lymph nodes. Diagnosis should be based on a comprehensive analysis of medical history, local and systemic examinations, and sometimes post-tonsillectomy observations. Additionally, the tonsillar provocation test, dynamic monitoring of serum anti-streptolysin O (ASO), anti-streptokinase, and anti-hyaluronidase titers can provide valuable diagnostic references.

This disease should be differentiated from the following conditions.

1. **Keratosis of tonsil** This condition involves excessive keratinization of the epithelial cells at the tonsillar crypt openings, presenting as yellowish-white, horn-like, or pointed granular keratinized masses. These lesions are hard to the touch, firmly rooted, and cannot be wiped away. Patients may have no obvious symptoms or may experience throat discomfort or a foreign body sensation. The condition can also occur simultaneously in the posterior pharyngeal wall, lateral pharyngeal bands, and tongue base. It has a prolonged course and mostly affects individuals under 30 years of age. The **disease cause** remains unclear, and generally, no specific treatment is required.

2. **Tonsillar tumor** Rapid unilateral enlargement of the tonsil or tonsillar swelling with **ulceration** should raise suspicion for a tumor. For example, a **fleshy tumor** of the tonsil may initially be confined beneath the tonsillar **mucosa**, with a smooth surface. The main symptom is rapid unilateral tonsillar enlargement, often accompanied by cervical lymph node metastasis, and it is more common in young adults. A biopsy is necessary for definitive diagnosis.

3. **Symptomatic hypertrophy of the tonsil** This is a local manifestation of certain systemic diseases. For instance, in leukemia, the tonsils may exhibit symmetrical enlargement. Sometimes, pharyngeal symptoms may be the initial presentation. Diagnosis is based on peripheral blood tests and bone marrow examination.