Symptoms of chronic tonsillitis

One of the most reliable signs of the disease is the presence of tonsillitis in the anamnesis. In this case, it is necessary to find out from the patient what kind of increase in body temperature accompanies the sore throat and for what period of time.

Sore throats with chronic tonsillitis can be pronounced (severe pain in the throat when swallowing, significant hyperemia of the mucous membrane of the pharynx, with purulent attributes on the tonsils according to the forms, febrile body temperature, etc.), but in adults, such classic symptoms of sore throat are often absent. In such cases, exacerbations of chronic tonsillitis occur without pronounced severity of all symptoms: the temperature corresponds to small subfebrile values (37.2-37.4 C), pain in the throat when swallowing is insignificant, a moderate deterioration in general health is observed. The duration of the disease is usually 3-4 days. Such a picture of sore throat is typical for patients with rheumatism. In other cases, the patient notes only a slight pain in the throat with a deterioration in health for several days. However, the unexpressed manifestation of exacerbations of chronic tonsillitis does not reduce the aggressiveness of the pathological process in relation to the occurrence of toxic-allergic complications. After such "soft" tonsillitis, the number of exacerbations of rheumatism increases several times, and repeated deformation of the mitral valve often occurs.

The clinical picture of chronic tonsillitis is characterized by the recurrence of sore throats, usually 2-3 times a year, often once every few years, and only 3-4% of patients do not have sore throats at all. Sore throats of other etiologies (not as an exacerbation of chronic tonsillitis) are characterized by the absence of their recurrence.

In chronic tonsillitis, moderate symptoms of general intoxication are observed, such as periodic or constant subfebrile body temperature, sweating, increased fatigue, including mental fatigue, sleep disturbances, moderate dizziness and headache, loss of appetite, etc.

Chronic tonsillitis often causes the development of other diseases or aggravates their course. Numerous studies conducted over the past decades confirm the connection between chronic tonsillitis and rheumatism, polyarthritis, acute and chronic glomerulonephritis, sepsis, systemic diseases, dysfunction of the pituitary gland and adrenal cortex, neurological diseases, acute and chronic diseases of the bronchopulmonary system, etc.

The main feature of the symptoms of chronic tonsillitis is the non-specificity of some of them. Thus, subjective symptoms largely coincide with those in various forms of chronic pharyngitis. According to their size, the palatine tonsils are classified into three degrees, but the size and appearance of the tonsils also do not reflect their true condition: there are tonsils of absolutely normal appearance and yet they may contain a source of chronic infection, causing various metatonsillar complications. Removal of such tonsils often confirms this position. And yet, in most cases of chronic tonsillitis, a number of subjective (from the anamnesis) and objective symptoms are revealed, which provide grounds for establishing a diagnosis of chronic tonsillitis and differentiating it into two clinical forms - compensated and decompensated chronic tonsillitis and, depending on this, determining the tactics and strategy of treating the patient.

In compensated chronic tonsillitis, some signs of chronic inflammation are revealed macroscopically, but this process is limited to the territory of the palatine tonsils, does not spread beyond its limits, does not manifest itself in anginal exacerbations and, especially, paratonsillar complications. This condition of the tonsils is due to the existing balance between local tissue immunity and the general reactivity of the body, on the one hand, and the inflammatory process occurring in the palatine tonsils. In decompensated chronic tonsillitis, local signs of chronic tonsillitis are usually clearly expressed, some of them are typical only for this form and are absent in compensated chronic tonsillitis, in this form, exacerbations often occur in the form of tonsillitis, peritonsillitis, paratonsillar abscesses, regional lymphadenitis, and in clinically advanced cases - metatonsillar complications at a distance (according to B.S. Preobrazhensky, non-anginal course of chronic tonsillitis occurs in only 2% of cases of this disease).

Subjective symptoms of chronic tonsillitis

Subjective symptoms of chronic tonsillitis are characterized by periodically occurring pain in the tonsils when swallowing and talking, tingling in them, burning, dryness, discomfort and a sensation of a foreign body in the throat. As a rule, these signs in compensated chronic tonsillitis are not accompanied by an increase in body temperature, but in some cases, especially in decompensated forms, a constant or periodically occurring subfebrile temperature may be observed. During this period, weakness, malaise, increased fatigue appear, which are often accompanied by aching pain in the joints and in the heart area. The appearance of subjective symptoms at a distance indicates the transition of the compensated form of chronic tonsillitis to the decompensated one. In other cases, patients feel a pronounced burning and tickling sensation in the throat, causing them to have attacks of severe coughing (irritation of the pharyngeal branches of the vagus nerve) - one of the symptoms of the lacunar form of chronic tonsillitis, during which caseous masses are released from the enlarged lacunae into the oral cavity. Patients often squeeze them out of the tonsils themselves using a finger or a teaspoon. The smell of these "purulent plugs" is extremely unpleasant; its putrid nature indicates the presence of fusospirocheleous microorganisms in the crypts of the palatine tonsils. A number of patients experience a symptom of reflex pain in the ear - tingling and "shooting" in it.

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Objective symptoms of chronic tonsillitis

Objective symptoms of chronic tonsillitis are revealed by endoscopic examination of the pharynx and external examination of the area of regional lymph nodes. In this case, inspection, palpation, a test with "dislocation" of the tonsil, a test with squeezing out caseous masses from the lacunae, probing of the lacunae, taking material for bacteriological examination, including aspiration puncture of the tonsil are used.

During examination, attention is primarily paid to the size of the palatine tonsils, the color of the mucous membrane, the condition of its surface and surrounding tissues. Objective signs of HT proper are determined no earlier than 3-4 weeks after the end of the exacerbation process or angina. According to the descriptions of B.S. Preobrazhensky (1963), in the follicular form of parenchymatous chronic tonsillitis, "yellowish bubbles" are found on the surface of the tonsils under the epithelium, indicating the degeneration of the follicles and their replacement with small cyst-like formations filled with "dead" leukocytes and dead microbial bodies. In the lacunar form, dilated outlet openings of the lacunae are determined, which contain caseous white masses. When pressing with a spatula on the lateral part of the anterior palatine arch and on the area of the upper pole of the tonsil, caseous masses or liquid pus are released from it, like minced meat from a meat grinder.

When examining the area of the palatine tonsils, it is often possible to detect a number of signs of chronic tonsillitis, reflecting the involvement of surrounding anatomical structures in the inflammatory process:

1. Guise's symptom [Guisez, 1920] - hyperemia of the anterior arches;
2. Zak's symptom [Zak V.N., 1933] - swelling of the mucous membrane above the upper pole of the palatine tonsils and the upper parts of the palatine arches;
3. Preobrazhensky's symptom [Preobrazhensky B.S., 1938] - arcuate infiltration and hyperemia of the upper halves of the arches and the intercostal angle.

In chronic tonsillitis, as a rule, regional lymphadenitis develops, determined by palpation behind the angle of the lower jaw and along the anterior edge of the sternocleidomastoid muscle. Lymph nodes may be painful upon palpation, and upon palpation of the retromandibular nodes, pain radiates to the corresponding ear.

Palpation and dislocation of the palatine tonsils are of great diagnostic importance. During digital palpation (there is also palpation with an instrument), the elasticity, compliance (softness) of the tonsil or, on the contrary, its density, rigidity, and parenchyma contents are assessed. In addition, digital palpation can determine the presence of a large pulsating arterial vessel in the tonsil parenchyma or in close proximity to its niche, which must be taken into account as a risk factor for bleeding during tonsillotomy and tonsillectomy. If, when pressing hard with a spatula on the lateral part of the anterior palatine arch, the tonsil does not protrude from its niche, and dense tissue is felt under the spatula, then this indicates the adhesion of the tonsil to the tissues of its bed, i.e. chronic sclerotic tonsillitis, as well as the difficulties of extirpation of the tonsil with its extracapsular removal.

Probing of crypts, carried out using a special curved button probe by G.G. Kulikovsky (with a handle or a separate one, inserted into a special holder that fixes the probe with a screw), allows one to determine the depth of crypts, their contents, the presence of strictures, etc.

Thus, the basis of the clinical picture of chronic tonsillitis is considered to be a symptom complex associated with the formation of a chronic infection focus in the palatine tonsils. This process has certain patterns of local development and spread in the body. The focus of chronic infection in the tonsils affects the work of all organs and functional systems, disrupting their vital activity, on the one hand, and on the other hand, it often becomes an etiological factor of a new, usually severe disease and in all cases aggravates any diseases occurring in the body.

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Classification of chronic tonsillitis

Many authors offer various options for classifying chronic tonsillitis. According to these classifications, the disease is mainly considered from the position of the degree of protection of the body from tonsillar intoxication, using the terms "compensated" and "decompensated" inflammatory infectious process in the tonsils in relation to the entire body. Based on previous classifications and new data, the classification of K.S. Preobrazhensky and V.T. Palchun was created, according to which clinical forms of the disease are differentiated and from modern scientific and practical positions, determining the treatment tactics.

In most cases, the patient has all the signs of chronic tonsillitis, characteristic of a certain form, but in some cases only a few or even one sign are detected. According to this classification, the diagnostic value is the assessment of one or another sign or signs of an infectious focus in the tonsils and in the general condition of the body.

There are two clinical forms of chronic tonsillitis: simple and toxic-allergic, of two degrees of severity.

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Simple form of chronic tonsillitis

It is characterized only by local symptoms and 96% of patients have a history of tonsillitis.

Local signs:

• liquid pus or caseous-purulent plugs in the lacunae of the tonsils (may have a smell);
• In adults, tonsils are often small and can be smooth or have a loose surface;
• persistent hyperemia of the edges of the palatine arches (Hieze's sign);
• swelling of the edges of the upper parts of the palatine arches (Zak's sign);
• ridge-shaped thickening of the edges of the anterior palatine arches (Preobrazhensky's sign);
• fusion and adhesions of the tonsils with the arches and triangular fold;
• enlargement of individual regional lymph nodes, sometimes painful upon palpation (in the absence of other foci of infection in the region).

Concomitant diseases include those that do not have a common infectious basis with chronic tonsillitis, the pathogenetic connection of features of general and local reactivity.

Treatment is conservative. The presence of purulent contents in the lacunae after 2-3 courses of treatment is an indication for tonsillectomy.

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Toxic-allergic form of the 1st degree

It is characterized by local signs of a simple form and general toxic-allergic reactions.

Signs:

• periodic episodes of subfebrile body temperature;
• episodes of weakness, fatigue, malaise;
• rapid fatigue, decreased performance, poor health;
• periodic joint pain;
• enlargement and pain upon palpation of regional lymph nodes (in the absence of other foci of infection);
• functional disorders of cardiac activity are inconstant and can manifest themselves under stress and at rest, during periods of exacerbation of chronic tonsillitis;
• Laboratory abnormalities may be intermittent and inconsistent.

Associated diseases are the same as in the simple form. They do not have a single infectious basis with chronic tonsillitis.

Treatment is conservative. Lack of improvement (pus in the lacunae, toxic-allergic reactions) after 1-2 courses of treatment is an indication for tonsillectomy.

Toxic-allergic form of the 2nd degree

It is characterized by local signs of a simple form and general toxic-allergic reactions.

Signs:

• periodic functional disorders of cardiac activity (the patient presents complaints, the disorders are recorded on the ECG);
• palpitations, heart rhythm disturbances;
• pain in the heart area or joints occurs both during tonsillitis and outside of exacerbation of chronic tonsillitis;
• subfebrile body temperature (may be prolonged);
• functional disorders of infectious origin in the functioning of the kidneys, heart, vascular system, joints, liver and other organs and systems, recorded clinically and using laboratory methods.

Associated diseases may be the same as in the simple form (not associated with infection).

Associated diseases have common infectious causes with chronic tonsillitis.

Local diseases:

• peritonsillar abscess;
• parapharyngitis.

Common diseases:

• acute and chronic (often with veiled symptoms) tonsillogenic sepsis;
• rheumatism:
• arthritis;
• acquired heart defects:
• infectious and allergic nature of diseases of the urinary system, joints and other organs and systems.

Treatment is surgical (tonsillectomy).

Pharyngoscopic signs occur secondarily: purulent contents released from the crypts onto the surface of the tonsil, being a strong irritant, cause local inflammation, so the edges of the palatine arches are hyperemic, infiltrated and edematous. For the same reason, chronic tonsillitis usually causes catarrhal or granular pharyngitis. Regional lymphadenitis in the form of enlarged lymph nodes at the angles of the lower jaw and along the sternocleidomastoid muscle also indicates an infection in the overlying areas, most often in the tonsils. Of course, in all these cases, the infection can come not only from the palatine tonsils, but also from diseased teeth, gums, pharynx, etc. In this regard, it is necessary to take into account all possible causes of pharyngoscopic signs of inflammation in the differential diagnosis.