Chronic Tonsillitis

Persistent low grade inflammation of the tonsils with continuous rather than episodic symptoms, distinguished from recurrent acute tonsillitis by the absence of symptom free intervals.

Pathophysiology

The tonsillar crypts, which number 10 to 30 per tonsil and which extend deep into the parenchyma, become chronically colonised. Three processes maintain the condition:

• Crypt obstruction by debris, desquamated epithelium and bacteria, forming an anaerobic environment.
• Biofilm formation on the crypt epithelium, in which organisms exist in a protected extracellular polymeric matrix that resists both antibiotic penetration and host immune clearance. Biofilms are demonstrable in the great majority of chronically inflamed tonsils and explain the failure of repeated antibiotic courses.
• Fibrosis of the tonsillar capsule and parenchyma, with scarring that obliterates crypt drainage and perpetuates the cycle.

Tonsilloliths

Concretions formed within the crypts from trapped debris, food, desquamated epithelium and bacteria, which calcify over time with deposits of calcium, phosphorus, magnesium and ammonium. Anaerobic organisms within them produce volatile sulphur compounds, which are the cause of the characteristic halitosis. They are a specific and frequently underestimated cause of distress, since patients are commonly told nothing is wrong.

Microbiology

Polymicrobial, with anaerobes predominating: Fusobacterium, Prevotella, Porphyromonas, Peptostreptococcus and Actinomyces. Aerobes include Staphylococcus aureus, Haemophilus influenzae, Moraxella catarrhalis and streptococci. Beta lactamase production by these organisms inactivates penicillin within the crypt environment.

• Persistent or near continuous sore throat, typically low grade and described as a chronic irritation or a lump sensation rather than the severe pain of acute infection.
• Halitosis, which is often the dominant complaint and which causes considerable social and psychological distress. Patients frequently report that partners or colleagues have commented.
• Tonsilloliths, which patients describe as small white or yellow foul smelling stones that they cough up or dig out, with an intensely unpleasant taste and smell.
• Foreign body sensation in the throat.
• Odynophagia that is mild but constant.
• Referred otalgia.
• Chronic cough and throat clearing.
• Malaise and fatigue.
• Absence of fever and systemic upset, which distinguishes this from acute disease.

Examination

• Tonsils that may be small and fibrotic rather than enlarged, which is an important point since patients and clinicians often assume chronic tonsillitis requires large tonsils.
• Persistent erythema of the anterior pillars, which is a characteristic sign.
• Cryptic debris, cheesy material or visible tonsilloliths within the crypts, which can be expressed with gentle pressure using a tongue depressor.
• Irregular, scarred tonsillar surface with prominent crypts.
• Persistent tender cervical lymphadenopathy, typically at the jugulodigastric node.
• Halitosis detectable on examination.

Red flags

• Unilateral tonsillar enlargement, ulceration, induration or fixation in an adult, which requires biopsy for squamous cell carcinoma or lymphoma. A tonsil that is asymmetrically enlarged and firm is malignant until proven otherwise, particularly in a smoker or with a neck mass.
• A neck mass, particularly a cystic level II node in an adult, which may be a metastasis from human papillomavirus related oropharyngeal carcinoma with an occult tonsillar primary.
• Weight loss, night sweats and generalised lymphadenopathy.
• Persistent ulceration, which requires biopsy for tuberculosis, syphilis, fungal infection and malignancy.

Largely clinical, with investigation directed at excluding malignancy and identifying alternative causes of the symptoms.

• Full examination of the oral cavity, oropharynx, nasopharynx and larynx, including flexible nasoendoscopy in adults, which is essential to exclude malignancy and to assess the tongue base and hypopharynx.
• Neck palpation for lymphadenopathy.
• Throat swab culture, which typically grows mixed flora and is of limited diagnostic value but may guide antibiotic choice.
• Full blood count.
• Human immunodeficiency virus testing where clinically indicated.
• Computed tomography or magnetic resonance imaging of the neck where malignancy or deep extension is suspected, or where there is unilateral disease.
• Ultrasound guided fine needle aspiration of any suspicious neck node, with p16 immunohistochemistry and human papillomavirus testing on the specimen.
• Tonsillectomy with histology for any unilateral or suspicious tonsil, which is both diagnostic and therapeutic.
• Assessment for other causes of halitosis before attributing it to the tonsils: dental caries and periodontal disease, which are the commonest cause overall; tongue coating; xerostomia; gastro oesophageal reflux; sinonasal disease with postnasal drip; and systemic causes including ketosis, uraemia and hepatic failure. A dental assessment should generally precede tonsillectomy performed solely for halitosis.

Differential diagnosis

• Recurrent acute tonsillitis, with symptom free intervals.
• Chronic pharyngitis from reflux, smoking or allergy, in which the tonsils themselves are normal.
• Laryngopharyngeal reflux, which produces throat clearing, globus and a chronic sore throat with posterior laryngeal changes on endoscopy.
• Globus pharyngeus.
• Tonsillar malignancy.
• Tuberculosis and syphilis of the tonsil.
• Actinomycosis, with sulphur granules.

Conservative measures, which resolve symptoms in many patients with tonsilloliths

• Regular salt water or alkaline gargles.
• Mechanical removal of tonsilloliths by the patient using a cotton bud, an oral irrigator on a low setting, or gentle pressure. Warn against sharp instruments, which cause bleeding and infection.
• Oral irrigation with a water flosser directed at the crypts, which is effective and is the single most useful self management measure for tonsilloliths.
• Meticulous oral and dental hygiene, including tongue cleaning, which addresses the commonest coexisting cause of halitosis.
• Adequate hydration and management of xerostomia.
• Antiseptic mouthwashes containing chlorhexidine or cetylpyridinium, and preparations containing zinc which neutralise volatile sulphur compounds.
• Smoking cessation.
• Treat reflux where present with lifestyle modification and a proton pump inhibitor such as omeprazole 20 mg twice daily for 8 to 12 weeks.

Antibiotics

• Prolonged courses have limited efficacy because of biofilm and fibrosis, and repeated courses drive resistance without curing the condition. Set this expectation with the patient.
• Where a trial is justified, use an agent active against anaerobes and stable to beta lactamase: co amoxiclav 625 mg three times daily for 10 to 14 days, or clindamycin 300 mg four times daily for 10 days, which achieves good tonsillar tissue concentrations and covers anaerobes and biofilm associated organisms.
• Metronidazole 400 mg three times daily may be added for anaerobic cover and for halitosis specifically.
• A single trial is reasonable; repeated failed courses indicate the need for surgery or a reconsideration of the diagnosis.

Tonsillectomy

Indications:

• Chronic symptoms persisting beyond 3 to 6 months despite conservative measures, with a demonstrable effect on quality of life.
• Recurrent troublesome tonsilloliths with halitosis, after dental causes have been excluded and addressed.
• Persistent unilateral enlargement or any suspicion of malignancy.
• Coexisting recurrent acute episodes meeting frequency criteria.
• Chronic tonsillitis as a focus of infection in specific circumstances, such as before immunosuppression or transplantation, or in immunoglobulin A nephropathy and psoriasis where tonsillectomy has been reported to improve disease in selected patients.

Technique and postoperative care are as for recurrent tonsillitis. Cold steel dissection with careful haemostasis is standard. Intracapsular techniques are less suitable here, since residual crypt bearing tissue may perpetuate symptoms.

Alternatives to tonsillectomy for tonsilloliths

• Laser cryptolysis using carbon dioxide or diode laser, performed under local anaesthesia in the clinic, which flattens and ablates the crypts. It is effective in a substantial proportion, avoids general anaesthesia and the risks of tonsillectomy, and may be repeated. It is not suitable where malignancy is a consideration, since no tissue is obtained for histology.
• Coblation cryptolysis, similarly performed under local or general anaesthesia.
• These are reasonable options for the patient whose sole complaint is tonsilloliths and halitosis and who wishes to avoid tonsillectomy.

Counselling

• Explain the mechanism of tonsilloliths and halitosis clearly, since patients are frequently distressed and have often been dismissed.
• Explain that tonsillectomy reliably eliminates tonsilloliths and the associated halitosis, but does not address dental or gastric causes, and that halitosis from those sources will persist. This distinction must be made before surgery.
• Discuss the pain, recovery time and haemorrhage risk honestly, particularly in adults where recovery is longer and more painful than in children.

Follow up

Review histology in all adult specimens. Review at 6 weeks where symptoms were multifactorial, to determine whether residual halitosis or throat symptoms require dental, gastroenterological or laryngological assessment.