Chronic Tonsillitis: Clinical Guidelines

List of Abbreviations

ASLO – antistreptolysin O

GAS – group A beta-hemolytic streptococcus

ICD-10 – International Classification of Diseases 10th Revision

NSAIDs – non-steroidal anti-inflammatory and antirheumatic drugs

RF – rheumatoid factor

CRP – C-reactive protein

TE – Tonsillectomy

CT – chronic tonsillitis

Terms and Definitions

Chronic tonsillitis (CT) is an infectious-allergic systemic disease with local manifestations in the form of a persistent inflammatory reaction of the palatine tonsils, morphologically expressed by alteration, exudation, and proliferation

Tonsillogenic diseases (diseases associated with chronic tonsillitis) are diseases of internal organs and systems pathogenetically linked to chronic tonsillitis

Tonsillogenic complications are conditions developed as a result of the unfavorable course of tonsillitis

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Chronic tonsillitis is an infectious-allergic systemic disease with local manifestations in the form of a persistent inflammatory reaction of the palatine tonsils, morphologically expressed by alteration, exudation, and proliferation [1; 2; 3].

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

Chronic tonsillitis is considered a polyetiological disease. Microbial associations of streptococci (with a leading role assigned to group A β-hemolytic streptococcus – S. pyogenes), staphylococci (S. aureus), non-fermenting bacteria, and Candida fungi are most frequently detected in cultures from the tonsillar mucosa in patients [1; 4; 5]. Data are cited on the role of viral (adenovirus, Epstein-Barr virus, cytomegalovirus), persistent mycoplasmal, and chlamydial infections [6; 7]. The role of anaerobes is also discussed [8].

S. pyogenes are microorganisms represented by Gram-positive cocci with a typical streptococcal arrangement—in chains, producing complete erythrocyte lysis (beta-hemolysis) on blood agar and belonging to serological group A in F. Lancefield's streptococcal antigen classification. Pyogenic streptococcus possesses significant resistance to physical and chemical environmental factors. The only natural reservoir of pyogenic streptococcus in the macroorganism is the distal parts of the crypts of the palatine tonsils.

The pathogenesis of pyogenic streptococcal infections is associated with the activation of these microorganisms in the deep parts of the crypts of the palatine tonsils, followed by their invasion into the lymphoid tissue structures of the tonsils due to the presence of a large amount of extracellular enzymes: streptokinase, which catalyzes the conversion of plasminogen into the proteolytic enzyme plasmin; hyaluronidase, which breaks down hyaluronic acid, the main component of connective tissue; streptodornase (DNase), which destroys the genome elements of connective tissue cells, and others. The production of membrane-damaging O- and S-streptolysins specific to this pathogen leads to systemic intoxication and cardiotoxicity, which is explained by the suppression of energy processes in myocardial cell mitochondria under the activity of O-streptolysin. The toxin also exhibits hemolytic activity and immunogenic properties. The action of S-streptolysin together with the anti-chemotactic factor (C5a peptidase) is associated with the suppression of phagocyte activity and the destruction of cell mitochondrial membranes in the lesion focus. The specificity of clinical symptoms of palatine tonsil involvement is primarily due to the action of these specific pathogenicity factors.

In addition, a feature of the cell wall of pyogenic streptococcus is the presence of a large number of surface protein structures and, in particular, M-protein, which is an important adhesin of these microorganisms. M-protein provides binding to collagen, fibronectin, as well as blood serum proteins—fibrinogen, complement system components, and other elements of various organs and systems, causing the activation of the initial phase of metatonsillar complication development. It is the presence of M-protein that accounts for the ability of pyogenic streptococcus to penetrate inside epithelial cells with the development of the internalization phenomenon. In addition, pyogenic streptococcus has a hyaluronic acid capsule that protects it from immune surveillance organs and acts as an anti-phagocytic factor.

S. pyogenes also possesses and synthesizes a large number of substances that have superantigen properties, cause mitogenic activity, and lead to polyclonal proliferation of T-lymphocytes. Streptococcal superantigens include pyogenic exotoxins (SPE A, SPE B, SPE C, SPE D), the mitogenic factor SPE F, and presumably typespecific M-proteins. Pyogenic toxin A (Spe A), the gene for which is localized on a temperate bacteriophage, is associated with the most severe forms of streptococcal infection. The gene encoding this toxin is detected in half of the cases of scarlet fever and rheumatic fever. The pyogenic toxin B gene is localized in the chromosomal DNA of the cell and represents a cysteine protease capable of cleaving fibronectin in the macroorganism. Patients with invasive forms of streptococcal infection (cellulitis, pneumonia, necrotizing fasciitis) show elevated levels of antibodies to pyogenic exotoxin B [39].

It has now been proven that streptococci can not only attach to host cells but also penetrate them. Thus, A. Osterlund, studying the palatine tonsils of children with recurrent tonsillitis, identified intracellular streptococci, which may be one of the reasons for therapeutic failures in patients with chronic tonsillar pathology [40].

It should also be noted that β-hemolytic streptococcus persists in the mucosal structure of the crypts of the palatine tonsils not as planktonic cultures, but in the form of pathological biofilms, which provide not only protection against exogenous environmental factors, but also resistance to various therapeutic intervention methods [41].

Several factors associated with pyogenic streptococcus take part in the development of the phased clinical picture of tonsillitis: 1) the toxic factor, which causes the pathological effect of streptolysins on the cardiovascular, nervous, and endocrine systems, manifested by general intoxication, fever, etc.; 2) the septic factor, which is associated with the action of beta-hemolytic streptococcus pathogenicity enzymes, resulting in a local inflammatory reaction within the palatine tonsil structures and, subsequently, invasion of microorganisms deep into the tissues with the possibility of further generalization of the process, most often via hematogenous routes, up to the development of tonsillogenic sepsis, marked lymph node reaction, etc.; 3) the allergic factor (a complex of surface substances of pyogenic streptococcus), which causes sensitization of the macroorganism to beta-hemolytic streptococcus and antigens of destroyed host tissues, subsequently leading to the development of glomerulonephritis, myocarditis, etc. [39].

In the pathogenesis of chronic tonsillitis, interrelated processes of forming a chronic inflammatory focus in the palatine tonsils and host reactions in the form of tonsillogenic disorders in distant organs and systems, along with changes in the functioning of the macroorganism as a whole, are of significance. The chronic inflammatory process is the result of a prolonged interaction between the infectious agent and the macroorganism under altered general reactivity and insufficiently developed immunity. Contributing factors include the anatomical and topographical features of the palatine tonsils: narrow, repeatedly branching crypts or lacunae, entrapment between the palatoglossal and palatopharyngeal arches, and a high position of the upper pole. Pathological changes in the receptors of the palatine tonsils during chronic inflammation are often reversible [1]. They serve as a source of pathological impulses, leading to dysfunctions of various organs and alterations in the reactivity of the organism as a whole. The adverse effect on tonsillar tissue trophism exacerbates existing functional and structural disorders.

In the development of chronic inflammation of the tonsils, an important role is assigned to the functional insufficiency of mononuclear cells—lymphocytes and, especially, macrophages, which leads to incomplete phagocytosis, intracellular persistence of pathogenic microorganisms (predominantly in macrophages), and the development of opportunistic infections [2]. It is suggested that the primary link in the pathogenesis of chronic tonsillitis is an immunodeficient state of the body [9]. The active functioning of the tonsils contributes to their hypertrophy, enlargement of follicles in the parenchyma, and deterioration of the drainage function of the lacunae [10; 11].

Chronic focal infection in the palatine tonsils is accompanied by multidirectional changes in the synthesis of major proinflammatory cytokines [12]. Antigen-antibody immune complexes formed in the tonsillar tissue, possessing chemotactic activity, increase the proteolytic capacity of macrophage enzymes, leading to the lysis of tonsillar tissue and denaturation of tissue proteins, which acquire antigenic properties. The entry of autoantigens into the bloodstream causes the formation of autoantibodies that, by fixing onto cells, damage them. The palatine tonsils become a site of "permanent" delayed-type sensitization to the antigens of microorganisms most commonly vegetating in the lacunae [1; 13]. General nonspecific sensitization exacerbates the course of chronic tonsillitis. At the same time, it is noted that autoantibody formation is a physiological process with respect to altered body cells, but when the number of antibodies increases significantly, autoallergy becomes a pathological process [14].

The observed "familial" pattern of chronic tonsillitis is associated with a combination of the child's hereditary characteristics and the influence of similar environmental conditions [15]. Phenotyping for HLA antigens has made it possible to identify a genetically determined risk group and predict the course of chronic tonsillitis [9; 10]. A regularity in the development of chronic tonsillitis down the maternal line and a predisposition to the disease in probands with blood groups O(I) and A(II) has been established [16]. Among endogenous factors, impaired nasal breathing due to a deviated nasal septum, adenoids, chronic rhinitis, chronic inflammatory processes in adjacent areas—adenoiditis, rhinosinusitis, inflammatory diseases of the teeth and gums—as well as autonomic dysfunction and allergy are of significance [8; 17].

Many exogenous factors contribute to the development of the disease—general and local hypothermia, irrational nutrition, in particular, a lack of B vitamins, unfavorable working and living conditions, and occupational and domestic air pollution.

1.3 Epidemiology of the Disease or Condition

Chronic tonsillitis is widespread among the population, accounting for 5–6% to 37% in adults and 15% to 63% in children [10; 11; 13; 18; 19]. A correlation has been established between the incidence rates of chronic tonsillitis and anthropogenic load factors, specifically the atmospheric concentration of carbon monoxide, hydrogen sulfide, and phenol [20].

The incidence of chronic tonsillitis increases with age: from 2 to 3 years it is 1–2%, in preschool age—5%, in older children—7.9–14.5%, and at 18–20 years—25–30% [21]. Among frequently ill children, chronic tonsillitis accounts for 43% [18]. Chronic tonsillitis is detected 1.5–2 times more often in girls than in boys [21]. The healthcare-seeking rate for chronic tonsillitis is twice as high in women as in men [22].

1.4 Features of Coding the Disease or Condition

J31.1 – Chronic nasopharyngitis

J35.0 – Chronic tonsillitis (indicated when chronic nonspecific inflammation has a typical localization in the area of the palatine tonsils)

J35.8 – Other chronic diseases of tonsils and adenoids (indicated for atypical localization of chronic nonspecific inflammation in the area of the lingual, tubal, and pharyngeal tonsils. Enlargement of the pharyngeal tonsil—adenoids—is often accompanied by its chronic inflammation—adenoiditis).

J35.9 – Chronic disease of tonsils and adenoids, unspecified

1.5 Classification of the disease or condition

Currently, 2 clinical classifications of chronic tonsillitis are used in Russia.

The most widely used classification was proposed by Academician I.B. Soldatov, which provides for two forms of chronic tonsillitis: compensated and decompensated [1].

In the compensated form, the patient has visually detectable local signs of chronic tonsillitis, but clinical symptoms are indistinct, mild, and may even be absent.

The decompensated form of chronic tonsillitis is characterized, along with the presence of local signs of chronic tonsillitis, by signs of conditions and/or diseases pathogenetically related to chronic tonsillitis, which manifest as various types of decompensation. The type of decompensation is indicated in the full clinical diagnosis and is essential in determining the treatment of a patient with chronic tonsillitis.

The classification of chronic tonsillitis by Academician B.S. Preobrazhensky and Corresponding Member of the RAS V.T. Palchun [23] distinguishes two forms of the disease: simple and toxico-allergic grade I (TAF I) and grade II (TAF II). Treatment tactics also depend on the form of chronic tonsillitis.

1.6 Clinical presentation of the disease or condition

The clinical picture of chronic tonsillitis is caused by ongoing (permanent) chronic inflammation of the tonsils (predominantly palatine), as a result of which morphological changes are formed in the tonsils themselves, surrounding tissues, and regional lymph nodes; moreover, acute tonsillitis pathogenetically related (syn.: associated) to this process, as well as functional and organic changes in other organs and systems, may occur.

There are 5 groups of local signs of chronic tonsillitis [1]:

1. hyperemia and ridge-like thickening of the edges of the palatine arches (Guisez, V.N. Zak, and B.S. Preobrazhensky signs);

2. scar adhesions between the tonsils and the palatine arches;

3. looser or scar-altered and indurated tonsils;

4. caseous-necrotic plugs or liquid pus in the tonsillar lacunae;

5. enlargement of regional lymph nodes.

Guisez sign – hyperemia of the edges of the palatoglossal (anterior) arches

V.N. Zak sign – edema in the area of the junction angle of the palatoglossal (anterior) and palatopharyngeal (posterior) arches.

B.S. Preobrazhensky sign – ridge-like thickening (hyperplasia and infiltration) of the edges of the upper parts of the palatoglossal (anterior) and palatopharyngeal (posterior) arches.

To clarify the clinical picture of chronic tonsillitis and select treatment tactics, a detailed diagnosis is made using one of two clinical classifications.

The classification proposed by Academician I.B. Soldatov provides for two forms of chronic tonsillitis: compensated and decompensated [1].

In the compensated form, the patient has visually detectable local signs of chronic tonsillitis, but clinical symptoms are indistinct, mild, and may even be absent.

The decompensated form of chronic tonsillitis is characterized, along with the presence of local signs of chronic tonsillitis, by signs of conditions and/or diseases pathogenetically related to chronic tonsillitis, which manifest as various types of decompensation.

The following types of decompensation of chronic tonsillitis are distinguished:

1. recurrent sore throats (tonsillitis);

2. paratonsillitis and peritonsillar abscess;

3. tonsillogenic intoxication in the form of prolonged low-grade fever, prolonged malaise, and decreased work capacity, not having another justified cause;

4. tonsillogenic functional disorders of internal organs;

5. diseases of individual organs and systems pathogenetically related to chronic tonsillitis (synonyms: tonsillogenic, "metatonsillar", "associated" with chronic tonsillitis).

When establishing the form of chronic tonsillitis (compensated or decompensated), recent anamnesis data over the past three years should be taken into account.

According to the clinical classification of Academician B.S. Preobrazhensky and Corresponding Member of the RAS V.T. Palchun [23], two forms of chronic tonsillitis are also distinguished: simple and toxico-allergic grade I (TAF I) and grade II (TAF II)

The simple form of chronic tonsillitis is characterized by local signs of chronic tonsillitis, with the vast majority of patients having an anamnestic history of prior sore throats.

The toxico-allergic form is divided into two degrees. The signs of chronic tonsillitis of the toxico-allergic form grade I are:

1. periodic episodes of low-grade body temperature;

2. episodes of weakness, body aches, malaise; rapid fatigue, decreased work capacity, poor general well-being;

3. periodic joint pain;

4. enlargement and tenderness upon palpation of regional lymph nodes (in the absence of other foci of infection);

5. functional disorders of cardiac activity, which may be inconstant, manifesting during physical exertion or at rest, during periods of exacerbation of chronic tonsillitis;

6. unstable and inconstant deviations from the norm in laboratory test data.

Signs of the toxico-allergic form grade II:

1. periodic functional disorders of cardiac activity (the patient presents complaints, and the disorders are recorded on an electrocardiogram (ECG));

2. palpitations and cardiac arrhythmias recorded during objective research methods.

3. pain in the cardiac region or joints both during tonsillitis and outside of exacerbations of chronic tonsillitis;

4. low-grade fever may occur;

5. infectious functional disorders in the functioning of the kidneys, heart, vascular system, joints, liver, and other organs and systems, detected clinically and by laboratory methods;

6. «conjugated» diseases sharing common infectious causes with chronic tonsillitis: peritonsillar abscess, parapharyngitis, tonsillogenic sepsis, rheumatism, arthritis, acquired heart defects, diseases of the urinary system (glomerulonephritis), joints, and other organs. Currently, about 100 diseases have been described whose onset has been linked to chronic tonsillitis [8; 23]. The heart, joints, kidneys, endocrine system, and skin are considered the most vulnerable; therefore, in any ambiguous case, the decision on treatment tactics should be made after a joint discussion of the disease progression and prognosis with the relevant specialist.

2. Diagnostics, medical indications and contraindications for diagnostic methods

Diagnostic criteria

The diagnosis of «Chronic tonsillitis» is established based on:

1. anamnestic data on recurrent episodes of tonsillitis accompanied by a prolonged period of unmotivated fatigue, decreased performance, low-grade fever, regional lymphadenitis—including those running with complications—and the presence of diseases associated with tonsillar pathology (of the heart, kidneys, joints, endocrine organs, etc.).

2. physical examination, including the physician's assessment of the patient's general condition and the results of examinations by other specialists;

3. laboratory tests;

4. instrumental examination of the pharynx – pharyngoscopy

2.1 Complaints and Anamnesis

A patient with CT, regardless of the form of the disease, may present with pharyngeal complaints:

mild pain, tickling sensation,

a foreign body sensation in the throat area, particularly in the tonsils, periodic dry cough,

bad breath (halitosis).

These complaints are non-specific and are also observed in chronic pharyngitis, pathology of the larynx, oral cavity, and teeth. In some patients with CT, pharyngeal complaints may be completely absent.

In the decompensated form, systemic complaints may be observed:

prolonged malaise,

decreased performance,

prolonged episodes of low-grade fever.

Systemic complaints are also non-specific and always require a thorough examination of the patient to rule out other causes and to establish whether they are caused by chronic tonsillitis. In addition, in the decompensated form of CT, patients present complaints corresponding to the clinical picture of the condition or disease that is pathogenetically linked to CT.

The history of present illness is important for indications of frequent respiratory infections, especially acute tonsillopharyngitis, complications such as peritonsillitis and peritonsillar abscess, previously administered treatment for chronic tonsillitis and its efficacy, as well as follow-up and treatment for diseases pathogenetically associated with chronic tonsillitis.

Comments: A number of authors consider history data on past acute tonsillitis (quinsy) to be the most reliable sign of chronic tonsillitis [11; 13, 23]. However, in this case, anamnestic data must have reliable confirmation. For subsequent diagnosis of the form of chronic tonsillitis (compensated or decompensated) and determination of the type of decompensation in the form of recurrent tonsillitis, the history over the past 3 years is relevant.

2.2 Physical Examination

Assessment of the general condition, general physical examination, and pharyngoscopy allow ruling out an acute condition affecting the pharynx and proceeding to the diagnosis of chronic tonsillitis.

Comments: Local signs of acute tonsillitis include:

• marked hyperemia and edema of the mucosa of the palatine arches, palatine tonsils, and posterior pharyngeal wall (less commonly, the soft palate and uvula);

• exudate and plaque on the palatine tonsils, less commonly on the posterior pharyngeal wall;

• regional lymphadenitis (tenderness, enlargement, and induration upon palpation of the submandibular, retromandibular, anterior, and posterior cervical lymph nodes);

• petechial enanthema on the soft palate and uvula.

Local manifestations of an acute pharyngeal disease do not allow diagnosing chronic tonsillitis; only 3–4 weeks after the resolution of acute pharyngeal inflammation can morphological signs of chronic tonsillitis be reliably determined [23].

2.3 Laboratory Diagnostics

Laboratory diagnostic methods: General (clinical) blood and urine tests bacteriological examination of throat swab for group A Streptococcus (Streptococcus gr. A), bacteriological and mycological culture of swabs from the tonsillar mucosa, cytologic examination of lacunar contents (cytologic examination of oral cavity tissue micropreparation or cytologic examination of upper respiratory tract discharge and imprints), are not of substantial importance in detecting chronic tonsillitis, but are used to clarify the disease course: the form of chronic tonsillitis, the etiological role of the microbial biocenosis, the relationship with diseases of other organs and systems, and the efficacy of the administered treatment.

Comments: High ASO levels (Appendix A3, Table 1) in the absence of beta-hemolytic streptococci (GABHS) in cultures of palatine tonsil lacunar contents and pharyngeal mucosal swabs indicate the possibility of intracellular persistence of microorganisms, which is considered confirmation of chronic tonsillitis decompensation [24]. However, high ASO titers without clinical symptoms of palatine tonsil involvement cannot be considered an indication for prescribing therapy and require microbiological testing (bacteriological examination of throat swab for group A Streptococcus (Streptococcus gr. A)), including immunochromatographic rapid tests (immunochromatographic rapid swab test for group A streptococci). In intracellular persistence of streptococci, which is characteristic of chronic tonsillitis, the pathogen is not detected using the culture method (microbiological (culture) examination of mucus from the tonsils and posterior pharyngeal wall for aerobic and facultatively anaerobic microorganisms). Isolation of streptococci is difficult in the presence of hemolytic staphylococci (predominantly S. aureus) in the material, as well as when using nutrient media supplemented with donor blood containing antibodies to GABHS [23; 24]. Even a single use of antibiotics (systemic antibacterial drugs) sharply reduces the probability of detecting bacterial pathogens using the culture method (bacteriological examination of throat swab for group A Streptococcus (Streptococcus gr. A)).

Comments: Group A beta-hemolytic streptococcus is considered the most significant etiological factor in the development of chronic tonsillitis and the occurrence of pathogenetically related and GABHS-mediated severe diseases of organs (heart, kidneys, joints, skin) and systems (cardiovascular, nervous, endocrine), as well as the development of complications during recurrent acute tonsillitis.

2.4 Instrumental Diagnostics

Routine pharyngoscopy performed by primary care physicians is generally insufficient for a comprehensive assessment of the palatine tonsils to detect or rule out chronic tonsillitis.

The examination is performed under bright, directed lighting using a special head illuminator or an otorhinolaryngological frontal reflector. Two tongue depressors are used, and if it is necessary to differentiate adhesions or probe lacunae, a buttoned or hollow probe (Reusable Otorhinolaryngological Probe) is additionally used. Before the examination, the patient is advised to avoid eating, drinking hot, cold, or carbonated beverages, smoking, and talking at low ambient temperatures and in windy weather for 20–30 minutes. This helps prevent misinterpretation of the pharyngeal mucosa condition, particularly transient hyperemia. The use of a second depressor (Disposable Examination Tongue Depressor) allows for the detection of pathological contents in the lacunae of the palatine tonsils, as well as scars and adhesions between the palatine tonsils and the palatine arches.

Comments: The detection of pharyngoscopic signs is crucial in the diagnosis of CT. The diagnosis of CT is established in the presence of the above-mentioned combinations of local signs of chronic tonsillar inflammation. The presence of liquid purulent contents in the tonsillar lacunae, often with an unpleasant odor, is considered the most important sign [1; 4; 23]. Enlargement of regional lymph nodes may not be associated with CT and can be observed in other inflammatory processes in the head and neck region.

The size of the tonsils is not relevant for the diagnosis of CT. However, hypertrophy of the pharyngeal and palatine tonsils in childhood often accompanies CT and may contribute to its development [1; 13; 14; 23].

Other diagnostic methods serve to clarify the form of the disease and select therapeutic and preventive measures.

2.5 Other Procedures

To objectify chronic tonsillitis, additional diagnostic methods have been developed—laser Doppler flowmetry of vessels [25], ultrasound examination [27] and others [15, 24, 26], which are not yet widespread; there is no objective evidence of their efficacy.

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

Treatment of patients with CT is carried out in the inter-recidive period involving an otorhinolaryngologist and specialist physicians in the presence of clinical and anamestic signs of comorbid conditions. Treatment of an acute tonsillitis relapse (a relapse in the form of acute tonsillitis/angina) is carried out based on clinical guidelines for the treatment of acute tonsillopharyngitis. Treatment of complications (paratonsillitis, paratonsillar abscess, etc.) is carried out based on clinical guidelines relevant to these diseases.

The choice of treatment method for CT—conservative or surgical—depends on the form of the disease and clinical manifestations.

Before starting any type of treatment for CT, it is recommended to evaluate the condition of the teeth, paranasal sinuses, and nasopharynx and, if necessary, perform their sanitation.

3.1. Conservative treatment.

The goal of conservative treatment is the sanitation of the palatine tonsils and the restoration of their function through the use of pathogenetically substantiated treatment methods and medicinal products.

Conservative treatment is indicated for:

• patients with clinical diagnoses: "Chronic tonsillitis, compensated form", "Chronic tonsillitis, simple form" (course treatment 2 times a year in spring and autumn);

• patients with clinical diagnoses: "Chronic tonsillitis, decompensated form - relapses of angina", "Chronic tonsillitis, toxic-allergic form grade I" (course treatment up to 4 times a year, carried out 1–1.5 months before the expected relapse of acute tonsillitis);

• patients with chronic tonsillitis of the decompensated form with other types of decompensation, or with toxic-allergic form grade II, if there are contraindications to surgical treatment.

Conservative treatment is carried out routinely in courses—in the period between relapses of acute tonsillitis/tonsillopharyngitis. An indispensable condition for the effectiveness of conservative treatment is the drainage of the lacunae of the palatine tonsils, and the cleansing of tonsillar folds and crypts from pathological exudate and detritus.

3.1.1. General treatment

Comments: The proposition regarding the important role of the microbial flora of the tonsils in the development of CT is shared by the majority of researchers, emphasizing that GAS is the main infectious agent in CT, as well as in acute tonsillitis. However, attitudes toward prescribing etiotropic systemic antibacterial therapy for CT during the inter-recidive period vary significantly.

CT caused by GAS infection has the most unfavorable course, is accompanied by frequent relapses of acute tonsillitis and the development of severe complications from the very first days (paratonsillar abscess, purulent lymphadenitis, etc.), as well as GAS-caused diseases (glomerulonephritis, rheumatic fever, etc.) several weeks after the resolution of an acute tonsillitis relapse. As a rule, a patient with CT has already had a history of multiple courses of antibacterial therapy; during remission, pathogens exist within biofilms or persist intracellularly within tissues. All of this prevents the effective eradication of pathogens and contributes to their acquisition of resistance properties. In addition, systemic antibacterial therapy contributes to the disruption of the microbiome of the oral cavity, upper respiratory tract, and gastrointestinal tract, and may have an immunosuppressive effect. In this regard, there is an opinion that systemic antibacterial therapy during the remission period is not necessary [23].

Proponents of the opposite opinion consider the fact of pathogen persistence in tonsillar tissues to be extremely dangerous, creating conditions for the emergence of GAS-caused acute diseases and complications, which often occur against the background of a "non-angina course" of CT. Therefore, high and non-decreasing ASO titers are considered an indicator of chronic streptococcal infection, requiring the prescription of appropriate systemic antibiotics (systemic antibacterial drugs) [8; 24].

The presented facts and opinions make the decision to prescribe antibacterial therapy to a CT patient in the inter-recidive period extremely important and responsible, requiring an individual approach based on objective indicators, monitoring the dynamics of clinical symptoms, laboratory data, and additional studies in connection with the prescribed antibacterial therapy.

Upon confirmation of fungal etiology of CT, systemic antifungal drugs are prescribed orally, taking into account the results of susceptibility testing to antifungal drugs (systemic antifungal drugs J02A) [23].

Comments: to obtain the predicted clinical effect and minimize adverse events, preparations containing marshmallow root, chamomile flowers, yarrow herb, oak bark, horsetail herb, walnut leaves, and dandelion root are used. The complex effect includes anti-inflammatory, immunomodulatory, antibacterial, and antiviral actions. Recommended dosages, frequency, duration of administration, and age restrictions should be strictly followed.

3.1.2. Local treatment

Local treatment is performed by an otorhinolaryngologist and is an important component of the conservative therapy course for CT in the inter-recidive period.

Comments: Washing of the palatine tonsil lacunae (tonsil lacunae irrigation) is performed in courses of 10 daily or every-other-day procedures. Potential microtraumatization of the tonsil tissues during the procedure should be taken into account; therefore, irrigation should not be performed earlier than 2-3 weeks after an acute inflammation.

The technique of irrigation using a blunt thin cannula and a syringe was proposed by Professors N.V. Belogolovov and V.G. Ermolaev. It makes it possible to assess the contents of the tonsil lacunae, tonsillar folds, pockets between the tonsils and arches, remove them in the most sparing manner, and administer a medicinal product. The procedure is performed by an otorhinolaryngologist.

It is possible to irrigate the lacunae of the palatine tonsils (tonsil lacunae irrigation) using a special device, utilizing the "vacuum" effect to aspirate the contents of the lacunae and cleanse the folds, which allows for effective cleaning of the deep sections.

Sterile solutions are used for irrigation: sodium chloride**; solutions of antiseptics, systemic antifungal agents, etc. When using antiseptics, one should adhere to approved doses and age restrictions due to the certain toxicity of some of them and take into account the possibility of allergic reactions (iodine preparations D08AG).

Lubrication of the palatine tonsils is carried out in a course of 10-15 procedures as an independent sanitizing procedure or immediately after tonsil irrigation to prevent acute inflammation [1; 8; 23].

In preschool and early school-age children, irrigation and lubrication of the tonsils should be avoided to eliminate the risk of reflex laryngospasm [42].

Comments: Topical antiseptics (antiseptics and disinfectants) during course treatment of chronic tonsillitis are prescribed to target the pathogenic and opportunistic flora of the tonsils. Their predominantly superficial or shallow action and penetration into tissues should be taken into account. Considering the certain toxicity of some of them (chlorhexidine**) and the possibility of allergic reactions (iodine preparations D08AG, sulfonamides and trimethoprim J01E), one should adhere to the approved dosage, frequency, duration of administration, and age restrictions.

Comments: Benzydamine (beta-lactamase-sensitive penicillins J01CE) is able to penetrate into the focus of chronic inflammation, interrupt this process by affecting pro-inflammatory mediators, and slow down the process of excessive neutrophil activation. Selective NSAIDs (non-steroidal anti-inflammatory and antirheumatic products) are characterized by minimal adhesion on the mucosal surface, which reduces the undesirable effect on the pharyngeal saprophytic microbiota [54, 55, 56].

Comments: The use of topical bacterial lysates (other immunostimulants L03AX) for infectious and inflammatory diseases of the upper respiratory tract is justified regardless of the etiology of the disease (viral, bacterial, fungal). Due to the optimal delivery form of the active substance to the target organ in chronic tonsillitis, it is advisable to use topical bacterial lysates (other immunostimulants L03AX) in the form of lozenges [44, 45].

3.1.3. Physiotherapy

Physiotherapy is used in the treatment of chronic tonsillitis during the inter-recidive period. It can be used as an independent method of general (on the body surface or parts thereof) and local (on the area of the tonsils and regional lymph nodes) exposure. Physiotherapeutic devices facilitate the introduction of medicinal substances into tissues. The procedures are performed by a physical therapy doctor.

Comments: the course of tonsil irrigation should be performed before physiotherapeutic procedures.

3.2. Surgical treatment.

The most radical and effective surgical method for treating chronic tonsillitis is bilateral extracapsular tonsillectomy [1; 4; 13; 23; 36].

Comments: Indications for bilateral tonsillectomy in chronic tonsillitis according to the classification proposed by Academician I.B. Soldatov [1]:

1. All types of decompensation of chronic tonsillitis, except for relapses of acute tonsillitis (quinsy), if patients with relapses of acute tonsillitis did not receive conservative anti-relapse treatment between relapses.

2. Decompensation in the form of relapses of acute tonsillitis (quinsy), if the conservative treatment administered proved ineffective and, despite the anti-relapse treatment, acute tonsillitis continues to occur or another type of decompensation arises.

Indications for bilateral tonsillectomy in patients with chronic tonsillitis according to the classification of chronic tonsillitis proposed by USSR Academy of Medical Sciences Academician B.S. Preobrazhensky – Corresponding Member of the RAS V.T. Palchun [2017]:

1. Chronic tonsillitis form TAFII;

2. Ineffectiveness of repeated (2-3 times a year) carefully conducted courses of conservative treatment in patients with simple chronic tonsillitis and TAFI form;

Indications for tonsillectomy in children with chronic tonsillitis [43]:

1. Anginous form of chronic tonsillitis with frequent exacerbations (≥7 episodes per year for a duration of not more than 1 year; ≥5 episodes per year for the last 2 years; ≥3 episodes per year for the last 3 years or more) caused by S. pyogenes

2. A history of 2 or more episodes of peritonsillar abscesses (a history of only 1 episode of peritonsillar abscess may also be considered by the physician as an indication for planned tonsillectomy, taking into account the clinical features of the abscess course and a number of other factors)

3. Conclusion of specialized experts on the necessity of tonsillectomy as a stage of treatment for comorbid pathology»

Criteria for indications for tonsillectomy developed by Jack L. Paradise (Paradise tonsillectomy criteria) [53].

These criteria recommend considering tonsillectomy as the sole therapeutic measure in the presence of at least 7 episodes of sore throat in the previous year, at least 5 episodes in each of the previous 2 years, or at least 3 episodes in each of the previous 3 consecutive years [51-53].

At the same time, an episode of chronic tonsillitis exacerbation (sore throat episode) in children is understood as a situation with a sore throat (pharyngeal pain aggravated by swallowing; odynophagia – painful swallowing, or dysphagia) combined with at least one of the following symptoms:

1. body temperature increase ≥38.3°C;

2. presence of exudate in the palatine tonsils;

3. cervical lymphadenitis or enlargement of cervical lymph nodes to more than 2 cm in size combined with their tenderness;

4. isolation of GAS (group A beta-hemolytic streptococcus) by bacteriological method or a positive result of a streptest (immunochromatographic rapid test of a throat swab for group A streptococci).

All episodes must be documented, indicating not only the number of episodes, but also how they proceeded (how serious and severe), whether other indicators of the chronic disease predominated: general poor health, a large number of days missed from school/work, the need for antibiotics (systemic antibacterial drugs), a decrease in quality of life due to systemic manifestations and comorbid conditions associated with GAS; an increase in the concentration level of serum antibodies.

Contraindications to bilateral tonsillectomy [23; 38] Absolute:

1. blood diseases (hemophilia, leukemias, hemorrhagic diatheses);

2. presence of anomalous blood vessels in the pharynx (pulsation of the lateral pharyngeal wall);

3. severe heart diseases with marked stage II-III heart failure;

4. chronic kidney diseases with marked renal failure;

5. severe diabetes mellitus with ketonuria;

6. severe progressive liver diseases;

7. severe neuropsychiatric disorders;

8. malignant tumors;

9. active form of tuberculosis.

Relative:

1. period of acute infectious diseases, presence of prodromal signs of childhood infections, and the immediate post-recovery period following an acute infectious disease (3–4 weeks);

2. acute inflammatory diseases and exacerbations of chronic inflammatory diseases, including those of the ENT organs;

3. period of epidemic outbreaks of influenza and infectious diseases;

4. before and during menstruation in women;

5. closed, inactive forms of tuberculosis;

6. transient thrombocytopenia;

7. diabetes mellitus, mild to moderate forms;

8. carious teeth.

Comments: Bilateral tonsillectomy is performed under local or general anesthesia (narcosis). Extracapsular removal using standard surgical instruments is most commonly employed. Alternative methods are also used, including cryo-, ultrasonic, mono- and bipolar diathermic, laser, and coblation (cold-plasma) tonsillectomy (tonsillectomy using video-endoscopic technologies, laser pharyngeal tonsil coagulation), etc.

The most frequent complication of bilateral tonsillectomy is pharyngeal hemorrhage from the tonsillar fossa, occurring during surgery or within the first 5–7 days postoperatively. Postoperative pharyngeal hemorrhages may occur even on the 8th–15th day after tonsillectomy [1; 8; 23], which necessitates patient monitoring after surgery until the tonsillar fossae are completely cleared of fibrinous plaque and epithelization begins. The patient spends the first 5–7 days in the hospital, is then discharged under outpatient supervision, and is excused from work for another 5–7 days, with a sick leave certificate issued [8; 10].

3.3. Other treatment

Postoperative management of a patient with chronic tonsillitis

During the first 24 hours, the patient observes strict bed and voice rest; a few sips of water are permitted a few hours after surgery. In the following days, the regimen is

gentle; food should be liquid (pureed), non-irritating, neither hot nor cold. Local and systemic analgesics (non-steroidal anti-inflammatory and antirheumatic drugs) are prescribed. Concurrently, prophylaxis of the exacerbation of associated diseases is carried out upon the recommendation of a relevant specialist.

Comments: patients with chronic tonsillitis require compliance with a daily routine, a balanced vitamin-rich diet, and, when indicated, medical nutrition therapy.

Periodic resort and climate therapy (local sanatoriums and health resorts, sanatoriums specializing in the treatment of upper respiratory tract pathology) has a favorable effect on increasing the body's natural resistance. Climate therapy factors (exposure to climate) are utilized: heliotherapy (sun exposure), thalassotherapy, pelotherapy, ozone therapy. General and local reflexology (reflexology for upper respiratory tract diseases) is prescribed and performed as indicated.

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Patients undergoing bilateral tonsillectomy are advised to restrict physical activity for one month; compliance with sleep and rest regimens, and general strengthening therapy are recommended.

5. Prevention and Dispensary Observation

Prevention of chronic tonsillitis consists of measures to prevent the development of the disease (primary), its worsening (secondary), and the development of complications (tertiary). The prevention of chronic tonsillitis is closely linked to the general health screening (dispensary evaluation) of the population and dispensary monitoring of the categories of the population in whom chronic tonsillitis has been identified.

Risk factors for the development of chronic tonsillitis must be identified at the first stage of dispensary evaluation. Risk factors for chronic tonsillitis include inadequately balanced nutrition, particularly with vitamins A, B, and E; non-compliance with work and rest standards; physical and psychological overstrain, especially in childhood; inadequate hygiene of housing and workplaces; microbiological contamination, dustiness, and gas pollution of the external environment and housing; smoking, including passive smoking; pathology of the teeth, nose, and paranasal sinuses; frequent acute respiratory viral infections (ARVI) and their inadequate treatment.

Preventive measures consist of eliminating risk factors; body hardening; sanitary and educational work with the public to explain the causes of tonsillitis; timely treatment of dental and gum diseases, pathology of the ears, nose, and paranasal sinuses; and restoration of impaired nasal breathing. Vaccination as a method of primary prevention of chronic tonsillitis is not feasible due to the variety of etiological factors and pathogenesis.

Comments: Such agents include those containing Streptococcus salivarius strain K12, which produces inhibitory substances (BLIS) – antimicrobial peptides [47, 48, 50].

A course of conservative treatment for the compensated form of chronic tonsillitis is carried out twice a year. In the absence of acute tonsillitis relapses and other signs of chronic tonsillitis decompensation for 3 years, the patient is removed from dispensary registration.

A course of conservative treatment for the decompensated form of chronic tonsillitis (decompensation manifested by recurrent tonsillitis/angina) is carried out 3–4 times a year. If treatment is ineffective for a year, or if complicated forms of acute tonsillitis occur, or if other types of decompensation develop or threaten to develop, the patient with chronic tonsillitis is referred for surgical treatment.

Following surgical treatment—bilateral tonsillectomy—the patient is under dispensary observation for 6 months.

6. Organization of Medical Care

Organization of medical care, indications for hospitalization and discharge 

Medical care is organized in accordance with the Patient Management Algorithm (Appendix B).

In most cases, treatment is carriedout on an outpatient basis by an otorhinolaryngologist. Sustained therapeutic remission can be achieved with combination therapy.

Ineffectiveness of treatment, suspicion of a purulent complication (paratonsillar, parapharyngeal, retropharyngeal abscess, purulent lymphadenitis), atypical pharyngoscopic presentation (suspicion of a neoplasm), or the need for surgical intervention (abscess drainage, biopsy, tonsillectomy) are indications for hospitalization in the appropriate surgical department.

Indications for hospital admission to a medical organization:

1) performance of bilateral tonsillectomy: planned hospitalization in the inpatient otorhinolaryngology department

Indications for patient discharge from a medical organization

1) completion of treatment in the otorhinolaryngology department following bilateral tonsillectomy on the 5th–7th postoperative day in cases of an uncomplicated course.

7. Additional Information

The risk of an unfavorable course of chronic tonsillitis—the transition from the compensated form to the decompensated/simple to toxic-allergic form—increases against the background of immunodeficiency states (congenital immunodeficiency, immunosuppressive and cytostatic therapy, HIV infection). The risk of autoimmune complications increases in patients with group A beta-hemolytic streptococcus (GABHS)-associated chronic tonsillitis and a history of acute rheumatic fever in the patient or close relatives.

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

1. Artyushkin S.A. – Doctor of Medical Sciences, Professor, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest.

2. Yunusov A.S. – Doctor of Medical Sciences, Professor, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest.

3. Ryazantsev S.V. – Doctor of Medical Sciences, Professor, Member of the National Medical Association of Otorhinolaryngologists. No conflict of interest.

4. Eremina N.V. – Doctor of Medical Sciences, Professor, Member of the National Medical Association of Otorhinolaryngologists. No conflict of interest.

5. Gurov A.V. – Doctor of Medical Sciences, Professor, Member of the National Medical Association of Otorhinolaryngologists. No conflict of interest.

6. Karneeva O.V. – Doctor of Medical Sciences, Associate Professor, Member of the National Medical Association of Otorhinolaryngologists. No conflict of interest.

7. Svistushkin V.M. – MD, Professor, Member of the National Medical Association of Otorhinolaryngologists. No conflict of interest.

8. Ilyenko L.I. – MD, Professor. No conflict of interest.

9. Zavaliy M.A. – MD, Professor, Member of the National Medical Association of Otorhinolaryngologists. No conflict of interest.

10. Polunin M.M. – MD, Professor, Member of the National Medical Association of Otorhinolaryngologists. No conflict of interest.

11. Shakhov A.V. – MD, Professor, Member of the National Medical Association of Otorhinolaryngologists. No conflict of interest.

12. Dzhamaludinov Yu.A. – MD, Professor, Member of the National Medical Association of Otorhinolaryngologists. No conflict of interest.

13. Yakovlev S.V. – MD, Professor. No conflict of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

1. pediatricians;

2. city (district) pediatricians;

3. district pediatricians;

4. general practitioners (internal medicine);

5. adolescent general practitioners;

6. district general practitioners;

7. general practitioners of industrial medical districts;

8. infectious disease specialists;

9. ship doctors;

10. general practitioners (family doctors);

11. otorhinolaryngologists;

12. otorhinolaryngologist-surdologists.

Table 1. Levels of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)

Table 2. Scale for assessing the levels of evidence (LE) for prevention, treatment, and rehabilitation methods, including those based on natural therapeutic factors (preventive, therapeutic, and rehabilitative interventions)

Table 3. Scale for assessing the grades of recommendation (GR) for prevention, diagnostic, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, diagnostic, therapeutic, and rehabilitative interventions)

Procedure for updating clinical guidelines.

The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

Table 1. Age-specific antistreptolysin-O (ASO) values [24].

Related documents

The clinical guidelines for "Chronic Tonsillitis" were developed taking into account the following regulatory documents:

1. Procedure for providing medical care in the field of "otorhinolaryngology": Order of the Ministry of Health of the Russian Federation No. 905n dated November 12, 2012, "On Approval of the Procedure for Providing Medical Care to the Population in the Field of 'Otorhinolaryngology'"

2. "Epidemiological surveillance and prevention of group A streptococcal infection". Methodological guidelines. MU 3.1.1885-04 (Approved by the Chief State Sanitary Doctor of the Russian Federation on 04.03.2004).

Appendix B. Physician Action Algorithms

Appendix C. Patient Information

Chronic tonsillitis is inflammation of areas of lymphoid tissue (palatine tonsils) with a systemic effect on the macroorganism. Normally, the palatine tonsils protect the body from the invasion of potentially dangerous viruses or bacteria, but in some cases they can become infected themselves. The chronic form of the disease is associated with the long-term persistence of bacteria in the tonsillar tissue. It requires comprehensive therapy and, in some cases, surgical intervention.

Signs of tonsillitis depend on its form and clinical course. The simple form presents with local symptoms only. The toxico-allergic variant is accompanied by damage to not only the tonsils, but also internal organs. Treatment for this form of chronic tonsillitis should be initiated as early as possible.

Possible symptoms of chronic tonsillitis:

sore throat, discomfort when swallowing;

signs of intoxication – fever, headache, weakness; redness, swelling of the tonsils, presence of caseous plugs;

bad breath (halitosis);

enlarged and tender cervical lymph nodes;

In addition to the infectious factor (Streptococcus pyogenes), factors that reduce the body's overall resistance – hypothermia, malnutrition, prolonged emotional stress, and others – also contribute to the development of the disease.

In chronic tonsillitis, pathogens persist in the tonsillar tissues, causing periodic exacerbations. Treatment of chronic tonsillitis is a complex challenge that can only be managed by experienced otorhinolaryngologists.

Chronic tonsillitis has 2 forms – simple and toxico-allergic. In the latter case, there are 2 degrees of severity of pathological changes.

The simple form is characterized by local symptoms only. In the toxico-allergic variant, the following pathological processes occur:

microbial toxins entering the bloodstream cause sensitization (altered reactivity) of the body;

they act directly on the tissues of internal organs;

toxins also lead to the development of allergic and autoimmune reactions.

Treatment of tonsillitis in this case requires a comprehensive effect on the entire body.

Chronic tonsillitis is characterized by repeated recurrences of tonsillitis (angina). A long-standing focus of infection forms in the palatine tonsils. This leads to a deterioration in general condition:

the patient experiences a constant or periodic increase in body temperature;

the patient complains of rapid fatigue, decreased mental and physical performance, and sweating;

headaches, sleep disturbances, and loss of appetite are noted.

Chronic tonsillitis is part of the pathogenesis of many other diseases – rheumatism, polyarthritis, glomerulonephritis, sepsis, connective tissue disorders, and pathologies of the endocrine, nervous, and digestive systems.

Chronic tonsillitis can cause local and general complications.

The first group includes damage to pharyngeal tissues: peritonsillar abscess, parapharyngitis, granular pharyngitis.

General complications associated with internal organ damage:

joint and connective tissue diseases: rheumatism, rheumatoid arthritis, infectious polyarthritis, systemic lupus erythematosus;

heart and mediastinal involvement: myocarditis with the development of dilated cardiomyopathy and heart failure, mediastinitis;

inflammation of the lungs, kidneys, appendix, sepsis, and others.

To prevent the development of such complications, complete treatment must be carried out if tonsillitis symptoms are present.

Treatment of chronic tonsillitis includes conservative therapy – tonsil washing, physiotherapy, and surgical intervention.

During the remission period of the disease, the following remedies can be used for the mechanical removal of pathogens and to increase the body's reactivity:

applying a mixture of aloe juice (1 part) and honey (3 parts) to the tonsils;

gargling with herbal infusions (chamomile, yarrow, St. John's wort, linden blossom, garlic, eucalyptus);

using propolis in the form of pieces or taking a propolis solution in warm milk orally.

Such treatment cannot completely cure the patient of tonsillitis. It only helps reduce the frequency of exacerbations and lower the risk of disease complications. If conservative methods are ineffective for 1–2 years, surgical intervention is indicated.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

No.