Chronic tonsillitis usually is the result of one or many attacks of
acute infections of the tonsils. Occasionally cases of marked chronic
tonsillitis occur in which the patient denies ever having had an acute
attack.
The pathology consists of hypertrophy of the lymphoid tissue and
connective tissue.
=Diagnosis.=—The purpose in diagnosis is not to determine whether the
tonsil is hypertrophied but to determine whether the tonsil is causing
any local or general physiological perversions and if so, whether local
treatment or surgery should be applied.
The direct examination should be made very carefully, because otherwise
a bad tonsil may be readily overlooked. The mere fact that a tonsil is
large or has open crypts from which a whitish mass may be expressed
does not mean that such a tonsil is directly responsible for local or
systemic physiologic perversions.
The examination should be made by means of a tongue depressor, tonsil
retractor and a good head mirror and reflecting lamp. Every part of
the tonsil and surrounding pillars should be carefully examined. Firm
pressure applied against the tonsil from in front and behind will
often force material from the crypts or out around the capsular margin.
Any such material thus expressed should be examined microscopically. By
probing the crypts with a small pointed cotton-wound probe and staining
the material obtained, the condition of the deep parts of the tonsil
can be determined.
The symptoms in every case, are to be considered with the microscopic
findings, but there are cases in which either of these, together with
appearance on direct examination, is sufficient to determine the
advisability of tonsillectomy.
In general, we may say that the following factors would indicate
tonsillectomy.
1. Chronic, recurrent tonsillitis with or without complications, which
does not respond to non-surgical treatment.
2. Positive evidence of arthritis of any form with microscopic evidence
of some virulent organism, such as staphylococcus, streptococcus or
long-chain pneumococcus, present deep in the tonsillar tissue.
3. Any persistent discharge of pus from the tonsil in which the
microscope shows the presence of virulent bacteria and which will not
be relieved by treatment.
4. Markedly hypertrophied tonsils which directly interfere with the
voice, deglutition or respiration and which do not respond to treatment.
5. Persistent focal infections of the middle ears, or sinuses or root
abscesses which do not respond to treatment and in which case there
is a virulent infection of the deep parts of the tonsil, shown by
microscopic examination.
The above are only general conditions and there are probably many other
indications or groups of symptoms that would indicate tonsillectomy.
In most cases, unless the findings show positively that tonsillectomy
should not be delayed, we advise treatment. If treatment does not
restore to normal, it will probably reduce the time of the surgical
sore throat following the operation.
=Non-surgical treatment.=—The local direct treatment, as we practice
it, consists of: 1. Direct aspiration by means of the tonsil cup,
applying from fifteen to twenty inches of vacuum. 2. Application of
phenol-glycerine by means of cotton applicator to the full depth of
each crypt. 3. Irrigation of the crypts by means of a catheter and
hot salt mixture solution. 4. Syringing of the crypts by means of the
catheter and phenol 10%, alcohol 20% and glycerine 70%.
The digital treatment of the tonsil consists of: 1. Applying pressure
against the anterior pillar thus forcing the contents out of the
tonsil, the Ruddy method. 2. By the bidigital technic, the front
finger of one hand inside, posterior and inferior to the tonsil and the
fingers of the other hand outside exerting deep pressure and opposing
the finger inside. In this way the tonsil can be lifted forward and
upward and its contents expressed. The digital treatment is not as
effective as that described above.
The osteopathic corrective treatment consists of adjustment of the
atlas and axis and the mandibular articulation and the obtaining of
free movement of the hyoid and the relaxation of the submaxillary
musculature and other deep structures.
This treatment, if followed persistently, will relieve the local
symptoms of a very high percentage of cases of chronic tonsillitis, and
in many cases even the systemic complications will be relieved. Whether
in cases of systemic absorption this is the preferable treatment I am
not sure, because, once the local condition is improved the patient
will usually refuse operation and even if the physician finds definite
evidence of toxic absorption he cannot convince the patient that his
tonsils require surgery.