Infective Conditions.—The majority of the infective conditions included under the popular term “sore throat” originate in the tonsils, and are due to the action of bacteria which under normal conditions are present in the crypts of the tonsils and of the mucous membrane of the naso-pharynx. The most important of these organisms are streptococci, various forms of staphylococci and of pneumo-bacteria, and diphtheritic and pseudo-diphtheritic bacilli. So long as the health is good these organisms are harmless, but when there is any lowering of the vitality they become virulent and give rise to various forms of infection.
Catarrhal tonsillitis—usually attributed by the laity to “catching cold”—is characterised by hyperæmia and congestion of the tonsils and mucous membrane of the pharynx, soft palate, and uvula. It is often met with in those who are much exposed to air contaminated with organisms—for example, patients who have been long in hospital, or the resident staff of hospitals (septic or hospital throat), and particularly in persons of a “rheumatic” tendency. There is slight pain on swallowing, and a tickling sensation passes along the Eustachian tube to the ear; the throat feels dry, and the patient has a constant desire to clear it, and there is usually a rise of temperature to 101°–102° F. As a rule the symptoms pass off in three or four days, but the condition may spread along the Eustachian tube to the ear, and interfere with hearing, or it may set up chronic suppuration of the middle ear.
A similar condition of the pharynx is frequently one of the initial symptoms in acute febrile diseases, such as scarlet fever, measles, influenza, or acute rheumatism.
The treatment of the throat affection consists in employing antiseptic and soothing gargles, inhalations of chloride of ammonium, or a spray of peroxide of hydrogen, menthol, or eucalyptol. Lozenges or pastilles containing chloride of ammonium, chlorate of potash, and cubebs may be employed. In rheumatic cases, salicin, aspirin, and salicylate of soda are indicated.
In follicular tonsillitis, the infection first implicates the lymphoid follicles. The crypts are distended with yellowish-white plugs, composed of inflammatory exudate, leucocytes, and desquamated epithelium, and these may project from the openings, giving the tonsil a spotted appearance. Sometimes the exudate accumulates on the surface of the tonsils and pharynx, forming a thin, greyish-white film, which is liable to be mistaken for the false membrane of diphtheria. It can, however, usually be wiped off, and when examined microscopically does not contain the typical Löffler's bacillus.
The tonsils are enlarged, and project so that they obstruct the isthmus of the fauces, sometimes even meeting in the middle line. There is pain on swallowing, and the respiration is impeded and noisy during sleep. There is usually some degree of fever, and the glands behind the angle of the jaw are enlarged and tender and may suppurate and set up cellulitis. The acute symptoms usually subside in four or five days, but if the deeper crypts are filled with plugs of exudate the condition may prove obstinate. The patient is liable to periodic attacks, particularly if the tonsils are chronically enlarged.
The treatment is carried out on the same lines as for the catarrhal form. In recurrent cases the tonsils should be removed.
Acute Suppurative Tonsillitis and Peri-tonsillitis—Quinsy.—This is an acute suppurative inflammation of the tonsils and peritonsillar tissue, due to infection with pyogenic bacteria. It affects the whole substance of the tonsils, and the cellular tissue of the pillars of the fauces, the soft palate, and the pharynx.
Clinical Features.—The onset is usually sudden, and the affection is ushered in by a rigor, high fever, and a feeling of malaise. There is persistent thirst and dryness of the throat, and the patient has the sensation of a foreign body being in the pharynx, with a constant desire to swallow. Swallowing is extremely painful, the pain shooting up to the ears, and the patient has difficulty in taking nourishment. The saliva accumulates in the mouth; the voice is thick and nasal; and the respiration impeded and noisy. If the patient can open the mouth sufficiently to afford a view of the back of the throat (which, however, is seldom the case), the inflamed parts are seen to be of a dull reddish-violet colour. One tonsil is often more swollen than the other, and the corresponding anterior pillar of the fauces more prominent. The uvula is swollen and œdematous, and is deviated towards the side on which there is least swelling. Suppuration occurs in from three to seven days; in adults it is usually in the peritonsillar tissue of the anterior pillar of the fauces, and extends into the soft palate. In children the pus sometimes forms in the substance of the tonsil. If left to burst, the abscess discharges itself into the mouth, and the patient experiences instant relief. The pus is always offensive, and if the abscess bursts during sleep, it may enter the air-passages and cause septic pneumonia. The lymph glands in the neck are usually enlarged and tender, and sometimes they suppurate and give rise to a diffuse cellulitis. General infection of the blood may follow, leading to metastatic invasion of different tissues and organs, particularly one or other of the large joints.
Treatment.—In the early stages soothing antiseptic gargles are indicated. Later, when the patient is unable to gargle, the inhalation of steam impregnated with the vapour of carbolic acid or friar's balsam, and the application of hot fomentations or a large linseed poultice to the neck may afford relief. When an abscess is formed, it should be opened by means of a fine-pointed pair of sinus forceps, thrust through the soft palate at a point opposite the base of the uvula, and in the line of the anterior pillar of the fauces. As those who suffer from quinsy are liable to have attacks coming on periodically, if the tonsils remain permanently enlarged they should be removed between attacks.