INTRODUCTION

Homoeopathy signifies a system of treatment based on the similarity between symptoms of the patient and those obtained during proving of drugs on healthy human beings. The basic concept of disease is that, all natural diseases are due to derangement of the vital force of an individual resulting in abnormal sensations and functions manifested as signs and symptoms both in mental and physical plains. This image of the disease which we call as totality of symptoms is the sole guide for the physician to select the similimum - the curative remedy. Thus Homoeopathy is a system of medicine giving more importance to the diseased individual than the disease itself.

Chronic  inflammatory  changes  in  the tonsil are usually  the  result of  recurrent  acute  infections  treated inadequately.  Recurrent  infections  lead to  development of  minute  abscesses  within  the  lymphoid  follicles..These  become  walled  off  by  fibrous  tissue  and  surrounded by  inflammatory  cells.

The  most   common  and  the  most important cause of  recurrent  infections  of  the  tonsils  is  persistent or  recurrent  infection  of the  nose  and  paranasal  sinuses.This  leads to  post  nasal discharge which  then infects  the  tonsils  as  well. Chronic And Recurrent Tonsillitis Are Much More Common As Causes Of Disability

Homoeopathy  firmly  believes  in  enhancing  body’s  own  defense  mechanism  to  maintain  the  healthy  status. Tonsils  are  looked  upon  as  immunological   booths. The  homoeopathic  approach  is  to  encourage  the  immunological  activation  of  the  tonsils, and to  save  them  for  body’s  own  long  term  interest.

          This is a humble effort made by me to show the homoeopathic fraternity and the whole suffering humanity, the efficacy and significance of homoeopathic medicines in the management of Chronic Tonsillitis.

AIMS AND OBJECTIVES

* To determine the efficacy and significance of homoeopathic medicines in the management of Chronic Tonsillitis.

* To determine the medicines and the corresponding potencies frequently indicated in the management of Chronic Tonsillitis

REVIEW OF LITERATURE

TONSILS are organised lymphoid structures situated between the faucial pillars.

Five tonsils are usually present

v One pharyngeal tonsil, commonly called adenoids, lies on the posterior wall of the pharynx behind the nose.

v Two palatine tonsils are located on the lateral walls of the pharynx, these are the ones readily seen and most commonly referred to as tonsils.

v Two linguals are located on the base of the tongue.

EMBRYOLOGY

                    The   palatine  tonsils  develop  in  relation  to  the  lateral  parts  of  the  second  pharyngeal  pouch. The  endoderm  lining  the  pouch  undergoes  considerable proliferation .As  a  result, most  of  the  pouch  is obliterated. Lymphocytes collect in relation to the endodermal cells. It  is  not  certain  whether  these  lymphocytes  differentiate  in  situ  or  are  derived  from  blood. The  intratonsillar  cleft  or  tonsillar  fossa  is  believed  to  represent  a  persisting  part  of  the  second  pharyngeal  pouch. Similar  epithelial  proliferations  and  aggregations  of  lymphoid  tissue  give  rise  to  the  tubal  tonsils,  the  lingual  tonsils  and  the  pharyngeal  tonsils.

ANATOMY

The palatine tonsil (tonsilla palatina) is a bilaterally paired mass of lymphoid tissue situated in the lateral wall of the oropharynx and forming part of a protective annulus of lymphoid tissue, the Waldeyer's ring.

The shape of the palatine tonsil is ovoid and its size is variable according to age, individuality and tissue changes leading to hypertrophy and/or inflammation. It is therefore difficult to define its normal appearance. For the first 5 or 6 years of life the tonsils increase rapidly in size, reaching a maximum at puberty when they average 20–25 mm in vertical and 10–15 mm in transverse diameter, projecting conspicuously into the oropharynx. Tonsillar involution begins at puberty when the reactive lymphoid tissue starts to undergo atrophic changes, and by old age only a little tonsillar lymphoid tissue remains.

The long axis of the tonsil is directed from above, downwards and backwards. Its medial or free surface usually presents a pitted appearance. These pits, 10–15 in number, lead to a system of blind-ending, often highly branching crypts, which extend through the whole thickness of the tonsil and almost reach the connective tissue hemicapsule. In a healthy tonsil the openings of the crypts are fissure-like and the walls of the crypt lumina are collapsed and in contact with each other. The human tonsil is a polycryptic structure, unlike the monocryptic tonsil of some other mammals, e.g. rabbit and sheep. The branching crypt system reaches its maximum size and complexity during childhood. In the upper part of the medial surface of the tonsil is the mouth of a deep intratonsillar cleft, or recessus palatinus, often erroneously termed the supratonsillar fossa. It is not situated above the tonsil but within its substance, and the mouth of the cleft is semilunar in shape, curving parallel to the convex dorsum of the tongue in the parasagittal plane. The upper wall of this recess contains lymphoid tissue extending into the soft palate as the pars palatina of the palatine tonsil. After the age of 5 years this embedded part of the tonsil diminishes in size; from the age of 14, there is a tendency for the whole tonsil to retrogress, and for the tonsillar bed to flatten out. During young adult life a mucosal fold termed the plica triangularis, stretching back from the palatoglossal arch down to the tongue, is infiltrated by lymphoid tissue and frequently represents the most prominent (antero-inferior) portion of the tonsil. However, it rarely persists into middle age.

The lateral or deep surface of the tonsil spreads downwards, upwards and forwards. Inferiorly, it invades the dorsum of the tongue, superiorly, the soft palate, and, anteriorly, it may extend for some distance under the palatoglossal arch. This deep, lateral aspect is covered by a layer of fibrous tissue, the tonsillar hemicapsule, separable with ease for most of its extent from the underlying muscular walls of the pharynx which is formed here by the superior constrictor, with the styloglossus on its lateral side. Antero-inferiorly the hemicapsule adheres to the side of the tongue and to the palatoglossus and palatopharyngeus muscles. In this region the tonsillar artery, a branch of the facial, pierces the superior constrictor to enter the tonsil, accompanied by venae comitantes. An important and sometimes large vein (the external palatine or paratonsillar vein) descends from the soft palate lateral to the tonsillar hemicapsule before piercing the pharyngeal wall; haemorrhage from this vessel, from the upper angle of the tonsillar fossa, may complicate tonsillectomy. The muscular wall of the tonsillar fossa separates the tonsil from the ascending palatine artery, and, occasionally, from the tortuous facial artery itself which may be near the pharyngeal wall at the lower tonsillar level. The internal carotid artery lies about 25 mm behind and lateral to the tonsil.

Surface Anatomy:

The palatine tonsil is too deeply placed to be felt externally, even when enlarged. When the mouth is closed the medial surface of the tonsil touches the dorsum of the tongue. In this position the surface marking of the palatine tonsil on the exterior of the face corresponds to an oval area over the lower part of the masseter muscle, a little above and in front of the angle of the mandible and behind the third lower molar tooth.

Microstructure

The basic structure of the palatine tonsil is that of an accumulation of mucosa-associated lymphoid tissue covered by stratified squamous non-keratinizing epithelium on its oropharyngeal surface, and supported by connective tissue septa arising from the hemicapsule. On the medial, oropharyngeal surface the tonsillar epithelium is deeply invaginated to form 10–30 or more crypts. Like other neighbouring masses of mucosa-associated lymphoid tissue forming Waldeyer's ring, the palatine tonsil is a major source of T and B lymphocytes for local mucosal defence.

Blood Vessels:

The arterial blood supply to the palatine tonsil derives from branches of the external carotid artery. The principal artery is the tonsillar artery, which is a branch of the facial or sometimes the ascending palatine artery. The tonsillar artery and its venae comitantes often lie within the palatoglossal fold; hence a haemorrhage may be caused by interference with this fold during an operation. Additional small tonsillar branches may derive from the following: the ascending pharyngeal artery; the dorsales linguae, branches of the lingual artery, supplying the lower part of the palatine tonsil; the greater palatine artery (a branch of the maxillary artery) supplying the upper part of the tonsil; and the ascending palatine artery, a branch of the facial artery.

Vein:

The tonsillar veins are numerous and emerge from the deep, lateral surface of the tonsil as the paratonsillar veins. They pierce the superior constrictor either to join the pharyngeal venous plexus, or to unite to form a single vessel which enters the facial vein.

Lymphatics:

Unlike lymph nodes, the tonsils do not possess afferent lymphatics or lymph sinuses, but dense plexuses of fine lymphatic vessels surround each follicle, forming efferent lymphatics which pass towards the hemicapsule, pierce the superior constrictor and drain to the upper deep cervical lymph nodes, especially the jugulodigastric nodes. Typically, the latter are enlarged in tonsillitis; they then project beyond the anterior border of the sternocleidomastoid muscle and are palpable superficially 1–2 cm below the angle of the mandible. They represent the most common swelling in the neck.

Nerves:

The tonsillar region receives its nerve supply through tonsillar branches of the trigeminal (maxillary) and the glossopharyngeal nerves. The maxillary nerve fibres passing through (though not synapsing in) the pterygopalatine ganglion and are distributed through the lesser palatine nerves, which, together with the tonsillar branches of the glossopharyngeal nerve, form a plexus around the tonsil. From this plexus, termed the 'circulus tonsillaris', nerve fibres are also distributed to the soft palate and the region of the oropharyngeal isthmus. The glossopharyngeal nerve additionally supplies, through its tympanic branch, the mucous membrane lining the tympanic cavity. Hence, tonsillitis may be accompanied by pain referred to the ear. The nerve supply to the tonsil is so diffuse that tonsillectomy under local anaesthesia is performed successfully by local infiltration rather than by blocking the main nerves.

Waldeyer’s ring

The  lymphatic  tissues  of  the  pharynx  and  oral  cavity  are  arranged  in  a  ring  like  manner  around  the  oropharyngeal  inlet. The  inner  ring  consists  mainly  of  the  nasopharyngeal  tonsil, peri-tubal  lymphoid  tissues, faucial  tonsil  and  lingual  tonsil. The  efferent  from  this  ring  drain  to  lymph  nodes  situated  around  the  neck  forming  the  outer  ring. The lymphoid tissues have a protective function.

Function of tonsils

1.     It  plays  a  major  role  in  body  immunity  mechanism  and  antibody  reaction  most  probably  in  children.

2.     It  is  helpful  in  forming  lymphocytes  which  protect  our  body  as  a  defense mechanism

3.     It  traps  the  germs  that  enter  the  body  by  its  antibodies  and  drains  into  the  lymph node  for  elimination.

4.     It  is  also  supposed  to  kill  bacteria  that  enter  into  the  tonsil  through  the  blood  stream.

5.     It  monitors  the  quality  of  the  air, food  and  water  which  enters  our body.

Immunology of tonsils

                   The  tonsils  work  as  a  filter  which  fights  and  protects  the  entire  human  system  against  the  foreign  organism. They  also  help  preventing  spread  of  infection  from  the  nearby  organisms  such  as  mouth, sinuses, post  nasal  part etc.tonsils  produce  antibodies, which  fight  against the  infection, stopping  its  further  spread  to  other  parts  of  the  body. when  bacteria  or  virus  attack  the  body, they  initially  have  to  face  the  tonsils. In  the  process  of  fighting  towards  the  germs  and  microbes  the  tonsils get  inflamed[ called  tonsillitis]which  is  simply  a  symbol  of  the  local  defence  mechanism  at  work. In  the  process, they  produce  lymphocytes  and  antibodies  to  generate  the  required  immune  response.

Tonsillar Pathology:

While the palatine tonsil is a substantial part of the pharyngeal immune system, it may itself become infected; in particular, pathogenic bacteria, for example streptococci, may invade the tonsillar crypts and proliferate within them, causing an inflammatory reaction including the migration of leucocytes into the cryptal spaces. Various factors including the expansion of germinal centres cause swelling of the tonsillar mass, and the pus within the crypts is visible as yellowish spots on its inflamed surface. Tonsillectomy after repeated episodes of tonsillitis might be expected to cause considerable reduction of pharyngeal defence, but this usually does not appear to be the case, probably because other related lymphoid tissue masses, for example the lingual tonsil, increase their lymphocytic output.

CHRONIC TONSILLITIS

Chronic  inflammatory  changes  in  the tonsil are usually  the  result of  recurrent  acute  infections  treated inadequately. recurrent  infections  lead to  development of  minute  abscesses  within  the  lymphoid  follicles. These  become  walled  off  by  fibrous  tissue  and  surrounded by  inflammatory  cells.

The  most   common  and  the  most important cause of  recurrent  infections  of  the  tonsils  is  persistent or  recurrent  infection  of the  nose  and  paranasal  sinuses. This leads to post nasal discharge which then infects the tonsils as well

CHRONIC AND RECURRENT TONSILLITIS ARE MUCH MORE COMMON AS CAUSES OF DISABILITY

POTENTIAL PROBLEMS INCLUDE

· Multiple acute infections, each accompanied by pain and fever, causing frequent and prolonged absence from school or work

· Chronically enlarged tonsils can cause upper airway obstruction and difficulty with difficulty with normal respiration

· At night, airway obstruction can be manifested as loud snoring and may even lead to sleep apnoea syndrome, where the airway totally closes off for brief period leading to oxygen deprivation and heart failure

· Swallowing problems due to tonsillar enlargement can lead especially in children, to failure to thrive or gain weight as expected

· Voice changes are noted with partial upper airway obstruction

· There may be a constant feeling of pain or fullness in the back of the throat

· Persistent enlargement of lymph nodes in the neck can also be caused by c/c tonsillitis.

SYMPTOMS

a.     Sore throat :repeated  attacks of  sore throat  with  little  remission  in  between  attacks  indicates  chronic  inflammation.

b.      Odynophagia

c.     Fever

d.     Halitosis

e.     Cough  and  irritation  in  the  throat

f.      In  hypertrophic  tonsillitis  breathing  problems  and  snoring  are  present

g.     Unpleasant taste

On examination: three clinical types are seen

A.    Chronic  parenchymatous  or  hypertrophic  tonsillitis

Tonsils  are  uniformly  enlarged  and    congested; some times they meet  in  the  midline and  are           called kissing  tonsils

B.    Chronic follicular  tonsillitis

                       Beads  of  white  discharge  on  surface  of  tonsils  at     the  entrances  to  tonsil  crypts. Often asymptomatic

            C. Chronic fibrotic tonsillitis

· Tonsils are small, and inflamed, occurs in adults.

· Anterior   pillars  are  hyperemic

·  The most  reliable sign  is  enlarged tender, jugulo digastric lymphnodes at the angle of  mandible

· The most reliable indication  of  tonsil problem in  children  is  a  history  of  repeated acute  attacks of  tonsillitis

· Clinical finding may be deceptive.

Diagnosis

·        History  of  repeated  attacks of sore throat or acute  tonsillitis, associated with symptoms of  dysphagia and  discomfort, rise o temperature[at  least 3 0r 4 attacks per year]

·        These symptoms if seen with enlarged tonsils, hyperaemic pillars and enlarged jugulodigastric lymph nodes, a diagnosis of chronic tonsillitis is considered.

Investigation

Blood

Routine

E.S.R

A.S.O titer

Urine

Sugar

Albumin

Chronic lingual tonsillitis

                   Chronic inflammation of the lingual tonsils may be a problem after tonsillectomy when the lingual tonsils undergo compensatory hypertrophy.

                   The patient complains of discomfort in the throat, dysphagia and a thick plumy voice. Most patients respond to medical treatment of avoiding irritant foods.

Complication

Local

·        Chronic rhino-sinusitis

·        Intratonsillar abscess

·        Peritonsillar abscess

·        Para pharyngeal abscess

·        Tonsillolith

·        Tonsillar cyst

·        Ear infections

·        Middle ear effusion

General

·        Rheumatic fever

·        Acute nephritis

·        Sleep apnoea syndrome

Causes of unilateral tonsillar enlargement

a.    causes  in the tonsils

·        foreign bodies

·        peritonsillar abscess

·        gumma

·        tuberculosis

·        diphteria

·        tonsillar calculi

·        Vincent’s angina

·        intratonsillar abscess

·        cysts

·        tumors of tonsils like lymphomas, carcinomas

·        aneurysm of tonsillar artery

B. causes outside the tonsil pushing the tonsil medially

·        carotid artery aneurysm

·        unilateral cervical lymphadenitis

·        parapharyngeal abscess

·        parapharyngeal tumors

·        deep lobe of parotid gland tumours

GENERAL MANAGEMENT

·        Attention should be given to general health, nutritious diet, and well ventilated room

·        Infections of the nose and paranasal sinuses forms the most important factor leading to chronic or recurrent infection of the tonsils, so treat these factors

·        Avoid cold food and drinks

·        Avoid sour food, curd, pickles

·        Avoid fried and oily food 

SURGICAL MANAGEMENT

                   Tonsillectomy

Indications for Tonsillectomy

          Absolute:

o   sleep apnoea

o   suspected tonsillar malignancy

           Relative:

o   recurrent  tonsillitis

o   chronic tonsillitis

o   quinsy

o   diphtheria carriers

o   systemic disease due to beta hemolytic streptococcus