Complications of Chronic Tonsillitis
Chronic tonsillitis can lead to both suppurative complications (peritonsillar abscess, cervical lymphadenitis, acute otitis media, mastoiditis, acute sinusitis) and non-suppurative complications (acute rheumatic fever, acute glomerulonephritis), with peritonsillar abscess being the most common serious complication requiring immediate intervention. 1
Suppurative (Infectious) Complications
Peritonsillar Abscess
- Most frequent complication of acute and chronic tonsillitis, occurring primarily in young adults 1, 2
- Presents as a polymicrobial infection with group A streptococcus as the main organism, forming a purulent collection between the tonsillar capsule and superior pharyngeal constrictor 1, 2
- Clinical features strongly associated with abscess formation include trismus, uvular deviation, and anterior pillar bulging 2
- History of >1 peritonsillar abscess is a modifying factor that may favor tonsillectomy even without meeting standard frequency criteria 1
- Recurrence rate after drainage and antibiotics is approximately 5% 2
Other Suppurative Complications
- Cervical lymphadenitis: tender or enlarged (>2 cm) cervical nodes associated with tonsillar infection 1
- Acute otitis media, mastoiditis, and acute sinusitis: can develop as extensions of tonsillar infection 1
- Lemierre syndrome (thrombophlebitis of the internal jugular vein): rare but life-threatening complication that warrants consideration for tonsillectomy 1
Non-Suppurative (Post-Infectious) Complications
Acute Rheumatic Fever
- Incidence is very low in developed countries but remains important for high-risk patients 1
- Prevention depends on effective control of group A streptococcal pharyngitis 1
- Personal or family history of rheumatic heart disease is an exclusion criterion that may warrant earlier surgical intervention 1
Acute Glomerulonephritis
- Rare consequence following group A streptococcal pharyngitis after a latency period of several weeks 1
- Causal relationship with group C and G streptococci has been reported but not clearly established 1
Complications Requiring Hospitalization
- Severe infections requiring hospitalization are a modifying factor that may favor tonsillectomy regardless of episode frequency 1
- Male patients aged 21-40 years who smoke are significantly more likely to develop peritonsillar abscess after initial presentation of uncomplicated sore throat 1
- Patients with immunosuppression, valvular heart disease, or history of rheumatic fever are at increased risk of severe complications 1
Quality of Life Impact
- Chronic tonsillitis causes disturbing symptoms, treatment costs, sick leave, and significantly impaired quality of life even without acute complications 3, 4
- Recurrent infections create a repository of biofilm-forming microorganisms in tonsillar crypts, leading to persistent symptoms despite antimicrobial therapy 4
Clinical Pitfall to Avoid
Never delay evaluation for complications in patients presenting with severe symptoms such as trismus, difficulty swallowing, voice changes, or unilateral tonsillar swelling, as these may indicate peritonsillar abscess requiring urgent drainage 2, 5. The presence of these warning signs mandates immediate assessment rather than continued observation, even in patients who do not meet standard criteria for tonsillectomy 1.