Chronic tonsillitis - Classification

At present, the classification adopted at the 7th All-Union Congress of Otolaryngologists (1975), proposed at this congress by I.B. Soldatov, and also set out in his Methodological Recommendations (1979), is still in effect, according to which numerous pathological anatomical types of chronic tonsillitis are reduced to two clinical forms - compensated and decompensated chronic tonsillitis. Of course, this classification has nothing in common with the principles of scientific classification of diseases of the pharynx and tonsils, and in general, including acute tonsillitis, is only a list of long-known causes and types of diseases of the pharynx, and in particular the palatine tonsils. Each classification should identify the essential features of the classified object and contain information on the internal processes (etiology and pathogenesis) and external signs (symptoms, dynamics of the clinical condition) of a particular nosological form of the disease. For well-known reasons, there are great difficulties in developing such a classification. Monomodal systems and phenomena outlined by a certain structural and functional complex are classified correctly. Such classifications can meet truly scientific requirements for systematization of quantitative and qualitative features of the phenomenon under study, consisting in fixing regular connections between elements of the system to determine the place of each of them in the classified system. In this sense, classification, as the result of a whole layer of research work in the field of a specific medical problem, serves as a "bank" of identified information, and in the area of existing internal connections between elements of the system - a means of searching for new patterns, phenomena and objects that develop this problem. Nevertheless, returning to the classification of I.B. Soldatov, one cannot fail to note its practical significance, since it offers an alternative solution in choosing a method for treating chronic tonsillitis.

In 1978, V. T. Palchun "reanimated" the classification of chronic tonsillitis by B. S. Preobrazhensky (1954), slightly changing and supplementing it. According to this classification, chronic tonsillitis is divided into simple and toxic-allergic forms.

The author characterizes the simple form by local signs of chronic tonsillitis and the presence of tonsillitis in the anamnesis in 96% of patients. The classification lists all known signs of chronic tonsillitis. In this form, so-called concomitant diseases may occur, which, according to V. T. Palchun, "do not have a single etiological basis with chronic tonsillitis; the pathogenetic connection is realized through general and local resistance." The given definition of the simple form lacks the key phrase, namely, that this form is characterized by the absence of metatonsillar complications. In the author's interpretation, the "simple form" is identified with the "compensated form" of I.B. Soldatov; such "additions" as a list of local signs of chronic tonsillitis and a reference to "concomitant diseases", vaguely hinting at the possibility of potentiation of chronic tonsillitis by the corresponding risk factors, distance this part of V.T. Palchun's classification from the true purpose of this definition, as an exhaustive classification definition, and bring it closer to a diagram or list of local symptoms of chronic tonsillitis.

The toxic-allergic form of chronic tonsillitis in its descriptive part is even more reminiscent of a student's notes made at a lecture on the clinical manifestations of chronic tonsillitis. In essence, it details the concept of "decompensated chronic tonsillitis" proposed by I.B. Soldatov in 1975. According to V.T. Palchun (1978), this form is divided into I and II degrees. Further, detailed information is given on the tonsillar and general signs characteristic of these forms of chronic tonsillitis. Without a doubt, the classification of chronic tonsillitis by B.S. Preobrazhensky and V.T. Palchun has a certain didactic value, contributing to the understanding of chronic tonsillitis as a systemic disease, detailing its clinical manifestations, however, this form of presentation of information is more suitable for the concepts of a scheme or a list of symptoms than for the concept of classification of the pathological process as such.

Many other classifications proposed by different authors repeat each other in different terms or make minor changes to existing ones, but none of them have stood the test of time, and today the most acceptable classification for practical application remains the classification of I.B. Soldatov.

Classification of diseases of the palatine tonsils

Acute tonsillitis.

• Primary: catarrhal, lacunar, follicular, ulcerative-membranous tonsillitis.
• Secondary:
  • in acute infectious diseases - diphtheria, scarlet fever, tularemia, typhoid fever;
  • for diseases of the blood system - infectious mononucleosis, agranulocytosis, alimentary-toxic aleukia, leukemia.

Chronic tonsillitis.

• Non-specific:
  • compensated form;
  • decompensated form.
• Specific: for infectious granulomas - tuberculosis, syphilis, scleroma.

In concluding the “problem” of the classification of academician I.B. Soldatov, one cannot help but notice its brevity and, in contrast to the classification of Preobrazhensky - Palchun, its small information content.

According to V.I. Voyachek: “Chronic forms of tonsil diseases are divided into two main ones:

1. dystrophies, mainly of the hypertrophic type, and
2. associated with inflammatory and infectious processes."

Even in this seemingly simple classification, two fundamental concepts already appear - dystrophy and inflammatory-infectious process, the “decoding” of which in relation to chronic tonsillitis as a nosological form allows, if necessary, to create a coherent classification of this disease, which would organically include such obligatory factors as etiology, pathogenesis, pathomorphology, clinical forms and the “integral” - the method of treatment.

Continuing the analysis of V.I. Voyachek's classification, it is necessary to recall his conceptual approach to the two forms of chronic tonsillitis. According to V.I. Voyachek, the first form is an expression of the so-called tonsillar stereotype - the biological necessity of lymphadenoid tissue for functional (physiological) hypertrophy for certain, genetically determined functions. And although V.I. Voyachek does not talk about this, all subsequent research in the field of chronic tonsillitis showed that physiological hypertrophy of the palatine tonsils is a tissue immune response to external antigens, the deep mechanisms of which are not limited to the replication of "killer" systems, but also the formation of so-called HLA markers with an immense number of their mutual combinations, linking individual genetic characteristics of a person with the nature of the immune response and clinical polymorphism of diseases. The second form is a combination of productive and inflammatory processes that arise against the background of gradual decompensation of the physiological form due to the growth of microbiota virulence and a decrease in the tension of tissue and systemic immunity. Thus, although in other words, but corresponding to the stated meaning, V.I. Voyachek, in essence, outlined the path that the development of the doctrine of chronic tonsillitis should follow and on which the modern concept (theory) of this disease should be formed. How this concept was and is being formed is the subject of special discussions and publications that are not included in the scope of this manual, we will only note that the reader can find some information on this issue in the literature we recommend, and in particular, in the very remarkable monograph by V.R. Gofman et al. (1998) "Clinical Immunology of Chronic Tonsillitis".

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