European Journal of Cardiovascular Medicine

Chronic tonsillitis is a persistent inflammation of the palatine tonsils, commonly affecting both children and adults, and is typically characterized by repeated episodes of sore throat, tonsillar enlargement, halitosis, and lymphadenopathy. This condition significantly impacts patients’ quality of life, leading to absenteeism from school or work and frequent use of antibiotics (1). Although antibiotics and analgesics form the cornerstone of initial management, recurrent cases often necessitate surgical intervention in the form of tonsillectomy, which carries potential risks such as bleeding, infection, and prolonged recovery (2).

Recent advancements in non-invasive technologies have introduced cold plasma therapy as a novel modality for treating various chronic infections and inflammatory conditions. Cold plasma, also referred to as non-thermal plasma, is an ionized gas composed of electrons, ions, reactive oxygen species (ROS), and reactive nitrogen species (RNS) generated at room temperature, which exerts potent antimicrobial and anti-inflammatory effects without damaging healthy tissue (3). It has been effectively used in dermatology, wound healing, and dental procedures, demonstrating its biocompatibility and efficacy in reducing microbial load and enhancing tissue regeneration (4,5).

Given the limitations of traditional therapy and the potential advantages of cold plasma, exploring its application in managing chronic tonsillitis is warranted. This study investigates the efficacy of cold plasma therapy as a non-surgical treatment option, comparing it with conventional medical management in terms of symptom relief, reduction in tonsillar size, and recurrence rate.

A total of 60 patients aged between 10 and 40 years, diagnosed clinically with chronic tonsillitis based on criteria such as recurrent sore throat, tonsillar enlargement, and tonsillar crypt debris persisting for more than three months, were enrolled. Exclusion criteria included patients with acute tonsillitis, history of tonsillectomy, immunodeficiency, bleeding disorders, or concurrent systemic illness.

Study Design and Grouping
Participants were randomly assigned into two equal groups (n=30 each) using a computer-generated randomization table:

• Group A (Intervention Group): Received cold plasma therapy.
• Group B (Control Group): Received conventional medical treatment (antibiotics and analgesics).

Cold Plasma Application Protocol
In Group A, a helium-based cold plasma device was used. Each patient received four weekly sessions, with the plasma probe applied directly to the tonsillar surface for 60 seconds per tonsil under topical anesthesia. The device operated at low temperature (<40°C) to ensure patient comfort and tissue safety.

Conventional Therapy Protocol
Patients in Group B were prescribed a standard course of oral antibiotics (amoxicillin-clavulanic acid or azithromycin based on sensitivity) and analgesics (paracetamol/ibuprofen) for 7 days.

Outcome Measures
Primary outcomes included reduction in Tonsillitis Severity Index (TSI) score, frequency of throat infections, and Visual Analog Scale (VAS) score for pain. Tonsillar size was graded using a standard four-point scale. Follow-up assessments were performed at baseline, 4 weeks (end of treatment), and 12 weeks post-intervention.

Statistical Analysis
Data were compiled and analyzed using SPSS version 25. Continuous variables were expressed as mean ± standard deviation, and categorical data were presented as percentages. Intergroup comparisons were performed using the Student’s t-test for continuous variables and Chi-square test for categorical variables. A p-value of less than 0.05 was considered statistically significant.

Out of the 60 patients initially enrolled, all participants completed the study without any dropouts. Baseline characteristics such as age, gender distribution, and initial severity scores were comparable between the two groups (p > 0.05).

Reduction in Tonsillitis Severity Index (TSI)
At baseline, the mean TSI score was 7.8 ± 1.2 in Group A and 7.6 ± 1.3 in Group B. By the end of 12 weeks, Group A showed a significant reduction in TSI to 2.1 ± 0.9, whereas Group B recorded a mean score of 4.9 ± 1.4 (p < 0.01). These findings suggest a superior clinical improvement in the cold plasma group (Table 1).

Table 1: Comparison of Tonsillitis Severity Index (TSI) Scores between Groups

Visual Analog Scale (VAS) for Pain
Patients in Group A reported a reduction in VAS score from 6.4 ± 1.1 at baseline to 1.5 ± 0.6 post-treatment. In contrast, Group B showed a decrease from 6.2 ± 1.0 to 3.7 ± 1.2 (p < 0.05), indicating a more substantial pain relief in the intervention group (Table 2).

Table 2: Visual Analog Scale (VAS) Score for Pain

Tonsillar Size Regression
Based on a four-point tonsillar grading scale, 76% of Group A participants showed a reduction by at least one grade, compared to only 42% in Group B. Tonsillar size regression was notably more pronounced in the cold plasma group (p = 0.02) (Table 3).

Table 3: Reduction in Tonsillar Size Grading

Recurrence Rate during Follow-up
During the 3-month follow-up, only 2 patients (6.7%) in Group A experienced a recurrence of symptoms, as opposed to 9 patients (30%) in Group B. The recurrence rate was significantly lower in the cold plasma therapy group (p = 0.01) (Table 4).

Table 4: Recurrence of Symptoms during Follow-up

As observed in Tables 1 to 4, cold plasma therapy resulted in significantly better outcomes across all measured parameters, including symptom severity, pain relief, tonsillar regression, and recurrence prevention.

This study demonstrated that cold plasma therapy significantly improves clinical outcomes in patients suffering from chronic tonsillitis when compared to conventional medical management. The marked reduction in Tonsillitis Severity Index (TSI), decreased pain scores, tonsillar size regression, and lower recurrence rates in the intervention group affirm the efficacy and safety of this novel approach.

Chronic tonsillitis has long posed a therapeutic challenge due to its recurrent nature and limited long-term efficacy of antibiotic therapy, often culminating in surgical intervention (1,2). The high recurrence rate and antibiotic resistance associated with traditional treatment have necessitated alternative therapies that can offer both microbial control and anti-inflammatory benefits (3,4).

Cold plasma, a non-thermal, partially ionized gas, has been recognized for its potent antimicrobial, immunomodulatory, and tissue-repairing properties without inducing thermal damage to adjacent tissues (5,6). The mechanism of action involves the generation of reactive oxygen and nitrogen species, which disrupt bacterial cell membranes and biofilms, common in chronic tonsillitis cases (7,8). Our findings support earlier reports indicating that cold plasma effectively reduces microbial burden in mucosal tissues (9).

In the current study, patients treated with cold plasma therapy exhibited a significant drop in TSI scores, reflecting notable symptomatic relief. Similar reductions in symptom severity have been documented in plasma-treated chronic wounds and sinus infections, suggesting a consistent anti-inflammatory effect across mucosal applications (10,11). The decrease in VAS scores among Group A patients further emphasizes the role of plasma in alleviating chronic inflammatory pain, likely through modulation of nociceptive signaling pathways (12).

Tonsillar hypertrophy often contributes to airway obstruction and recurrent infections. In our study, 76% of patients in the cold plasma group showed a reduction in tonsillar size. This aligns with findings from mucosal regeneration studies, where cold plasma stimulated angiogenesis and fibroblast activity, promoting tissue remodeling and shrinkage of inflamed structures (13,14).

Another noteworthy observation was the significantly lower recurrence rate in the intervention group. This is attributed to the long-lasting antimicrobial effect of plasma, which not only eradicates pathogenic organisms but also disrupts their biofilm-forming capabilities—a key factor in recurrent tonsillitis (15,16). The ability to achieve microbial suppression without reliance on antibiotics makes cold plasma a promising tool in reducing the risk of resistance development (17).

Importantly, the therapy was well tolerated with no reports of adverse effects, reflecting its safety and biocompatibility. Previous clinical applications in dermatology, wound healing, and dental procedures have consistently confirmed the minimal cytotoxicity of cold plasma when applied under controlled settings (18,19).

Despite the encouraging results, this study has some limitations. The follow-up duration was limited to three months, which may not fully capture long-term recurrence patterns. Moreover, microbial analysis to determine bacterial load reduction post-treatment was not included. Future research should incorporate microbial diagnostics and extend follow-up periods to validate these findings further.

In conclusion, cold plasma therapy offers a safe, effective, and non-invasive alternative to conventional management of chronic tonsillitis. Its antimicrobial and regenerative capabilities position it as a valuable addition to the therapeutic arsenal, especially in patients unsuitable for surgery or those with recurrent disease unresponsive to antibiotics.

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