In situ localization of Streptococcus pyogenes during acute tonsillitis: an immunocytochemical study with gold markers

Epithelial cells were harvested from the surface of the palatine tonsils of seven patients with current acute tonsillitis, proven culture-positive for Streptococcus pyogenes. The epithelial cells harboured attached bacteria, which expressed positive affinity to gold-labelled antiserum to S. pyogenes. The gold particles adhered selectively to the bacterial capsules. The microorganisms were held in place by projections protruding from the epithelial cells, which were in close contact with the pili of the bacteria. In some areas, positive immunogold-labelled bacteria intermingled with bacteria lacking such labelling. None of the culture-negative controls harboured epithelial cells with positive immunogold-labelled bacteria. Orally administered phenoxymethylpenicillin caused a significant reduction in both culture-positive S. pyogenes and bacteria displaying positive coating with specific gold-labelled antiserum to S. pyogenes.

[The morphofunctional characteristics of the palatine and pharyngeal tonsils in children with chronic tonsillitis and adenoids]

22 palatine and 10 pharyngeal tonsils of 20 children, 4 to 15 years of age, with chronic tonsillitis and adenoids were studied histologically and immunohistochemically. The material was obtained at tonsillectomy, adenotomy and adenotonsillectomy. The expression of LCA, CD20, CD45 RO, CD45 RA, CD68 and HLA DR-antigen was determined immunohistochemically. Functional heterogeneity of the whole lymphoid population in the tonsil tissue is structured by dividing lymphoid tissue into T- and B-regions. However, this subdivision is relative. Interpenetration of T- and B-cells into structurally determined functional zones reflects cooperative cell relations in the immune response the obligatory participant of which are non-lymphoid cells of the microenvironment: antigen-representing macrophages of the follicle germinative centres and reticular epitheliocytes in the regions of lymphoepithelial symbiosis. HLA-DR-antigen expression of the reticulum epithelium cells and the presence of activated T-lymphocytes in the lymphoepithelial symbiosis zones allow one to consider these zones as an immunoregulatory compartment of the tonsils.

The production of immunoregulatory cytokines is localized to the extrafollicular area of human tonsils

The localization and production at the single cell level of 19 different human cytokines, IL-1 alpha, IL-1 beta, IL-1ra, IL-2, IL-3, IL-4, IL-5, IL-6, IL-8, IL-10, IL-13, TNF alpha, TNF beta, IFN gamma, GM-CSF, G-CSF, and TGF beta 1-3, were studied in cryopreserved tonsillar tissue using immunohistochemical staining. The cytokine producing cells, with the exception of IL-1 expressing cells, had a characteristic morphology due to the accumulation of cytokine onto the Golgi organelle. The production of each cytokine was localized to specific compartments in tonsillar tissue sections from children with tonsillar hypertrophy or recurrent tonsillitis in the resting state. Immunoregulatory cytokines such as IL-2, IL-3, IL-4, G-CSF, GM-CSF and TGF beta were produced in the extrafollicular area and entrapped on the cell membranes as well as in pudels in the extracellular matrix surrounding the producer cells. The dominating cytokines both in tissues from recurrent tonsillitis and tonsillar hypertrophy were GM-CSF, G-CSF, and TGF beta 1-3 which were synthezised predominantly in the reticular crypt site. IL-1 alpha, beta and IL-1ra, on the other hand, were localized to the surface and crypt epithelium and to scattered regions in the extrafollicular area. IL-2, IL-6, IFN gamma and IL-10 were found much more often in sections obtained from recurrent tonsillitis tissue compared with those from tonsillar hypertrophy. Reversely, an excessive production of IL-4 was noted in tonsillar hypertrophy compared with that in recurrent tonsillitis. Thus, concomitant production of multiple cytokines was evident with similarities but also differences in cytokine pattern between the two groups studied. The data suggest that T-cell mediated B-cell activation and differentiation take place in the extrafollicular area. Children with recurrent tonsillitis had a higher amount of B-cells and monocytes compared with children with tonsillar hypertrophy. However, the number of CD3, CD4, CD8 or cytoplasmic Ig-positive cells did not differ between the two groups.

Early adenotonsillectomy for relief of acute upper airway obstruction due to acute tonsillitis in children

Early adenotonsillectomy (TA) for acute upper airway obstruction precipitated by acute tonsillitis was performed in 17 children admitted to the Royal Childrens Hospital over a 15 year period. The age ranged from 13 to 83 months (mean 37 months) and surgery was performed from 1 to 11 days (mean 5.8 days) following admission. One child who underwent surgery within 24 h of admission had an intraoperative blood loss of 250 ml requiring transfusion, but there were no cases of post operative hemorrhage. Airway obstruction was relieved by surgery in all cases and patients were discharged 1 to 6 days (mean 2.4 days) later. Early TA should be considered for relief of upper airway obstruction due to acute tonsillitis after an initial 24 h of intravenous antibiotic therapy.

Reduced reticulization of palatine tonsils with IgA nephropathy

Tonsillar abnormalities have been observed in patients with IgA nephropathy (IgAN). In addition, it has been suggested that the reticulization of tonsillar crypt epithelium is important in tonsillar immunity. Therefore, we investigated reticulization of this area in patients with IgAN (10 cases) and compared results with those of control patients who exhibited recurrent tonsillitis or tonsillar hypertrophy (12 cases). Immunohistochemical staining of anti-keratin antibody PKK1 was employed to visualize reticulization. Tonsils of controls showed well developed reticular crypt epithelia with lymphoepithelial symbiosis, and the non-reticulated area was less than 7% (mean 1.9%, range 0-6.3%) of the total crypt epithelia per overall section. In IgAN tonsils, however, non-reticulated crypt epithelium was frequently observed and, in the advanced stage of IgAN, exceeded 50% (mean 62%, range 50-69%) of total crypt epithelia. The extent of glomerular damage in IgAN patients correlated significantly with the percentage of the area of non-reticulated crypt epithelia in palatine tonsils with a correlation coefficient of 0.91. Considering together with our finding that PKK1-positive epithelial reticular cells strongly expressed HLA-DR antigens in normal tonsils, the low level of reticulization in IgAN patients may induce the unusual immunity responsible for the pathogenesis of IgAN.

Chronic tonsillitis in children: activation of polymorphonuclear cells from peripheral blood and tonsillar tissue. In vitro production of MPO, ECP and EPX

Activation of polymorphonuclear cells (PMNs), neutrophils and eosinophils, occurs in response to infections. Myeloperoxidase (MPO) is an enzyme contained in neutrophils with toxic activity for many microorganisms including bacteria. Fosinophil cationic protein (ECP) and eosinophil X protein (EPX) are released by activated eosinophils in response to different inflammatory stimuli. Determination of serum levels of MPO, ECP and EPX permits assessment of the state of activation of these cells. The purpose of this study was to evaluate the state of activation of neutrophils and eosinophils present in tonsillar tissue and peripheral blood from 30 children (18 boys and 12 girls) undergoing tonsillectomy for chronic tonsillitis. For determination of serum levels of MPO, ECP and EPX, peripheral blood samples were obtained at the time of surgery: PMNs were separated by erythrosedimentation from peripheral blood and from tonsillar tissue after surgery and cultured for 7 days. The cells were plated (10(5) well) and the plates were incubated in 5% CO(2), 7% O(2), 80% N(2). After 2, 24, 48, 72, 96, 120, 144 h, supernatants were removed from the cultures of both tonsillar tissue and peripheral blood PMNs for determination of in vitro release of MPO, ECP and EPX. The assays were carried out using a radioimmunotechnique (RIA, Pharmacia) and the concentrations of the three proteins (mean/6 wells) for each time were expressed in mu g/l. The data suggest activation of PMNs in children with chronic tonsillitis.

Histopathological concept of chronic tonsillitis in children

The purpose of this study was to ascertain to what degree the clinical entity recurrent tonsillitis (RT) is associated with a histopathological pattern of chronic tonsillitis. Cases of idiopathic tonsillar hypertrophy (ITH) not associated with recurrent infections were used for comparison. We performed a histopathological study of 126 palatine tonsils of children (57 cases due to RT and 69 due to ITH). The following features were evaluated: cryptal reticulation, the relative amount of diffuse and follicular lymphoid tissues, the intensity of parenchymal fibrosis, the papillary arrangements of the epithelium, the amount of debris in the lumen of the crypts, and the presence of keratin cysts. There was no significant quantitative difference between the two groups (RT and ITH) and we did not find a histological distinctive pattern of RT or ITH. Recurrent infection in the tonsils in children is not associated with a histopathological pattern which could be termed chronic non-specific tonsillitis and is clearly distinguishable from idiopathic tonsillar hypertrophy.

The B-cell development in tonsillar lymphoid follicles

The palatine tonsils, and particularly the nasopharyngeal tonsil (adenoid), may be functionally comparable to nasal-associated lymphoid tissue in rodents. Primary follicles occur in human tonsils at 16 weeks' gestation, and formation of germinal centres (GC) takes place shortly after birth. The GC arise in T-cell-dependent B-cell responses and are associated with: i) clonal expansion; ii) somatic hypermutation in immunoglobulin variable (Ig V)-region genes; iii) positive selection of B cells based on affinity for antigen; iv) differentiation to memory B cells and plasma cells; and v) induction of the J-chain gene. The follicular dendritic cells (FDC) of GC retain native antigen which stimulates growth of B-cell blasts and hypermutation of their Ig V genes. The resulting centrocytes die by apoptosis unless they are selected by antigen. Cognate interaction between CD4+ helper T cells and B cells is important to promote downstream switching of the heavy chain constant (CH) genes. In human tonsillar GC this process normally gives rise mainly to IgG (55%-72%) and IgA (13%-18%) immunocytes, both isotypes normally being partially associated with J-chain expression (36% and 29%, respectively). Because J chain is a key peptide in secretory IgA, tonsillar GC may contribute precursor cells to mucosal effector sites. Thus, mucosal immunity can be induced in the airways by nasal immunization, and the level of nasopharyngeal and salivary secretory IgA is decreased after adenotonsillectomy.

The role of the middle ear and tonsil in the etiology of febrile convulsions

The middle ear and tonsil are thought to be important sources of infection in children with febrile seizures. However, these patients are rarely examined by an otolaryngologist in the acute phase and we are unaware of any previous studies where otolaryngologists have documented the presence of acute suppurative otitis media (ASOM) and tonsillitis in a series of children with febrile convulsions. We carried out a prospective study on 47 children admitted to two Dublin hospitals with a diagnosis of simple febrile convulsion. All children were examined by an otolaryngology resident within 6 h of admission. Nine children were noted to have ASOM and 18 had acute tonsillitis. The otolaryngology resident's opinion of the condition of the ears and throat often differed from that of the admitting pediatric resident, as documented in the clinical records. We review the recent literature on febrile convulsions and discuss the possible role of the otolaryngologist in the prevention of seizure recurrence.

The indication for tonsillectomy in children following peritonsillar abscess

The clinical course of 19 consecutive children treated for peritonsillar abscess (PTA), in the Chaim Sheba Medical Center, between 1988-1992 was retrospectively reviewed. The abscess was drained through an incision (12 children) and by needle aspiration (7 children), under local (11 children) or general (8 children) anesthesia. One child suffered from recurrent bouts of tonsillitis after the abscess resolved and eventually underwent tonsillectomy. Two others, with a pre-PTA history of recurrent tonsillitis (T+) underwent interval tonsillectomy. Recurrent PTA did not develop in any of the 16 non-operated children. The involvement of mainly older children can explain both the low rate of the pre-PTA history of T+ and the number of children whose abscess could be drained under local anesthesia. Tonsillectomy should be indicated in cases of recurrent PTA or in children with a pre-PTA history of T+. The need for general anesthesia for draining the abscess in young children does not seem, in itself, to warrant a routine hot tonsillectomy.

Neutrophil activating activity of tonsillar cells from patients with tonsillitis

The previous paper demonstrated that tonsillar cells cultured in vitro in the presence or absence of a streptococcal preparation, OK-432, produce factors that activate various neutrophil functions. In the present study, examination was made of the factor productivity of tonsillar cells from patients with chronic tonsillitis of varying severity, and palmoplantar pustulosis (PPP). Tonsillar cells from patients with severe tonsillitis and PPP incubated with culture medium alone produced a much greater amount of active factors compared with those from patients with mild tonsillitis. When tonsillar cells were incubated in the presence of OK-432, augmentation in factor production by the addition of OK-432 was less in former than latter cases, suggesting that factor production from tonsils correlates with the course of inflammation in this organ.

[Peripheral nervous system in children with chronic inflammatory otorhinolaryngologic diseases]

A comparative evaluation of central and vegetative nervous as well as cardiovascular systems in 20 normal children and 45 patients with ENT problems found out vegetative lability in 8 children. Three of them were from the control healthy group, 4 had tonsillitis, 1 purulent sinusitis. These children were referred to the vegetative dystonia risk group. In 28 patients (9.3 and 16 cases of purulent-polypous, purulent and decompensated tonsillitis, respectively) parasympathicotonic and sympathicotonic shifts revealed in the baseline vegetative tone and vegetative reactivity require adequate therapeutic correction.

Peritonsillar abscess as a cause of transient velopharyngeal insufficiency

"Hot potato voice" is a characteristic sign of peritonsillar abscess and peritonsillitis. Our findings show that the hot potato voice is the result of an underlying transient velopharyngeal insufficiency combined with muffled oral resonance. The hot potato voice should be distinguished from the muffled oral voice which can be occasionally encountered in cases of severe tonsillitis. The velopharyngeal insufficiency is the result of transient dysfunction of the palatal muscles on the affected side. Transient negative middle-ear pressure indicating eustachian tube dysfunction was found in few of the patients in whom concomitant sinusitis was also present. The clinical, nasendoscopic, and radiologic findings are analyzed and discussed. We believe that this phenomenon is valuable as a research tool for the investigation of the anatomy and physiology of the velopharyngeal valve.

Medullasin levels in neutrophils of patients with pustulosis palmaris et plantaris

Medullasin is one of the serine proteases found in human bone marrow cells. The protease in granulocytes is assumed to play an important role in the induction of chronic inflammation. We measured the medullasin levels as a parameter of neutrophil function in granulocytes from patients with pustulosis palmaris et plantaris. All 17 patients studied underwent tonsillectomies, and the changes in the amount of medullasin were followed after surgery. Seven of the 17 patients were cured during the follow-up period (average: 21 months). In all the patients in whom PPP improved, the medullasin levels decreased significantly from the period of active disease when pustules were present to the inactive period. The amount of medullasin did not fall significantly in patients whose PPP did not improve. It is concluded that medullasin levels may reflect the activity of PPP and may serve as a criterion for performing a tonsillectomy.

The importance of pulmonary function tests in adenotonsillectomy indications

Children who had undergone adenotonsillectomy for recurrent adenotonsillitis showing no signs of clinical or radiological obstructive manifestations were evaluated with pulmonary function tests before, and one month after the operation. In relation to the result obtained by function tests, 60% of 45 cases (27) had the findings of mild obstructive pulmonary disease whereby these findings were in transient character that vanished after the operation. The following parameters were measured and found that they were all increased, mean FVC from 82.22 +/- 6.82 to 93.11 +/- 7.81 (p < 0.01), mean PEF from 77.60 +/- 8.38 to 88.60 +/- 5.57 (P < 0.01), mean FEVI from 74.28 +/- 11.68 to 90.15 +/- 7.28 (p < 0.01), mean FEF 25 from 71.44 +/- 11.53 to 83.53 +/- 6.40 (p < 0.01), mean FEF 50 from 69.53 +/- 14.53 to 84.37 +/- 7.72 (p < 0.01), mean FEF 75 from 70.08 +/- 12.15 to 85.48 +/- 7.15 (p < 0.01). In conclusion, pulmonary function tests could reveal the obstructive effects of adenotonsillar hypertrophy with no clinical or radiological obstructive findings, and could be useful in surgical indications of adenotonsillar hypertrophy dur to recurrent infections in children.

[The characteristics of a streptococcal-etiology angina in an industrial center]

Results are presented of a study of the clinical picture of angina of streptococcal etiology in conditions of a large industrial center. The authors analyzed the state of unspecific adaptative reactions of the body at different periods of the disease. Conclusions on the characteristic aspects of sanogenesis in this type of pathology are made.

Hemorrhagic tonsillitis

Eleven patients with acute and/or chronic tonsillitis, who presented with a spontaneous tonsillar hemorrhage are reported and discussed. Two patterns of hemorrhage were noted: 1. diffuse, parenchymal bleeding and 2. localized bleeding from dilated surface vessels. Pharyngeal culture for group A beta-hemolytic Streptococcus was positive in six patients (55%). Monospot, heterophile antibodies, complete blood cell count, prothombin time, partial thromboplastin time, and viral studies did not consistently demonstrate any abnormality. Two patients, however, did have an elevation in liver enzymes. In five patients, the bleeding stopped spontaneously; in five patients the bleeding was controlled with local chemical cautery. In two patients, Avitene was used for hemostasis. One other patient's bleeding was controlled by electrocautery while the patient was under anesthesia for endoscopic evaluation of hemoptysis. Two patients required blood transfusions; one of these patients had a history of factor IX deficiency. Four case histories are discussed in detail to illustrate the varied clinical presentation and some pitfalls in diagnosing and managing this rarely reported complication of tonsillitis. Possible mechanisms for the pathophysiology include increased tonsillar blood flow, necrosis of tonsillar surface cells, and trauma to dilated surface vessels. No common bacterial or viral etiology could be determined in this rare, but potentially serious, complication of tonsillitis.