Are tonsils a reservoir for Helicobacter pylori infection in children?

Otitis media with effusion: The role of Helicobacter Pylori in its pathogenesis

BACKGROUND

Otitis Media with Effusion (OME) is the most common disease of the middle ear. Different factors play a role in its pathogenesis, such as viral and bacterial infections, allergy, morphological and functional changes of nasal passage, Eustachian Tube (ET), and cleft palate. This study aims to investigate the Helicobacter Pylori presence in middle ear effusions from patients with OME through RT-PCR and compare our results with results from other published articles.

METHODS

The study was carried out from October 2007 to February 2009, in the Department of Otorhinolaryngology of SS. Annunziata Hospital, Chieti, Italy. 132 consecutive patients with OME were included in the study. Fluid in the middle ear was assessed for the presence of Helicobacter Pylori through RT-PCR.

RESULTS

132 consecutive patients with OME were included in the study. The patients were between ages 8 and 78 (median 50); 62 were males (47%), 70 were females (53%), and 53 patients had bilateral OME (40%). 185 samples were collected from 132 patients. Of the 185 samples taken from the ear, 21 (11.35%) were not adequate for the correct execution of the DNA extraction procedure. The remaining 167 samples, subjected to RT-PCR, did not show in any case an increase in fluorescence linked to the FAM fluorophore, thus demonstrating the complete absence of Helicobacter Pylori.

CONCLUSION

Based on the results obtained, we can affirm that although a third of the cases of OME is correlated to the presence of reflux, Helicobacter Pylori does not seem to play any role in the pathophysiology of OME as it cannot be found in endo-tympanic exudate.

Does tonsillectomy affect the outcome of drug treatment for the eradication of gastric H pylori infection? A pilot study

Eradication of Helicobacter pylori, which is associated with diverse gastroduodenal pathologies of varying severity, is sometimes challenging. We conducted a prospective study to determine the effect of tonsillectomy on the eradication of H pylori from the gastrointestinal tract. Our study population was made up of 46 patients-32 females and 14 males, aged 14 to 58 years (mean: 28.84 ± 9.65)-who had chronic tonsillitis and concomitant dyspepsia. An initial gastrointestinal endoscopy was performed to obtain specimens for histology and a rapid urease test. These gastroscopies revealed that 32 patients were H pylori-positive (69.6%) and 14 were H pylori-negative (30.4%); these groups were designated A and B, respectively. The 32 H pylori-positive patients were divided into three subgroups based on the sequence in which they underwent drug therapy and tonsillectomy. All 3 subgroups received the same 14-day combination-drug regimen for eradication of gastric H pylori. The patients in group A1 (n = 12) underwent tonsillectomy prior to receiving drug treatment; 2 months after the cessation of drug therapy, they underwent a second gastroscopy. The patients in group A2 (n = 10) received drug treatment first followed by tonsillectomy; 2 months later, they underwent their second gastroscopy. The patients in group A3 (n = 10) received drug treatment first, then they underwent a second gastroscopy, and then they were taken for tonsillectomy. The success or failure of H pylori eradication was determined by the second gastroscopy. Also, analyses were performed after tonsillectomy to look for H pylori infection in tonsillar specimens. Eradication of gastric H pylori was achieved in 9 of the 12 group A1 patients (75.0%), 8 of the 10 group A2 patients (80.0%), and 7 of the 10 group A3 patients (70.0%); there were no statistically significant differences among the three groups. Likewise, there were no significant differences between any subgroups or combination of subgroups in terms of tonsillar positivity. As far as we know, this is the first study to investigate the effect of tonsillectomy on the outcome of H pylori eradication treatment. In light of our findings, we may speculate that tonsillar tissue does not seem to be a reservoir for H pylori infection. Although tonsillectomy had no significant effect on gastric H pylori eradication in our study, our results might have been skewed by the relatively small size of our sample.

The Role of Helicobacter pylori in Upper Respiratory System Infections: Is it More Than Colonization?

Helicobacter pylori (HP) is recognized as a common chronic human bacterial infection and is the most common cause of gastritis. Recent studies suggest an increased HP prevalence in patients with various extra-digestive inflammatory diseases. Since many respiratory diseases are characterized by chronic inflammation as well as increased immune response, and HP may enter the nasopharyngeal cavity by gastroesophageal reflux, an association between respiratory disorders and HP infection has been suggested. Several studies discover HP in clinical samples from the patients with upper respiratory system infections. Even some of them revealed a relief after the treatment directed to HP eradication. However some studies do not support this theory and whether this association means a definite proof of a causal relationship between HP and respiratory diseases needs to be clarified. In this study, we aimed to review the reports about the role of HP in upper respiratory system infections.

Incidence of Helicobacter pylori infection and their clarithromycin-resistant strains in otitis media with effusion regarding phenotypic and genotypic studies

Helicobacter pylori (H. pylori) are pathogenic bacteria that infect a half of the human population, colonize gastric mucosa and can be found in gastric juice. Reflux of gastric juice has been suggested to be associated with glue ear in children. It has been suggested that tonsil and adenoid tissues are potential reservoirs of H. pylori infection. These observations raise the question as to whether H. pylori infection might have a role in otitis media with effusion (OME) in children. The objectives of this research were to evaluate the incidence and possible role of H. pylori in the pathogenesis of OME in children and to evaluate the clarithromycin-resistant strains. Molecular assessment was done to evaluate the culture results vs. molecular study. A total of 60 children, who were prone to ventilation tube insertion, adenoidectomy and/or tonsillectomy were included in the study. The control group consisted of 40 children who underwent adenoidectomy and/or tonsillectomy without the history of OME. Samples of the middle ear fluid and mucosa, adenoid tissue, tonsillar tissue and gastric lavage were cultured and underwent polymerase chain reaction (PCR) analysis then were assembled by using QIAxcel System as capillary electrophoresis for H. pylori detection. There was significant difference between the results of cultures and PCR (P < 0.05). Middle ear fluid culture was positive for H. pylori in 40% of the patients vs. 56.7% PCR results while middle ear mucosa culture was positive in 20% vs. 26.7% PCR results. Gastric lavage culture was positive in 46.6% of the patients and PCR was positive in 63.3% of the patients. Adenoid culture and PCR were positive in 56.3% for each, while tonsil culture was positive in 70% and PCR was positive in 90%. H. pylori presence in the gastric lavage, the tonsillar and adenoid tissues by culture and PCR was significantly more frequent in the study group compared to the control group. The minimum inhibitory concentration (MIC) values of clarithromycin-resistant isolates ranged from 1.5 to 8 μg/ml. This study showed the presence of H. pylori in around 50% of the patients with OME. PCR revealed its sensitivity than culture techniques. The incidence of clarithromycin resistance was found to be high among the isolates (39.6%).

A study to detect Helicobacter pylori in adenotonsillar tissue

We conducted a prospective study to investigate the possibility of Helicobacter pylori colonization on tonsillar and adenoid tissues. Our study group was made up of 84 consecutively presenting children aged 4 to 12 years who had undergone adenotonsillectomy or adenoidectomy with or without ventilation tube insertion. The excised specimens were analyzed by rapid urease testing and histopathologic examination to detect H pylori. Histologic sections were subjected to hematoxylin and eosin staining and Giemsa staining as performed in routine gastric biopsies. We found no H pylori colonization in any specimen. Therefore, we consider the possibility of H pylori colonization of adenotonsillar tissue unlikely, even though the authors of some recent studies have reported such a finding. Other means of detecting possible H pylori colonization in the upper aerodigestive tract rely on invasive biopsy procedures, which are difficult to use in clinical practice. Therefore, on the basis of our findings and our review of the literature, we conclude that looking for H pylori in the upper aerodigestive tract is not only clinically useless, but damaging, as well.

Does helicobacter pylori have a role in the etiology of adenoid hypertrophy?

To investigate whether there is any association between nasopharyngeal reflux and adenoid hypertrophy in children by using 24-h pH monitoring with dual probe and to determine whether Helicobacter pylori simply colonises in adenoid tissue or it is present there temporarily due to extraesophageal reflux. A prospective study at a tertiary referral center. Thirty-two patients who underwent adenoidectomy, aged ranged between 4 and 13 were included. All children with adenoid hypertrophy underwent 24-h pH monitoring with a dual probe. Proximal probe was placed in the nasopharynx. The presence of nasopharyngeal reflux and gastroesophageal reflux were investigated by 24-h pH monitoring. The presence of H. pylori was investigated in adenoidectomy samples by HP-fast test. Of the 32 patients who underwent adenoidectomy, 5 had nasopharyngeal reflux positivity while 27 patients did not show nasopharyngeal reflux positivity with pH monitorisation. Helicobacter pylori could not be detected in 5 nasopharyngeal reflux positive children while 3 of 27 nasopharyngeal reflux negative children showed H. pylori positivity, one of them in the mucosa and others in the core. This study demonstrated the high incidence of nasopharyngeal reflux and gastroesophageal reflux in adenoid hypertrophy and the possible colonisation of H. pylori in the adenoid tissue. This may change the assesment of children with adenotonsillar hypertrophy in near future. However, more placebo controlled and double blind studies and larger series are still needed to support this hypothesis.

Detection of Helicobacter pylori in adenotonsillar tissue of children with chronic adenotonsillitis using rapid urease test, PCR and blood serology: a prospective study

OBJECTIVE

Contradictory results have been reported regarding Helicobacter pylori (H. pylori) detection in adenotonsillar tissue. The aims of this study were to investigate whether adenotonsillar tissue of symptomatic children with chronic adenotonsillitis harbors the H. pylori organism, using two biopsy-based invasive methods namely; rapid urease test (RUT) and polymerase chain reaction (PCR) as well as blood serology and to compare the results obtained from each of these methods to the "gold standard".

METHODS

This prospective clinical study was carried out on 20 children aged between 2 and 10 years scheduled for tonsillectomy +/- adenoidectomy in a tertiary referral center. Exclusion criteria included: use of antacids, H(2) blockers or antibiotics during the previous month before surgery and adenotonsillectomy for obstructive sleep apnea. Core biopsy samples from resected adenotonsillar tissue was tested for H. pylori detection using both RUT and PCR assay for the ureC gene. Preoperative patient venous blood samples were also tested for H. pylori IgG antibodies. As a "gold standard", examined tissue was considered to be H. pylori infected if the two biopsy specimen-based methods (RUT and PCR) yielded positive results.

RESULTS

Thirty adenotonsillectomy specimens were tested (20 tonsils and 10 adenoids). RUT was positive in 16 (53.3%) specimens (12 tonsils and 4 adenoids). According to the "gold standard", 11/16 were considered false-positive, yielding this test sensitivity 100% and specificity 56%. The ureC gene sequence was detected by PCR in 5 (16.6%) specimens (3 tonsils and 2 adenoids), all of which were also positive by RUT, thus were considered H. pylori infected. Accordingly, PCR had a 100% sensitivity and specificity. Serology testing was positive for H. pylori IgG antibodies in 4/20 patients (20%), only two of them were found to have H. pylori infected adenotonsillar tissue.

CONCLUSIONS

Based on our findings it seems that adenotonsillar tissue may constitute an extra-gastric reservoir for H. pylori in symptomatic children with chronic adenotonsillitis. RUT was found to be of less accuracy than PCR in H. pylori detection in an extra-gastric location, thus results of previous studies using this test alone for detection of oral H. pylori should be treated with caution.

Does Helicobacter pylori play a role in the development of chronic adenotonsillitis?

OBJECTIVE

Evaluation of the possible relationship between chronic adenotonsillitis and Helicobacter pylori (HP).

PATIENTS AND METHODS

The study was performed prospectively on 91 pediatric patients who underwent tonsillectomy, adenoidectomy or adenotonsillectomy due to chronic tonsillitis and/or adenoiditis. The adenotonsillectomy specimens were examined for HP colonization by rapid urease test (RUT) and immunohistochemical evaluation. Before surgery, anti-HP IgG and IgA antibody titers were detected by enzyme linked immunosorbent assay (ELISA) test in venous blood samples of the patients.

RESULTS

The RUT was positive in only two of the adenoidectomy specimens (2.2%) and in none of the tonsillectomy specimens. A positive result was not detected in any tonsillectomy specimens using immunohistochemical examination. Serum IgG antibody was positive in 21 (23%) patients, IgA antibody was detected in 7 (7.69%) patients and both tests were positive only in 3 (3.29%) patients.

CONCLUSION

The results of this study suggested that HP would not colonize in tonsil tissue of patients with chronic tonsillitis.

Comparison of Helicobacter Pylori Colonization on the Tonsillar Surface versus Tonsillar Core Tissue as determined by the CLO test

We conducted a prospective study to determine the correlation between the presence or absence of Helicobacter pylori on the tonsillar surface and in the tonsillar core as determined by the Campylobacter- like organism (CLO) rapid urease enzyme test. Our study population was made up of 55 patients who underwent adenoidectomy, tonsillectomy, or both from December 2002 through April 2003 at Khalili Hospital in Shiraz, Iran. Of these 55 patients, 45 (82%) were positive and 10 (18%) were negative for H pylori colonization as determined by CLO testing. Analysis of samples obtained from individual patients revealed differences in H pylori colonization between tonsillar surface samples and the core tissue samples. Of 106 tonsils obtained from 53 patients who underwent adenotonsillectomy or tonsillectomy, H pylori was found on 56 tonsillar surface samples (53%) and 24 tonsillar core samples (23%); only 13 tonsils (12%) contained H pylori both on the surface and in the core. We conclude that a surface swab is neither specific nor sensitive as an indicator of the presence or absence of H pylori colonization in tonsillar core tissue.

Tonsillar colonization is unlikely to play important role in Helicobacter pylori infection in children

OBJECTIVE

To determine (i) seroprevalence of Helicobacter pylori (HP) infection in children undergoing tonsillectomy, (ii) possible HP colonization on tonsils of children and its importance in HP transmission, and (iii) if four examined socio-economic factors are the risk factors for HP transmission and HP colonization on tonsils in children.

METHODS

Rapid urease test (RUT) of tonsils, and serologic blood tests for HP were performed in 77 children (aged 4-14 years) in Bosnia and Herzegovina (B-H), undergoing tonsillectomy. RUT positive tonsils were cultured for HP. RUT positive children were tested using (13)Carbon-urea breath test ((13)C-UBT). Information about socio-economic potential risk factors was obtained from the parents.

RESULTS

Out of 139 pharyngeal and palatine tonsils, 17 palatine tonsils in 14 children were RUT positive and had negative HP culture. Eight children had positive both RUT and (13)C-UBT. There was no significant difference between children with hypertrophy and those with recurrent tonsillitis comparing their serologic tests results. There was no significant difference between seronegative (n=61) and seropositive (n=16) children comparing their age, sex, parental education level, owning a family courtyard, attending a children's collective, and owning a pet cat.

CONCLUSIONS

The results in this prospective study do not support the notion that tonsils are an important reservoir for HP transmission in children in B-H. The examined socio-economic factors did not enhance HP seropositivity rate in children.

Is Helicobacter pylori really present in the adenoids of children?

Adenoid hyperplasia is a common cause of nasal obstruction in the pediatric age group. Recently, the adenoids were shown to harbor Helicobacter pylori (HP) based only on the rapid urease test (RUT). We conducted this pilot study to identify the presence of HP in the adenoids histologically and assess the reliability of both the RUT and histology in detecting HP in an extragastric location, using nested (two-steps) polymerase chain reaction (nPCR). Consecutive patients undergoing adenoidectomy for obstructive adenoid hyperplasia were enrolled. Adenoid specimens were subjected to the RUT. Histological sections stained with hematoxylin and eosin, Giemsa and Warthin-Starry were examined. We then used nPCR to detect the presence of HP in the studied specimens. Twenty-five patients (3-10 years; mean of 5.5 years) were enrolled. Twenty-one (84%) adenoids were positive by the RUT. Seventeen (68%) had bacteria on histological sections; four (16%) contained HP-like organisms. However, all specimens were negative by nPCR. No patient had a history of symptoms suggestive of laryngopharyngeal reflux within 6 months of the study. In conclusion, the children enrolled in this study did not have HP in their adenoids. High false positive results can occur with the RUT when used on adenoid tissues. It is not possible to rely solely on morphology to detect HP in an extragastric location. The nPCR remains the best way to identify HP accurately, but does not imply its presence in an active role.

Association of cagA+ Helicobacter pylori with adenotonsillar hypertrophy

Cytotoxin-associated gene A (cagA) of Helicobacter pylori (H. pylori) encodes a highly immunogenic and virulence-associated protein. The presence of cagA(+) H. pylori strains in tonsil and adenoid tissues may affect clinical outcome. The aim of the present study was to determine the presence of H. pylori cagA gene in tonsil and adenoid tissues and to establish the potential association of cagA(+) H. pylori in recurrent adenotonsillitis (RAT) and adenotonsillar hypertrophy (ATH). For this aim, a total of 118 tissue samples (71 tonsil and 47 adenoid tissues) were collected from a total of 71 children: 28 cases with RAT and 43 cases with ATH. The samples were analyzed for glmM gene to detect the infection with H. pylori by polymerase chain reaction (PCR). H. pylori-positive samples were further analyzed for the presence of the cagA gene. The PCR analysis showed that 29 samples (24.6%) were positive for H. pylori. Seventeen out of these 29 samples (58.6%) were found positive for cagA; the cagA gene was detected in 12 samples of ATH and 5 samples of RAT. The presence rate of cagA gene was significantly higher (p < 0.05) in ATH patients than that found in RAT patients. These results suggest that presence of cagA(+) H. pylori may be associated with development of ATH.

Helicobacter pylori infection in the pharynx of patients with chronic pharyngitis detected with TDI-FP and modified Giemsa stain

AIM: To detect whether there is Helicobacter pylori (H pylori) colonization in the pharynx mucous membrane of healthy people and whether chronic pharyngitis is related to H pylori infection.

METHODS: Fifty cases of chronic pharyngitis refractory over three months were prospectively studied from March 2004 to August 2004 in the otolaryngology outpatient department of the Second Hospital of Xi’an Jiaotong University. Template-directed dye-terminator incorporated with fluorescence polarization detection (TDI-FP) and modified Giemsa stain were used to examine pharynx mucous membrane tissue for H pylori colonization in the patients with chronic pharyngitis and the healthy people as a control group.

RESULTS: In the control group, no people were detected to have H pylori in the pharynx. In contrast, in 50 cases with chronic pharyngitis, 19 (38.0%) cases were H pylori positive with a TDI-FP assay and 4 (8%) cases were TDI-FP positive with Giemsa staining in the pharynx. Sixteen of the 50 pharyngitis cases had stomach ailment history, 11 cases (68.8%) of these 16 patients were determined to be H pylori positive in the pharynx with the TDI-FP assay. χ² test showed that this infection rate was remarkably higher (P = 0.0007) than that in the cases without stomach ailment history. Giemsa staining showed that 3 cases (18.8%) of the patients with stomach ailment history were infected with H pylori in the pharynx, which was remarkably higher (P  = 0.042) than that in the patients without stomach ailment history (1 case, which was 2.9%).

CONCLUSION: H pylori may not be detected in the pharynx of healthy people. Chronic pharyngitis may be related to H pylori infection. The infection rate with H pylori in the pharynx is higher in patients with stomach ailment histories than in patients without stomach ailment histories, suggesting that chronic pharyngitis may be related to stomach ailment history.

Does Helicobacter pylori have role in development of otitis media with effusion?

OBJECTIVE

Recently, it was suggested that tonsil and adenoid tissues may act as a reservoir for Helicobacter pylori (HP). A connection between chronic tubotympanal disorders and gastroesophageal reflux is well recognized, but the mechanism underlying this relationship is unclear. In this study, we investigated possible presence of HP in adenoid tissue and middle ear effusions in patients with chronic otitis media with effusion (OME) and we compared the data with the results of the children who had adenoid hypertrophy without OME.

METHODS

The study was comprised of 38 consecutive children with adenoid hypertrophy and/or chronic OME. The patients were divided into two groups. The first group included 18 subjects having OME+adenoid hypertrophy and the second group included 20 subjects having solely adenoid hypertrophy. Each patient underwent the appropriate surgical procedure; myringotomy, placement of tympanostomy tubes and/or adenoidectomy. After myringotomy, the middle ear effusions were collected in a suction and collection device and a core biopsy specimen was taken from each adenoid tissue following adenoidectomy. DNA extracted from these samples was used for the amplification of 23S ribosomal RNA gene of HP by real-time polymerase chain reaction (RT-PCR).

RESULTS

In the first group 34 effusion samples were obtained from ears of 18 patients (two had unilateral OME). HP was found to be positive in 12 children (67%) and 16 of 34 ears (47%) with RT-PCR. In eight children HP was positive in only one ear and in four children in both ears. No positive reaction was seen in tissue samples obtained from adenoids of these patients. In the second group a positive reaction was seen in adenoid tissue of only one patient.

CONCLUSIONS

This study showed that there is HP presence in middle ears of the children with chronic OME, indicating HP having a possible role in OME pathogenesis. In addition, we demonstrated HP presence in only 1 of 38 adenoid specimens supporting the idea that adenoid tissue does not act as a reservoir for HP.