Long-term effects of pediatric adenotonsillectomy on serum immunoglobulin levels: results of a randomized controlled trial

Tonsillectomies are associated with an increased risk of meningococcal carriage

BACKGROUND

Neisseria meningitidis is a commensal organism with the potential to cause life-threatening disease. Colonisation is most common in adolescence and young adulthood. Various social factors have been associated with an increased risk of meningococcal carriage, but less is known about host factors that may influence the carriage status. Tonsillectomies have been shown to alter the pharyngeal microflora. This study assessed whether a history of tonsillectomy affects the risk of meningococcal colonisation.

METHODS

Oropharyngeal swabs were collected from 15- to 16-year-old adolescents and 18- to 20-year-old young adults. Conventional culture methods and qPCR were used to detect meningococci. 16S qPCR was done to assess bacterial abundance in the samples. Data on history of tonsillectomies were collected from a central national database and the national university hospital.

RESULTS

A total of 722 samples were collected; 197 from adolescents and 525 from young adults. Thirty-five participants were colonised with meningococci (4.8%). Eighty-eight participants had undergone a tonsillectomy, of which 10 (11.4%) carried meningococci, compared to 4% of those that had not. Prior tonsillectomy was associated with a threefold increased risk of meningococcal colonisation (OR 3.10, 95% CI 1.44-6.70, p = 0.004). Tonsillectomies remained a risk factor after adjusting for age, sex, recent antibiotic use and meningococcal vaccinations (aOR 2.49, 95% CI 1.13-5.48, p = 0.024).

CONCLUSIONS

A history of tonsillectomy is associated with an increased risk of meningococcal colonisation. More studies are needed to shed light on the effects of tonsillectomies on the pharyngeal microbiome.

Efficacy of montelukast for adenoid hypertrophy in paediatrics: A systematic review and meta-analysis

INTRODUCTION

Leukotrienes play a significant role in the pathogenesis of adenoid hypertrophy (A.H.). Therefore, we aimed to analyse the role of montelukast, a leukotriene receptor antagonist, alone or in combination with mometasone, a potent local intranasal steroid, for the treatment of A.H.

METHODS

Participants were children with A.H. were treated with montelukast alone or montelukast and mometasone furoate. The main outcome measures were effect of montelukast on clinical symptoms of A.H. A literature review was conducted using online search engines, Cochrane Library, PubMed, Web of Science and Scopus, for randomized clinical trials assessing children with A.H. treated with montelukast alone or montelukast and mometasone furoate. Seven randomized clinical trials (RCTs) were included with 742 children.

RESULTS

Our study reveals that montelukast alone or in combination with intranasal mometasone furoate significantly improves clinical symptoms of adenoid hypertrophy such as snoring, sleeping disturbance, mouth breathing and A/N ratio. Montelukast was superior to placebo in decreasing snoring (SMD = -1.00, 95% CI [-1.52, -0.49]), sleep discomfort (SMD = -1.26, 95% CI [-1.60, -0.93]), A/N ratio (MD = -0.11, 95% CI [-0.14, -0.09]) and mouth breathing (SMD = -1.36, 95% CI [-1.70, -1.02]). No difference was detected between montelukast and mometasone versus mometasone alone in snoring (SMD = -0.21, 95%CI [-0.69, 0.27]); however, the combination group was superior to the mometasone alone in mouth breathing (SMD = -0.46, 95% CI [-0.73, -0.19]).

CONCLUSIONS

The limitation of studies included a small sample size, with an overall low to medium quality. Thus, further larger, higher-quality RCTs are recommended to provide more substantial evidence.

Effects of tonsillectomy and adenoidectomy on the immune system

Surgical removal of the tonsils and adenoids, important immune organs, is a frequent and recurrent class of surgery, and currently, there is no consensus on the effects these surgical procedures may have on the immune system. Here, we examine individual studies on tonsillectomy, adenoidectomy, and adenotonsillectomy, discuss their postoperative humoral and cellular immune changes, and explore their effects on the incidence of related diseases. There is evidence that these three surgeries have no negative effects on humoral immunity; however, there has been contrary results. Furthermore, these procedures seem to have no significant effects on cellular immunity, although tonsil and adenoid removal can cause an increased incidence of certain illnesses, especially infectious diseases. Based on this comprehensive review, we conclude that the removal of tonsils and adenoids does not negatively affect cellular and humoral immunity. However, surgery may lead to an increased incidence of related infectious diseases. This finding may inform the surgeon's decision to perform the procedure in a clinical setting.

Can the effectiveness of tonsillectomy for PFAPA syndrome be predicted based on clinical factors

OBJECTIVES

To evaluate the clinical factors associated with the outcome of tonsillectomy in children with periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome, thereby clarifying who would most likely benefit from that surgery.

METHODS

This was a case-control study of 53 PFAPA patients who underwent tonsillectomy and were divided into a complete-resolution group and a postoperative-fever group. Logistic regression analyses were performed using 17 clinical factors as variables to identify factors associated with the surgical outcome. Hierarchical cluster analysis was also performed to evaluate for relationships between phenotypes and surgical outcomes.

RESULTS

Thirty-nine (73.6%) patients had complete resolution after tonsillectomy. In simple logistic regression analysis, the surgical outcome showed significant positive trends with late-onset (odds ratio [OR] 7.1, P = 0.02) and presence of headache (OR 6.5, P = 0.01). In stepwise multiple logistic regression analysis adjusted for age at onset, presence of headache was significantly associated with complete resolution (OR 6.5, P = 0.01). The complete resolution rates for each combination of headache status and age at onset were as follows: presence of headache/age at onset ≥36 months, 100% (14/14); presence of headache/age at onset <36 months, 76.9% (10/13); absence of headache/age at onset ≥36 months, 75.0% (6/8); and absence of headache/age at onset <36 months, 43.8% (7/16). In hierarchical cluster analysis, complete resolution, age at onset, and headache were in the same cluster.

CONCLUSIONS

PFAPA patients with headache and late onset responded well to tonsillectomy. The mechanisms underlying this association may warrant further investigation.

Tonsillectomy in Adults over 40 Years of Age Does Not Increase the Risk of Pneumonia: A Three-Year Longitudinal Follow-Up Study

To evaluate the effect of tonsillectomy on the subsequent risk of pneumonia in an adult population, a longitudinal follow-up case control study was conducted using a national health screening cohort dataset between 2003 and 2012. A total of 1005 tonsillectomy participants were 1:4 matched with 4020 control participants for age, sex, income, and region of residence. The number of pneumonia diagnoses were counted from the index date (ID) to the date after the first-year (post-ID 1y), second-year (post-ID 2y), and third-year (post-ID 3y) periods. Simple linear regression and multiple linear regression were conducted to calculate estimated values (EVs) and 95% confidence intervals for each post-ID pneumonia and compared between the two groups. Subgroup analyses were performed according to age, sex, and the number of pneumonia cases during the year prior to the ID (pre-ID 1y). In the simple linear regression model, post-ID pneumonia did not show a significant correlation with tonsillectomy (post-ID 1y: EV = 0.003; post-ID 2y: EV = 0.007; post-ID 3y: EV = 0.013; all p > 0.05). In the multiple regression model, post-ID pneumonia also did not show a significant correlation with tonsillectomy (post-ID 1y: EV = 0.001; post-ID 2y: EV = 0.006; post-ID 3y: EV = 0.011; all p > 0.05). In the subgroup analyses, tonsillectomy did not show a significant correlation with post-ID pneumonia in either the simple linear regression or multiple linear regression models (all p > 0.05). Tonsillectomy performed in the adult population did not show any effect in increasing the incidence of pneumonia during the first three postoperative years.

Adenotonsillectomy Does not Alter the Risk of Upper Airway Infections in Children

OBJECTIVE

Given the conflicting evidence regarding adenotonsillectomy and the risk of upper airway infections (UAIs), including acute pharyngitis (APT), rhinosinusitis (ARS), and otitis media (AOM), we evaluated the risk of developing UAIs following adenotonsillectomy in a childhood population.

METHODS

In this population-based follow-up study, we used data from the National Health Insurance Service-National Sample Cohort. The adenotonsillectomy group (n = 2,377) included patients aged <10 years who underwent an adenotonsillectomy. For every patient with APT (n = 2,309), ARS (n = 2,308), and AOM (n = 2,207) who had an adenotonsillectomy, four participants were randomly selected for the control groups (n = 9,204, n = 9,196, and n = 8,788, respectively) using propensity score matching. The number of postoperative hospital visits for UAIs was recorded for 1 to 9 years, and the equivalence test was used to compare the number of visits between the adenotonsillectomy and control groups.

RESULTS

There were no significant differences in the incidence of APT, ARS, or AOM at the margin of equivalence of difference (-0.5 < 95% confidence interval of difference < 0.5) between the two groups from postoperative year 1 to year 9. The hospital visits for these diseases gradually decreased over time in both groups. There was a significant decrease in the number of visits for APT, ARS, and AOM in the 5-9 years age group when compared with those in the <4 years age group (P < .01).

CONCLUSION

Our results suggest that adenotonsillectomy does not alter the frequency of UAIs in children.

LEVEL OF EVIDENCE

N/A Laryngoscope, 2021.

IL-32 exacerbates adenoid hypertrophy via activating NLRP3-mediated cell pyroptosis, which promotes inflammation

Adenoid hypertrophy (AH) is a common pediatric disease caused by inflammatory stimulation. The pro-inflammatory cytokine IL-32 has been reported to promote airway inflammation and also be involved in the pyroptosis pathway. However, whether IL-32 can contribute to AH by mediating pyroptosis remains to be elucidated. The present study aimed to investigate the role of IL-32 in AH and determine the potential underlying mechanisms. Adenoid tissues were collected from healthy children and children with AH, and the expression of IL-32, NACHT LRR and PYD domains-containing protein 3 (NLRP3) and IL-1β in normal and hypertrophic tissues were measured. Human nasal epithelial cells (HNEpCs) were exposed to a series of IL-32 concentrations. HNEpCs with or without IL-32 silencing were stimulated with lipopolysaccharide (LPS), and cell proliferation, cell apoptosis, gasdermin D (GSDMD) activation, production of inflammatory cytokines and the expression levels of proteins related to the potential mechanisms were evaluated by Cell Counting Kit-8, flow cytometry, immunofluorescence staining, ELISA and western blot assays, respectively. The results showed that IL-32, NLRP3 and IL-1β exhibited higher expression in adenoid tissues with AH compared with normal tissues. In HNEpC cells, treatment with IL-32 (2 and 10 ng/ml) promoted cell proliferation, while 50 ng/ml IL-32 inhibited cell proliferation at 12, 24 and 48 h post-treatment. IL-32 (2, 10 and 50 ng/ml) also resulted in differing degrees of apoptosis, GSDMD activation, release of IL-1β, IL-6 and TNF-α, and increased protein expression levels of NLRP3, cleaved-caspase-1, activated GSDMD, nucleotide-binding oligomerization domain-containing protein (NOD) 1/2 and Toll-like receptor (TLR)4 in a concentration-dependent manner. In addition, compared with the LPS group, IL-32 knockdown significantly inhibited LPS-induced enhancement of cell proliferation, cell apoptosis, GSDMD activation and production of inflammatory cytokines, and reversed the increased protein expression of NLRP3, cleaved-caspase-1, activated GSDMD, NOD1/2 and TLR4. In conclusion, IL-32 may play a role in the progression of AH via promoting inflammation, and the potential mechanism may involve the activation of NLRP3-mediated pyroptosis.

Short- and long-term impacts of adenoidectomy with/without tonsillectomy on immune function of young children <3 years of age: A cohort study

To investigate the short- and long-term impacts of adenoidectomy with/without tonsillectomy on the immune functions of young children < 3 years of age.This longitudinal prospective study included 40 pediatric patients (age <3 y) undergoing adenoidectomy with/without tonsillectomy for snoring and sleep apnea. Serum immunoglobulin IgA, IgG, IgM, complement C3, and C4 levels were measured for the status of humoral immunity; CD3+, CD4+, CD8+, CD4+/CD8+, CD19+, CD56+, CD3+CD4-CD8-, and CD3+CD4+CD8+ T cells were measured for the status of cellular immunity. Blood samples were taken at 3 time points: before surgery, 1 month after surgery (short-term), and 3 months after surgery (long-term). All patients were assessed for short-term outcome at 1-month postoperation, but only 30 patients were followed at 3 months after surgery. The incidence of recurrent respiratory tract infections and other immune-related conditions were recorded at each follow-up.The levels of IgA significantly decreased from the preoperative level at 1-month follow-up (P < .05), but still within normal range. No significant changes were found in the levels of IgA, IgG, IgM, C3, C4, CD3+, CD4+, CD8+, CD4+/CD8+, CD19+, CD56+, CD3+CD4-CD8-, and CD3+CD4+CD8+ T cell at 3-month follow-up in comparison with preoperative levels. There was also no episode of recurrent respiratory tract infection and other immune-deficiency conditions.Adenoidectomy with/without tonsillectomy may result in a reduction in individual antibodies in children <3 years of age, but did not show negative impacts on their immune functions. Also, the surgery does not lead to the increased risk of upper respiratory tract infection in these children.

Effectiveness and safety of Chinese herbal medicine for pediatric adenoid hypertrophy: A meta-analysis

OBJECTIVE

Chinese herbal medicine has been gradually used to treat pediatric adenoid hypertrophy. This meta-analysis were conducted to evaluate the clinical efficacy and safety of Chinese herbal medicine in the treatment of pediatric adenoid hypertrophy.

METHODS

Randomized controlled trials involving Chinese herbal medicine in the treatment of pediatric adenoid hypertrophy were identified from Cochrane Central Register of Controlled Trials, PubMed, EMBASE, Chinese National Knowledge Infrastructure, Chinese Biomedical Database, Wanfang Database and VIP Information Database. The methodological quality of trials was evaluated with Cochrane Handbook criteria, and the Cochrane Collaboration's Review Manager 5.3 software was used for Meta-analysis.

RESULTS

A total of 13 valid articles involving 1038 patients were included. The meta-analysis showed that: Compared with western medicine treatment, Chinese herbal medicine significantly improved clinical efficacy (RR = 1.33, 95% CI [1.24,1.43]), and significantly decreased A/N ratio (MD = -0.04,95%CI [-0.05,-0.03]). Chinese herbal medicine also prominently improved the quality of life (MD = -4.77,95%CI [-8.35,-1.20]). Meanwhile, it dramatically improved snoring (MD = -0.46,95%CI [-0.62,-0.30]); mouth breathing (MD = -0.52,95%CI [-0.66,-0.39]); nasal obstruction (MD = -0.56,95%CI [-0.68,-0.45]).

CONCLUSION

Chinese herbal medicine has good clinical efficacy and safety on pediatric adenoid hypertrophy, which need to be confirmed by high quality, multiple-centre, large sample randomized controlled trials.

Comparison of reference systems in the assessment of age-related serum immunoglobulin levels in pediatric patients

Background/aim

Ig level assessment is frequently used in the diagnosis and follow-up of immunodeficiency, as well as in studies investigating the prevalence of low serum Ig level in specific diseases.

Materials and methods

Patients who underwent Ig testing in the inpatient and outpatient clinics of our hospital in the years 2010–2016 were included. The Ig levels of the patients were assessed separately according to two reference systems commonly used in Turkey and another reference system used in the USA.

Results

A total of 20,138 patients (57.6% male) were included in the study. The median age of the patients was 55.7 months (interquartile range: 23.1–96.7). According to the reference intervals determined by Tezcan et al., 30.6% of the patients were deficient in one or more Ig values. This rate was 4 times higher than those based on the reference intervals determined by Aksu et al. (7.7%) and those in the Nelson Textbook of Pediatrics (6.8%). We also determined that the frequency of low Ig levels with three reference systems

Conclusion

In this study, we found that the rates of low Ig level in a group of pediatric patients differed significantly when evaluated using three different reference systems for age-related serum Ig levels

Patterns of adenoid and tonsil growth in Japanese children and adolescents: A longitudinal study

Lymphoid tissues, such as adenoids (Ad) and tonsils (Tn), are suggested to undergo hypertrophy during childhood and involution in adulthood. Enlargement of Ad and Tn can cause transient obstruction of the respiratory airways, thus inducing obstructive sleep apnoea. To date, the standard Ad and Tn sizes have not been reported, and there are no explicit objective criteria for evaluating their sizes or deducing whether they have enlarged, reduced, or remained constant over time. Our previous cross-sectional study revealed the age-dependent airway occupation ratio of Ad and Tn in Japanese individuals. We conducted a longitudinal observational study of the Ad and Tn sizes in Japanese individuals aged 6–20 years. Ninety individuals were retrospectively enrolled. The average and standard deviation of the sizes was calculated in 5 age-based groups.

Tonsillectomy increases the risk of retropharyngeal and parapharyngeal abscesses in adults, but not in children: A national cohort study

Objectives

The purpose of this study is to evaluate the risk of retropharyngeal and parapharyngeal abscesses (deep neck infection) after tonsillectomy in Koreans using national cohort data.

Methods

Using the national cohort study from the Korean Health Insurance Review and Assessment Service, participants who had undergone a tonsillectomy (5,299) and control participants (21,196) were selected and matched 1:4 (for age, sex, income, region of residence, and pre-operative upper respiratory infection visits). The Cox-proportional hazard model was used. A crude model and an adjusted model for age, sex, income, region of residence, hypertension, diabetes, and dyslipidemia were used in this analysis. For the subgroup analyses, the participants were divided into 2 groups: children (≤ 14 years old) and adolescents and adults (≥ 15 years old).

Results

The adjusted hazard ratio of deep neck infection after tonsillectomy was 1.43 (95% confidence interval, CI = 1.18–1.72, P < 0.001). In subgroup analysis, this ratio was 1.12 (95% CI = 0.86–1.47, P = 0.390) in children and 1.87 (95% CI = 1.43–2.45, P < 0.001) in adolescents and adults. The crude hazard ratios were almost the same as the adjusted ratios.

Conclusion

The risk of deep neck infection was higher in the tonsillectomy group. The subgroup analysis showed a similar finding in the adolescent and adult group but not in the child group.

Long-term effects of adenotonsillectomy on serum-specific immunoglobulin E

BackgroundThe biased immune reactions of the adenotonsillar tissues are not always reflected by the serum immunoglobulin E (IgE); thus, we hypothesize that the systemic atopic status may not be changed after the adenotonsillectomy (AT) in children.MethodsTwenty-five children with AT and 23 age-matched healthy children were enrolled into this study, and followed up for ~4 years. Nasal Symptoms Scores (NSS), Quality of Life Scores (QOLS), specific IgE (sIgE), cytokines, and inflammatory cell were documented in all the subjects before and after study.ResultsFourteen patients and three healthy controls had positive serum sIgE levels (>0.35 kU/l) at the study-start that was not changed by the study-end. Two patients and two sIgE-negative healthy controls showed the Dermatophagoidespteronyssinus sensitization at the study-end. NSS and QOLS showed significant improvement after the surgery in the sIgE-positive patients (P<0.05), whereas no significant changes were found in the sIgE-negative patients (P=1.00). In addition, the serum sIgE-negative patients showed significant increases in interleukin (IL)-4, IL-5, and IL-10 levels in the serum (P<0.001), although no significant differences were found post surgery (P=0.667, 0.408, and 0.714, respectively).ConclusionsOur study showed that AT did not affect the pediatric atopic status. The systemic atopy may be independent of the tonsillar and adenoid tissues in children.

Expression of CysLTR1 and 2 in Maturating Lymphocytes of Hyperplasic Tonsils Compared to Peripheral Cells in Children

Cysteinyl-leukotriene receptors 1 and 2 (CysLTR1 and 2) are related to allergic inflammatory responses. Recent studies demonstrated their role in lymphocyte division and maturation in the bone marrow. Few data are available about CysLTRs function in lymphocyte maturation in tonsils. The objectives of this study are to compare CysLTRs expression in peripheral blood lymphocytes with expression in maturating lymphocytes of hyperplasic tonsil and to check the influence of respiratory allergies in this process. Leukocytes of peripheral blood (PL) and hyperplasic tonsils of children were immunostained for CysLTR1, CysLTR2, CD3 (T cells), and CD19 (B cells) and read in flow cytometer. Lymphocyte of tonsils were divided in differentiating small cells (SC) and mitotic large cells (LC); percentage of B and T cells expressing CysLTRs was determined, and comparison was done using ANOVA and Tukey's tests. Data were analyzed as a whole and categorizing patients according the presence of allergies. Sixty children were enrolled in this study. There was a large expression of CysLTR1 and 2 in CD3+ LC, and such expression decreased progressively in SC and PL. In B cells, the highest expression of CysLTR1 and 2 was found in PL while SC showed the lowest and LC showed the intermediate expression. This pattern kept unchanged in groups of allergic and non-allergic individuals. CysLTRs seem to be involved in lymphocyte maturation that occurs in tonsils, without influence of allergies. New studies aiming the clinic treatment of tonsil hyperplasia must be targeted to the development of drugs capable of blocking both CysLTR1 and 2.

Adenoidal follicular T helper cells provide stronger B-cell help than those from tonsils

OBJECTIVES/HYPOTHESIS

The tonsils and adenoids are secondary lymphoid organs, where antigen processing and immune cell development occur to control bacterial colonization and infection in the upper respiratory tract. Both organs are abundant in follicular T helper cells (TFH), a subset of T cells specialized for promoting B-cell development. There are no prior studies on differences between the immune cells of the tonsils and adenoids and whether the cells function differently.

STUDY DESIGN

In vitro assays to assess cell phenotype of tonsils and adenoids from young children (median age = 40 months).

METHODS

Mononuclear cells from tonsils and adenoids were cultured with or without 1 µg/mL Staphylococcus enterotoxin B (SEB) for 4 days. Cell phenotype and function were assessed by flow cytometry and multiplex enzyme-linked immunosorbent assay.

RESULTS

We found that in resting adenoids, TFH expressed higher CXCR5 and inducible costimulator but lower PD-1 than those from the tonsils, and that adenoidal B cells expressed higher CD27. Upon polyclonal stimulation with SEB, both TFH and B cells from the adenoids proliferated to a greater extent, and culture supernatants contained higher levels of interleukin 21.

CONCLUSIONS

We conclude that the cells of the adenoid are disposed toward the provision of more robust B-cell help than the tonsils.

LEVEL OF EVIDENCE

NA.

The effect of tonsillectomy on the immune system: A systematic review and meta-analysis

IMPORTANCE

The immunological sequelae of tonsillectomy in children have been a source of debate among physicians and a continuous concern for parents. Contradictory pertinent results exist in the literature.

OBJECTIVE

To understand the real effect of tonsillectomy on the immune system.

DATA SOURCES

MEDLINE, EMBASE and COCHRANE.

STUDY SELECTION

Articles addressing the effect of tonsillectomy on the immune system, up to Dec 2014. Related keywords and medical subject headings were used during the search. The abstracts were reviewed to determine suitability for inclusion based on a set of criteria. Manual crosscheck of references was performed.

DATA EXTRACTION

We checked the tests results and the conclusion of each study to classify it as supporting or refuting the hypothesis of a negative effect of tonsillectomy on the immune system.

RESULTS

We reviewed 35 articles, published between 1971 and 2014, including 1997 patients. Only Four studies (11.4%), including 406 patients (20.3%) found that tonsillectomy negatively affects the immune system. We performed a separate meta-analysis on various reviewed humoral and cellular immunological parameters (e.g. total and specific serum Ig's, SecIgA, cellular immunity, and Ag specific Ig). There is more evidence to suggest that tonsillectomy has no negative clinical or immunological sequalae on the immune system. Study limitations included heterogeneity in the diagnostic tools, timing of testing, indication for tonsillectomy and patients' age.

CONCLUSION

It is reasonable to say that there is enough evidence to conclude that tonsillectomy has no clinically significant negative effect on the immune system. It will be important for future studies to uniformly use both preoperative and control laboratory tests' levels to compare the postoperative levels with, to have short and long term follow-up levels, and to include both humoral and cellular immunity in their measurements.

RELEVANCE

The results should reassure both surgeons and parents that tonsillectomy has no proven clinical sequalae. If more research is to be done in the future, it should be performed in a standardized way to avoid the heterogeneity seen in the literature.

Tonsillectomy and Risk of Oropharyngeal Cancer: Implications for Research and Prevention

The association of tonsillectomy, a common surgical procedure involving the removal of a majority of the palatine tonsillar tissue, with risk of tonsil cancer specifically or oropharyngeal cancers overall is not known. In this issue of Cancer Prevention Research, Fakhry and colleagues conduct an analysis within the Danish Cancer Registry and show that tonsillectomies were associated with significantly reduced risk of tonsil cancer, but were unrelated to risk of base of tongue cancers. This editorial discusses the implications of the results by Fakhry and colleagues for key prevailing questions in the field related to risk, rising incidence, secondary prevention, and treatment of oropharyngeal cancers.

Tonsillectomy and the risk for deep neck infection-a nationwide cohort study

BACKGROUND

Although the tonsils contribute to first line immunity against foreign pathogens in the upper aero-digestive tract, the association of tonsillectomy with the risk of deep neck infection remains unclear. The aim of this study was to assess the incidence rate and risk of deep neck infection among patients who had undergone a tonsillectomy.

METHODS

This retrospective cohort study evaluated all patients who had undergone tonsillectomy between 2001 and 2009 as identified from the Taiwan National Health Insurance Research Database. For each post-tonsillectomy patient, 10 age-, sex-, and index date-matched controls without a history of tonsillectomy were randomly selected. Cox Proportional hazard model and propensity score model were performed to evaluate the association between tonsillectomy and deep neck infection after adjusting for demographic and clinical data.

RESULTS

There were 34 (71.6 cases per 100,000 person-years) and 174 (36.6 cases per 100,000 person-years) patients that developed deep neck infection in the tonsillectomized and comparison cohorts, respectively. After adjusting for covariates, patients who had undergone a tonsillectomy had a 1.71-fold greater risk of deep neck infection by both Cox proportional hazard model (95% confidence interval, 1.13-2.59) and propensity score model (95% confidence interval, 1.10-2.66). This association was not altered regardless of the indication for tonsillectomy (i.e. chronic/recurrent tonsillitis or sleep apnea/hypertrophy of tonsil) (p = 0.9797).

CONCLUSIONS

Based on our review of a nationwide cohort study we identified that the risk of deep neck infection is significantly increased among patients who have undergone a tonsillectomy. Additional research is needed to explore the possible mechanisms behind these findings.

Age-related differences in human palatine tonsillar B cell subsets and immunoglobulin isotypes

The tonsils provide defense of the upper aerodigestive tract against pathogens. Although long known to undergo functional changes with age, the precise changes occurring within tonsillar B cell populations remain undefined. In the present study, we investigated age-related changes in palatine tonsillar B cell subsets and immunoglobulin (Ig) isotypes. Palatine tonsils were obtained from forty-two tonsillectomy patients without tonsillitis who were divided into three groups: young children (4-9 years), adolescents (10-19 years), and adults (20-60 years). Tonsillar B cells were then analyzed by flow cytometry. Using expression of CD38 and IgD to define B cell subsets, we found that the frequency of germinal center (GC) B cells in the tonsils was significantly higher, and the frequency of memory B cells lower, in young children as compared to adolescents and adults. Within the GC B cell subsets, adults had a higher frequency of IgA(+) cells and a lower frequency of IgM(+) cells as compared to individuals in the younger age groups. Moreover, young children had a higher frequency of IgG(+) cells in the GC B cell subsets than did individuals in the older age groups. We also observed an abundance of IgM(+) cells among memory B cells and plasmablasts in young children and IgA(+) cells in adults. In summary, the proportion of GC B cells in palatine tonsillar B cells decreases with age, while the proportion of memory B cells increases with age. In addition, Ig isotypes in tonsils preferentially switch from IgM to IgA as individuals age.

Pediatric autoimmune neuropsychiatric disorder associated with group a streptococcal infection: the role of surgical treatment

Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus (PANDAS) is a well-defined syndrome in which tics (motor and/or vocal) and/or obsessive compulsive disorders (OCD) consistently exacerbate in temporal correlation to a Group A beta-haemolytic streptococcal infection. In children with PANDAS, there is speculation about whether tonsillectomy or adenotonsillectomy might improve the neuropsychiatric course. Our objective was to examine whether such surgery impacted remission or, in patients without remission, modified clinical course of the disease, streptococcal antibody titers, neuronal antibodies or clinical severity of Obsessive-Compulsive Disorder (OCD) and/or tics. Study participants (n = 120) with positive PANDAS criteria were recruited, examined, and divided into surgical or non-surgery groups. The surgical group consisted of children with tonsillectomy or adenotonsillectomy (n=56). The remaining children were categorized as non-surgery (n=64). Clinical follow-up was made every 2 months for more than 2 years. Surgery did not affect symptomatology progression, streptococcal and neuronal antibodies, or the clinical severity of neuropsychiatric symptoms in these children. In conclusion, in our series clinical progression, antibody production, and neuropsychiatric symptom severity did not differ on the basis of surgical status. We cannot uphold surgical management as likely to impact positive remission rates, course of OCD/tics, or antibody concentrations in children with PANDAS.

Efficacy of Mometasone Nasal Spray in Children with Snoring due to Adenoids

Background

Snoring and OSA is very commonly seen among the pediatric population, most commonly due to adenoid and tonsil hypertrophy which requires adenotonsillectomy. The effect of this surgery on the immunity is controversial. This study was planned to see any alternative therapy which can delay or avoid the surgery by providing symptomatic relief to the patient.

Objective

To see the effect of intranasal mometasone on nasal obstruction due to adenoids, hence relieving the OSA and snoring.

Design

Prospective and observational study.

Materials and methods

Fifty-five children having snoring and or OSA due to adenoids were given intranasal mometasone. The symptoms before and after treatment were compared using OSA 18 questionnaire.

Results

There was significant improvement in all the domains of OSA 18. The average total score showed improvement from 56.33 to 51.51 which is significant (p < 0.001).

Conclusion

The use of intranasal steroids is easy and effective method to improve nasal obstruction, snoring and OSA among children having adenoid hypertrophy.

How to cite this article

Gupta V, Gupta M, Matreja PS, Singh S. Efficacy of Mometasone Nasal Spray in Children with Snoring due to Adenoids. Clin Rhinol An Int J 2014;7(1):1-4.

Pediatric adenoidectomy: a population-based regional study on epidemiology and outcome

OBJECTIVES

To evaluate population-based data on incidence of pediatric adenoidectomy and rate of revision surgery.

METHODS

A retrospective study of all adenoidectomies in children was performed in the year 2009 in all otolaryngology departments in one federal state, Thuringia, in Germany. Patients' characteristics, preoperative diagnostics and postoperative complications were analyzed. The association between baseline characteristics and the risk of re-adenoidectomy was examined using Kaplan-Meier method with univariate log-rank test, and with a multivariate Cox regression model. Population data were used to calculate age-related annual rates of adenoidectomies.

RESULTS

1939 adenoidectomies were performed in 2009 in Thuringia. 89% were primary cases and 11% of the children already had an adenoidectomy prior to 2009. Immediate re-surgery because of primary hemorrhage was necessary in 0.8% of the cases. Re-adenoidectomy because of recurrent symptoms was needed in 9% of patients after a median interval of 16 months. The univariate analysis showed that the factors age ≤3 years and primary surgery were significantly associated to a higher risk of surgery because of recurrent symptoms The multivariate analysis showed that primary surgery was independently associated with the risk of re-surgery (hazard ratio 1.66; 95% confidence interval 1.01-2.74). The annual adenoidectomy rate was 678/100,000 underage habitants. The incidence was highest between 2 and 4 years of age.

CONCLUSIONS

This population based analysis is showing that adenoidectomy is performed country-wide with good results and low risk on important scale in daily routine by otorhinolaryngologists. The risk of re-adenoidectomy seems to be higher than hitherto reported by hospital-based studies.

Tonsillectomies and adenoidectomies do not prevent the onset of pediatric autoimmune neuropsychiatric disorder associated with group A streptococcus

BACKGROUND

In children presenting with obsessive compulsive disorder (OCD) and/or tics, especially those with a temporal association with streptococcal pharyngitis (eg, Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus), there is speculation about whether tonsillectomy/adenoidectomy might improve the child's neuropsychiatric course. Our objective was to examine whether removal of the tonsils and/or adenoids impacted streptococcal antibody titers, the timing of onset of OCD and/or tics and the clinical severity of these symptoms.

METHODS

Study participants (N = 112; average age = 9.2 ± 2.4; 44 women) were recruited as part of a prospective investigation of neuropsychiatric phenomena with temporal association to streptococcal pharyngitis and examined by family history, diagnostic interview, physical examination, medical record review, psychological testing and streptococcal antibodies and divided into surgical or nonsurgical groups. The surgical group consisted of children having previously had a tonsillectomy and/or adenoidectomy (n = 32). The remaining children were categorized as nonsurgical group (n = 76). Measures of OCD and tic severity, streptococcal antibody titers and Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus classification were compared between both groups.

RESULTS

There were no significant differences as determined by streptococcal antibody titers, Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus classification and OCD or tic severity between the surgical and nonsurgical groups. Most participants had surgery before the onset of neuropsychiatric symptoms and surgery did not affect symptomology.

CONCLUSIONS

Streptococcal antibodies and neuropsychiatric symptom severity did not differ on the basis of surgical status. From these data, we cannot infer that tonsillectomy and adenoidectomy are likely to impact positively the course of OCD/tics or streptococcal antibody concentrations.

Short and long term impact of adenotonsillectomy on the immune system

Palatine and pharyngeal tonsils are immune reactive lymphoid organs that manifest specific antibodies and B/T-cell activity to respond to a variety of antigens. They perform humoral and cellular immune functions. The possible effects of adenotonsillectomy upon the immune system remain controversial.

Objective

To study the short and long-term impacts of tonsillectomy upon the cellular and humoral immunity of children.

Method

This longitudinal prospective study included 29 children referred to adenotonsillectomy for adenotonsillar hypertrophy. Serum IgA, IgM, and IgG and lymphocyte counts were analyzed at three points in time: before surgery, 1-2 months after surgery (short term), and 12-14 months after surgery (long term).

Results

TCD4+ cell counts were significantly increased shortly after surgery. IgA and IgG values were significantly reduced in the long run, but were within normal ranges for this age group.

Conclusion

This study indicated that adenotonsillectomy does not pose negative short or long term impacts upon the cellular and humoral immunity of children submitted to the procedure.

[S1 Clinical guideline"adenoids and adenoidectomy"]

On behalf of the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery, a clinical guideline for adenoids and adenoidectomy was developed in 5 consensus meetings after taking into consideration the current literature. This guideline was released by the presidium on 13 April 2011. Anatomy, pathology and pathophysiology, symptoms, diagnosis, therapy, and course are presented.

Clinical factors associated with pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections

OBJECTIVE

To explore associated clinical factors in children with pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS).

STUDY DESIGN

Children with tics, obsessive-compulsive disorder, or both (n=109) were examined with personal and family history, diagnostic interview, physical examination, medical record review, and measurement of baseline levels of streptococcal antibodies.

RESULTS

Significant group differences were found on several variables, such that children in whom PANDAS (versus without PANDAS) were more likely to have had dramatic onset, definite remissions, remission of neuropsychiatric symptoms during antibiotic therapy, a history of tonsillectomies/adenoidectomies, evidence of group A streptococcal infection, and clumsiness.

CONCLUSION

The identification of clinical features associated with PANDAS should assist in delineating risks for this subtype of obsessive-compulsive disorder/tics.

Non-surgical treatment of adenoidal hypertrophy: the role of treating IgE-mediated inflammation

Adenoidal hypertrophy (AH) and adenotonsillar hypertrophy are common disorders in the pediatric population and can cause symptoms such as mouth breathing, nasal congestion, hyponasal speech, snoring, and obstructive sleep apnea (OSA), as well as chronic sinusitis and recurrent otitis media. More serious long-term sequelae, typically secondary to OSA, include neurocognitive abnormalities (e.g. behavioral and learning difficulties, poor attention span, hyperactivity, below average intelligence quotient); cardiovascular morbidity (e.g. decreased right ventricular ejection fraction, left ventricular hypertrophy, elevated diastolic blood pressure); and growth failure. Adenoidectomy (with tonsillectomy in cases of adenotonsillar hypertrophy) is the typical management strategy for patients with AH. Potential complications have prompted the investigation of non-surgical alternatives. Evidence of a pathophysiologic link between AH and allergy suggests a possible role for intranasal corticosteroids (INS) in the management of patients with AH. This article reviews the epidemiology and pathophysiology of AH with a particular focus on evidence of its association with allergy and allergic rhinitis. Current treatment options are briefly considered with discussion on the rationale and evidence for the use of INS.

Retropharyngeal and parapharyngeal abscesses or phlegmons in children. Is there an association with adenotonsillectomy?

BACKGROUND

Retropharyngeal and parapharyngeal abscesses or phlegmons are relatively uncommon. Since the tonsils and adenoids are part of the lymphoid tissues of the nasopharynx and oral cavity, one may hypothesize that their removal would lead to an increased susceptibility to pharyngeal infections.

OBJECTIVE

Determine whether there is an association with a history of adenotonsillectomy and the development of retro- and parapharyngeal abscesses/phlegmons.

METHODS

A case-control study was performed. The charts of 180 children admitted to a tertiary care pediatric hospital between 1996 and 2006 were reviewed. The patients were age-matched to 180 children having visited the emergency department of the same hospital. The charts of these children were reviewed and used as controls.

RESULTS

13.9% of children admitted with a retro- or parapharyngeal abscess or phlegmon had previously undergone an adenotonsillectomy as compared to only 2.2% of children in the control group. The calculated odds ratio was 7.10 (95% CI [2.52-19.93], p<0.001).

CONCLUSION

In conclusion, the development of a retropharyngeal or parapharyngeal abscess or phlegmon is strongly associated with a history of adenotonsillectomy.

Randomized controlled studies and the treatment of middle-ear effusions and tonsillar pharyngitis: How random are the studies and what are their limitations?

Objective

To determine the applicability and external validity of randomized control studies (RCTs) in the light of patient susceptibilities and vulnerabilities to the sequelae of otitis media with effusion (OME) and tonsillar pharyngitis (T&A) and the composition of their cohorts.

Study Design

RCTs for OME and T&A were analyzed to determine which intrinsic and extrinsic susceptibilities to the otolaryngic disease and its sequelae were included or excluded and the composition of the cohort.

Methods

A Medline and a Science Direct search were performed for all RCTs concerning OME and T&A through 2007. The articles selected to be included in this study are the OME RCTs that reported language and/or hearing outcomes and the T&A RCT studies in which the outcome measure was infection, alleviation of airway obstruction, and/or quality of life. These were analyzed for their inclusion or exclusion of intrinsic and extrinsic susceptibilities to the otolaryngic disease and their sequelae and the composition of the cohort. The pertinent otolaryngologic literature was assessed to determine applicable risk factors.

Results

The analysis of the inclusion or exclusion of risk factors showed that for OME 0 percent were included and 16 percent were excluded, and there were no data for 84 percent. The T&A findings were similar in that 1 percent of risk factors were included, 8 percent excluded, and there were no data for 92 percent. Both the OME and the T&A cohorts data were similar in that approximately half of the suitable candidates completed the study; 25 percent of the OME and 13 percent of the T&A enrolled subjects were either withdrawn or placed into a different experimental group. On the average, with data available, it took 4.6 years to recruit the OME sample and 5.5 years to recruit the T&A sample.

Conclusion

The results of RCTs for these conditions are only applicable to narrowly defined and highly circumscribed populations. They cannot be generalized to the entire patient population because of their limited external validity. Future RCT protocols should be designed to control for the intrinsic and extrinsic susceptibilities that result in a propensity to acquire the disease and/or an exacerbation of the disease's sequelae. These studies would determine the most effective strategies for preventing disorders and/or their deleterious sequelae.