Immunoglobulin changes in a pediatric otolaryngic patient sample subsequent to T & A

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.

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.

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

BACKGROUND

It remains controversial whether pediatric adenotonsillectomy ultimately results in decreased serum immunoglobulin levels and if so whether such a decrease is associated with increased susceptibility to upper respiratory tract infections (URIs).

OBJECTIVE

To evaluate changes in serum immunoglobulin levels in relation to occurrence of URIs in children participating in a randomized controlled trial on the effectiveness of adenotonsillectomy.

METHODS

A total of 300 children aged 2 to 8 years, with symptoms of recurrent throat infections or tonsillar hypertrophy, were randomly assigned to either adenotonsillectomy or watchful waiting (WW). Serum samples were collected at baseline and at 1-year follow-up. Occurrence of throat infections and other URIs during first-year follow-up was recorded in a diary by the child's parents.

RESULTS

Paired serum samples were available for 123 children (63 in the adenotonsillectomy group and 60 in the WW group). IgG1 and IgG2 levels decreased but remained within the reference range for age in both study arms. IgM and IgA levels decreased as well but remained elevated. The IgA level in the adenotonsillectomy group decreased in significantly greater degree compared with the WW group, but this difference disappeared in cases where children experienced frequent URIs. In general, no relation between immunoglobulin levels and the number of throat infections or URIs at 1-year follow-up was found.

CONCLUSIONS

Immunoglobulin levels of children undergoing adenotonsillectomy decreased from elevated to slightly elevated or reference values for age during 1-year follow-up irrespective of treatment (adenotonsillectomy or WW). IgA showed a greater decrease in the adenotonsillectomy group but rose to levels comparable with the WW group in cases of frequent URIs. This finding indicates that the remaining mucosa-associated lymphoid tissue can compensate for the loss of tonsil and adenoid tissue.

The effect of tonsillectomy on neutrophil chemotaxis in adults with chronic tonsillitis

Neutrophil random motility and chemotactic responsiveness were determined in 17 healthy adults and 19 adult patients with chronic tonsillitis before and 10 days after tonsillectomy, using a modified Boyden chamber method. The mean chemotactic index values of the healthy controls were significantly higher when compared with the chronic tonsillitis patients before tonsillectomy. The postoperative mean chemotactic values were increased, and there was a statistically significant difference between the mean chemotactic index of neutrophils in preoperative and postoperative patients. The authors conclude that this change in host defense mechanism may be the reason for frequent attacks of acute tonsillitis in these patients.

Indication of tonsillectomy for recurrent tonsillitis

The indication of tonsillectomy for recurrent tonsillitis was discussed from the standpoint of clinical immunology. Elevated serum IgG was observed in 29.8% of the patients under 8 years of age preoperatively. In contrast, in 25% of patients between 9-15 years of age, serum IgG was low preoperatively. In the patients over 16 years of age no abnormal serum IgG was found, and the elevated serum IgG returned to normal after tonsillectomy. The patients with normal serum IgG preoperatively retained normal values postoperatively. The low preoperative IgG level group still remained low postoperatively. As to postoperative improving symptoms, high and low grade fever improved most (100%), followed by cervical lymphadenopathy (93%), frequent absence from school (93%), sore throat (88%) and recurrence of bronchitis (85%). The patients with recurrent tonsillitis for 8 years showing high serum IgG had indications for tonsillectomy.

Long-term observation of postoperative course of habitual tonsillitis

Tonsillectomy and adenoidectomy are among the most frequently held operations in the ENT field. In our hospital, the number of cases of tonsillectomy has been decreasing recently as compared with 10 to 15 years ago. Especially the number of cases under 10 years old has shown a decrease. It is sometimes difficult to decide the indication for tonsillectomy even for habitual tonsillitis. In this paper, the post operative course of tonsillectomy with habitual tonsillitis was investigated during 1976 to 1986 using a questionnaire. Answers evaluable were obtained from 207 cases. The efficacy of the operation on sore throats, high temperatures and recurrent colds was very high, but a few cases complained that a foreign sensation of the throat had occurred or worsened after operation. The incidence of nasal allergy gradually increased after tonsillectomy, but further studies may be necessary to decide the exact relationship. Laboratory examinations, such as ASLO, CRP, white blood cell counts, immune complex, C3a and C5a, were not particularly helpful in deciding the indication of tonsillectomy for habitual tonsillitis. In general, it is thought that tonsillectomy is very effective for habitual tonsillitis, but we must be more careful in deciding such an indication.

Immune complexes in the middle ear fluid and adenoid tissue in chronic secretory otitis media

Specimens of middle ear effusion and adenoid tissue were studied for bacteria and pneumococcal capsular antigen in 107 patients with secretory otitis media. 120 of 163 middle ear effusion samples (73.6%) were negative on bacterial culture. Hemophilus influenzae was present in 9.2% and Streptococcus pneumoniae in 1.8%. Hemophilus influenzae was cultured from 44.8% and Streptococcus pneumoniae from 35.5% of 107 adenoid tissue specimens. Free pneumococcal capsular antigen was demonstrated in 10.4% of the middle ear fluids and this figure rose to 23% when antigen was liberated from the immune complexes by heating. The corresponding figures for adenoid tissue suspension were 27.1% and 39%. The adenoid tissue or the lymphoid tissue of the entire oropharynx could act as the source of antigen which could maintain immune complex disease in some patients suffering from secretory otitis media.

Serum immunoglobulins in patients with chronic tonsillitis

In this work, the serum immunoglobulin (IgG, IgA, IgM and IgD) levels were determined in ten patients with chronic tonsillitis. The serum immunoglobulins were estimated before and two months after tonsillectomy, using the radial immuno-diffusion method. Ten normal individuals with intact tonsils were chosen as a control group. The patients had elevated serum levels of IgG and IgA. These high levels may be due to repeated antigenic stimulation. The IgM and IgD were not significantly higher than in the normal controls. The serum IgG level did decrease significantly following tonsillectomy; the other three immunoglobulins were reduced, but insignificantly. The fall in immunoglobulins may be due to a reduction in the antigenic load, to the removal of immunoglobulin-producing tissue, or to alteration in the oropharyngeal pathogenic bacteria. Tonsillectomy does not seem to compromise immunological integrity or the immunoglobulin-producting apparatus. Estimations of the serum immunoglobulin, or simply of IgA, may help us to select those candidates for adeno-tonsillectomy who will have a good prognosis, or at least to exclude those with an underlying sub-clinical immunodeficiency disease.

Continual observation of clinical and immunological parameters, in particular of salivary IgA, in tonsillectomised children

In 106 tonsillectomised children the following parameters were measured before and after operation: clinical parameters (length, weight, postoperative complications), haematological parameters (BSR, Hg, PCV, RBC, and WBC), and immunological parameters (IgG, IgA, IgM, and salivary IgA); in a number of children measurements were taken over a period of more than 3 years. Standard values of salivary IgA in relation to total salivary protein were determined in noninfected children of various age groups. Compared to the standard and initial values, we found some statistically significant changes in the serum immunoglobulin levels and in the salivary IgA, but no irreversible pathological decrease in the above-mentioned parameters.

Tonsillectomy and autoantibodies in patients with habitual tonsillitis

Tonsillectomy is virtually a routine operation now for ENT surgeons, but its immunological evaluation is still obscure. We have carried out an investigation in 57 patients who visited our clinic, with reference to autoantibodies by the immunofluorescence technique. We found autoantibodies at a higher frequency after tonsillectomy than before tonsillectomy in the young age group. There are studies that report close correlation of autoantibodies and malignancy. Since there are few reports that mention the relationship of the presence of autoantibodies and tonsillectomy, we have emphasized here careful follow-up of the patients from this standpoint.

Effects of adenoidectomy: a controlled two-year follow-up

A prospective controlled study was made on the effect of adenoidectomy performed on 105 children. For various reasons, mainly severe long-standing nasal obstruction, 29 children were omitted from the study. The remaining 76 children were randomly divided into two groups, one adenoidectomy, and one control. Both groups were slightly reduced in number due to drop out. Thus 36 adenoidectomized children were followed during one year and 35 children during two years. The corresponding numbers for the children in the control group were 37 and 33. The incidence of common cold, purulent and serous otitis media and moderate nasal obstruction was compared in the two groups. A considerable reduction in the incidence of these variables was observed in both groups. The occurrence of moderate nasal obstruction was reduced more among the operated than among the unoperated children. The difference was only slightly significant during the first and not at all during the second year. Regarding the other variables, the differences were not significant, implying that adenoidectomy seems to have no effect on the incidence of common cold, serous and purulent otitis media.

Immunoglobulin-producing cells in clinically normal, hyperplastic and inflamed human palatine tonsils

Patients suffering from recurrent tonsillitis (RT), hyperplastic tonsillitis (HT), or idopathic tonsillar hyperplasia (ITH) were compared in immunological studies with subjects showing clinically normal tonsils. Serum concentration of immunoglobulins, particularly IgG, were found to be increased in association with tonsillitis. Conversely, the number of IgG-, IgA- and IgM-producing immunocytes per tissue unit was reduced in the germinal centres of lymphoid follicles, in the extrafollicular areas, and in the reticular parts of the crypt epithelium. The overall percentage distribution of these cells was normally 65:30:3.5:1.2 for the IgG, IgA, IgM and IgD classes, respectively. In RT these figures were 53:39:4.7:4.4; in HT, 67:25:4.0:4.5; and in IHT, 50 : 33 : 7.2 : 10. Thus, there were only small alterations in the immunocyte class proportions, except for a significant relative increase in IgD-producing cells. The results indicate that there is a functional defect of the tonsils in association with disease. The relative accumulation of IgD cells is probably explained by an inadequate local maturational process in B-cell system, altough some influence of low age cannot be excluded in the HT and ITH groups.

Recurrent adenotonsillitis: a new concept

An update of original data is presented. These data continue to confirm the physiological effect of adenotonsillectomy on the abnormal oropharyngeal and nasopharyngeal microflora of children with recurrent adenotonsillitis. A new concept suggesting a bacterial-viral etiology of recurrent adenotonsillitis is presented. The advantages of such a concept are reviewed.