Local atopy is more relevant than serum sIgE in reflecting allergy in childhood adenotonsillar hypertrophy

Allergic Diseases and Chronic Adenotonsillar Diseases: A Mendelian Randomization Study

OBJECTIVE

The existing epidemiological evidence regarding the intricate relationship between allergic diseases and chronic adenotonsillar diseases (CATD) remains inconclusive. Herein, the objective of our study is to explore the causal association using Mendelian randomization (MR).

METHODS

Employing data from large genome-wide association studies, a comprehensive two-sample bidirectional MR study was conducted. The studied traits encompassed allergic rhinitis (cases n = 9707, controls n = 331173), allergic asthma (cases n = 8525, controls n = 193857), allergic conjunctivitis (cases n = 18321, controls n = 324178), atopic dermatitis (cases n = 11964, controls n = 306909), and CATD (cases n = 38983, controls n = 258553). All the patients were of European descent and participants in cohort studies. The primary analysis was executed using inverse-variance-weighted MR. Furthermore, six additional MR methods (MR-Egger, weighted median, simple mode, weighted mode, MR pleiotropy residual sum and outlier, MR robust adjusted profile score) were employed to ensure the reliability and detect potential horizontal pleiotropy within the results. The estimates obtained from the MR analysis were factored into the overall effect calculation.

RESULTS

Genetically anticipated outcomes demonstrated a significant association between CATD risk and allergic rhinitis (OR = 1.141, p = 6.30E-06), allergic asthma (OR = 1.115, p = 8.31E-05), allergic conjunctivitis (OR = 1.197, p = 8.69E-07), and a suggestive association with atopic dermatitis (OR = 1.053, p = 0.040). However, no substantial correlation was observed in the reverse direction.

CONCLUSIONS

Findings of our study provide evidence supporting a causal role of allergic diseases in the development of CATD, whereas the converse relationship does not appear to hold true.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:2653-2658, 2024.

Correlation Between Nasal Allergy and the Number of Eosinophils in Adenoid Tissue

To study adenoid tissue eosinophilia in allergic rhinitis. A single-centre clinical case-control prospective study with 66 subjects enrolled for the study after taking written informed consent from all the participants. All patients underwent adenoidectomy with histopathological evaluation of adenoid tissue samples for eosinophils. 36 patients (cases) with Symptoms for Allergic Rhinitis (SFAR) score indicative of allergic rhinitis. 30 patients (control) with SFAR scores not indicative of allergic rhinitis. All patients were evaluated for serum absolute eosinophil count and total serum immunoglobulin E (Ig-E). There was a significant relationship between allergic rhinitis and serum Ig-E levels using the Kruskal-Wallis rank sum test amongst case and control groups with a p-value of 0.031. Pathologically examined slides of adenoid tissue eosinophil count per 10 random high power fields in these patients showed significant results with a p-value of 0.002432, via the Kruskal-Wallis rank sum test. Statistical analysis, shows that adenoid tissue eosinophil count and serum Ig-E levels can somewhat predict the presence of clinical features of allergic rhinitis. Based on several similar studies with similar results, allergic rhinitis can be gauged with adenoid tissue histopathology and routine evaluation should be considered as a standard of care.

Altered intestinal microbiota enhances adenoid hypertrophy by disrupting the immune balance

Introduction

Adenoid hypertrophy (AH) is a common upper respiratory disorder in children. Disturbances of gut microbiota have been implicated in AH. However, the interplay of alteration of gut microbiome and enlarged adenoids remains elusive.

Methods

119 AH children and 100 healthy controls were recruited, and microbiome profiling of fecal samples in participants was performed using 16S rRNA gene sequencing. Fecal microbiome transplantation (FMT) was conducted to verify the effects of gut microbiota on immune response in mice.

Results

In AH individuals, only a slight decrease of diversity in bacterial community was found, while significant changes of microbial composition were observed between these two groups. Compared with HCs, decreased abundances of Akkermansia, Oscillospiraceae and Eubacterium coprostanoligenes genera and increased abundances of Bacteroides, Faecalibacterium, Ruminococcus gnavus genera were revealed in AH patients. The abundance of Bacteroides remained stable with age in AH children. Notably, a microbial marker panel of 8 OTUs were identified, which discriminated AH from HC individuals with an area under the curve (AUC) of 0.9851 in the discovery set, and verified in the geographically different validation set, achieving an AUC of 0.9782. Furthermore, transfer of mice with fecal microbiota from AH patients dramatically reduced the proportion of Treg subsets within peripheral blood and nasal-associated lymphoid tissue (NALT) and promoted the expansion of Th2 cells in NALT.

Conclusion

These findings highlight the effect of the altered gut microbiota in the AH pathogenesis.

A systematic review of the clinical evidence and biomarkers linking allergy to adeno-tonsillar disease

INTRODUCTION

allergy may be an important risk factor for adenotonsillar disease in children, although conflicting results have been reported in the literature. In previous articles, authors often failed in distinguishing between adeno-tonsillar hypertrophy and recurrent tonsillitis and in not discriminating between isolated or combined adenoid and tonsillar hypertrophy.

AIM

to evaluate clinical evidence and biomarkers linking allergy to different phenotypes of adeno-tonsillar disease. Furthermore, we questioned whether anti-allergy treatment might prevent occurrence of adeno-tonsillar disease or improve its specific management.

METHODS

our systematic review, in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) process, yielded 1010 articles finally screened. This resulted in 21 full texts that were included in a qualitative analysis.

RESULTS

literature data support the association between allergy and combined adeno-tonsillar hypertrophy and isolated adenoid hypertrophy, whereas describe a mainly negative correlation between allergy and isolated tonsillar hypertrophy. The results of this review suggest that local allergic inflammation may play a role in adeno-tonsillar hypertrophy. Data correlating bacterial recurrent tonsillitis and allergy are few, although evidence from the lab revealed that allergy might suppress innate immunity in tonsillar tissue by reducing levels of anti-microbial proteins.

CONCLUSION

basing on our qualitative analyses allergy should not be misdiagnosed in children with combined adenotonsillar hypertrophy or isolated adenoid hypertrophy, whereas evidence do not support a link between allergy and isolated tonsil hypertrophy. Finally, some data support a link between allergy and recurrent adeno-tonsillar infection although future studies are required to confirm this data. We summarized our conclusions in a practical algorithm.

Evaluation of the intranasal steroid treatment outcomes in adenoid tissue hypertrophy with or without allergic rhinitis

PURPOSE

To compare the intranasal steroid (INS) treatment outcomes in patients with adenoid tissue hypertrophy (ATH) with or without allergic rhinitis (AR).

MATERIALS AND METHODS

Medical records of 96 children diagnosed with ATH were retrospectively examined. The pediatric version of the Score for Allergic Rhinitis (SFAR) questionnaire was used to determine the AR status of the patients and classify them. The children were divided into two groups based on the questionnaire: Group 1, low probability of AR (SFAR<9); and Group 2, high probability of AR (SFAR≥9). Intranasal mometasone furoate (100 μg/mL) was used to treat ATH for at least 3 months. The severity of nasal obstruction and snoring was evaluated using the visual analog scale (VAS) score, the adenoid/choana (A/C) ratios before and after treatment were compared, and the rate of patient referral to surgery was recorded among groups.

RESULTS

The change in the A/C ratio within the group between before and after treatment was significant (both P < 0.001). However, the reduction in the adenoid size was more significant in Group 1 than in Group 2 (P = 0.025). A significant improvement in the VAS scores was observed between before and after treatment in both groups (P < 0.001). Furthermore, the rate of surgical referral of Group 1 was significantly lower than that of Group 2 (P = 0.035).

CONCLUSIONS

INS treatment was found more successful for reducing A/C ratio in ATH without AR. Related with this, when considering the INS treatment for ATH, AR status should be kept in mind for predicting the treatment success.

Eosinophils Are More Strongly Relevant to Allergic Sensitization Than Basophils in Pediatric Adenotonsillar Hypertrophy

The relationship between eosinophils/basophils and allergic sensitization is not clear in pediatric adenotonsillar hypertrophy (ATH). The objective of this study is to investigate the relationship between eosinophil/basophil counts and peripheral specific IgE levels, and identify the common allergens in children with ATH. We initially screened 1,031 consecutive children who underwent adenotonsillectomy in our department from June 2018 to June 2019, and finally included 676 children. The eosinophil count, basophil count, and levels of specific IgE were collected. Correlations between two quantitative variables were assessed using the Pearson or Spearman coefficient. Logistic regression analyses were performed to evaluate the odds ratios (ORs) for atopy after controlling for age, sex, vitamin D, BMI, and visiting season. Both the eosinophil and basophil counts in atopic participants were significantly higher compared to non-atopic participants. The eosinophil count correlated with the levels of IgE specific to all allergens, and eosinophilia was independently associated with all tested atopy allergens other than atopy to dander after multivariate adjustment. Additionally, the basophil count correlated with the IgE levels specific to A. alternate and food mix, and basophilia was still significantly associated with atopy to food mix after multivariable adjustment. Furthermore, among allergic participants, D. farinae was the most prevalent allergen, followed by food mix, D. pteronyssinus, and A. alternata. In conclusion, eosinophils were more relevant to allergic sensitization than basophils, with eosinophils being significantly associated with all tested atopy allergens apart from dander, and basophils being associated with atopy to food mix. Furthermore, D. farinae was the most prevalent allergen and may be indicative of desensitization therapy.

Relationship between tissue and serum eosinophilia in children undergoing adenotonsillectomy with allergic rhinitis

Background/aim

Previous reports suggested that allergic/eosinophilic inflammation affects the adenoid and tonsillar tissue. The aim of this study is to evaluate and compare the tissue and serum eosinophilia in children undergoing adenotonsillectomy with allergic rhinitis.

Materials and methods

The clinical registers of 125 children undergoing adenoidectomy/tonsillectomy due to adenoid/tonsil hypertrophy were examined and reviewed retrospectively. Fifty-seven children with positive skin prick test and symptoms of allergic rhinitis were included in the study as the atopic group, whereas 68 children with no allergic symptoms and negative skin prick test were included as the nonatopic group. Consequently, the total immunoglobulin E level and the serum and tissue eosinophilia of the atopic and nonatopic groups were compared.

Results

Serum eosinophilia in the atopic group was found to be significantly higher than in the nonatopic group (P = 0.045). A significantly higher eosinophil count was found in adenoid/tonsil tissue of the atopic group (P < 0.001, P = 0.023, respectively). However, no significant correlation between tissue and serum eosinophilia was found.

Conclusion

The inconsistency between tissue and serum eosinophilia in atopic children would particularly indicate a role of local atopy in adenotonsillar hypertrophy. Further studies are needed to better understand the effect and usefulness of serum and tissue eosinophilia in children with allergic rhinitis.

Multimorbidities of Pediatric Allergic Rhinitis

PURPOSE OF REVIEW

Most children and adolescents with allergic rhinitis (AR) present extra-nasal multimorbid conditions, including conjunctivitis, asthma, atopic dermatitis, rhinosinusitis, or seromucous otitis. Additionally, they may present nasal obstructive disorders, such as septal deformity, turbinate enlargement, and adenoidal hyperplasia, which worsen nasal symptoms, especially nasal obstruction. This is a narrative review on the current state of the concomitant presence of AR and one or more multimorbidities.

RECENT FINDINGS

The presence of AR and one or more accompanying multimorbidities is associated to a higher severity and duration of the disease, a negative impact on quality of life, with worse control and lack of improvement with medical treatment. Therefore, AR needs to be managed with a multidisciplinary collaborative approach. Pediatric AR needs to be considered in the context of a systemic disease, which requires a coordinated therapeutic strategy.

Can the number of eosinophils in adenoid and tonsil tissue determine the allergy in children?

OBJECTIVE

Previous reports have indicated the association of allergy with Waldeyer's ring. The aim of this prospective study was to evaluate the correlation between the allergy and the number of eosinophils in the adenoid and tonsil tissue.

METHODS

101 children who were underwent adenoidectomy and/or tonsillectomy were prospectively enrolled in this study. 46 children who had positive skin-prick test for at least one of the allergen panel were sensitized and 55 children were nonsensitized as a result of skin-prick test. Hematoxylin-eosin stained sections were examined under 400× magnification in a blinded fashion in 10 random sections for all samples and compared the groups.

RESULTS

The number of eosinophils in adenoid and tonsil tissue was significantly higher in sensitized patients. The number of eosinophils in the adenoid and tonsil samples also were interrelated too (p < 0.001, kappa coefficient: 0.617). As a result of ROC analysis, patients with a cut-off of ≥5 eosinophils was in the sensitized group for adenoid samples [Sensitivity value: 72.09 and specifity value: 91.84]. Patients with a cut-off of ≥3 eosinophils are in the sensitized group for tonsil samples [Sensitivity value: 52.94 and specifity value: 92.11].

CONCLUSION

Presence of sensitization can be distinguished by looking at the number of eosinophils in the adenoid and tonsil tissue. It can be used to determine whether the patient is allergic or not. Examination of the routine hematoxylin-eosin stained adenotonsillary specimen for eosinophilia will guide us the diagnosis and treatment of allergic rhinitis and also reduce the cost considerably.

Local Atopy in Childhood Adenotonsillar Hypertrophy

Background Although the cause of adenotonsillar hypertrophy remains unknown, some studies have shown that allergy may be a risk factor. Purpose This study determined the levels of allergen-specific immunoglobulin E (sIgE) in the adenotonsillar tissues of children with adenotonsillar hypertrophy and evaluated the clinical significance of local atopy in adenotonsillar tissues. Methods We measured 21 types of specific immunoglobulin E in the serum and adenotonsillar tissues of 102 children with adenotonsillar hypertrophy and compared the sensitization patterns of the serum and local tissues. The patients were divided into three groups-atopy, local atopy, and nonatopy-according to the sensitization of serum and adenotonsillar tissues, and the clinical symptoms among the groups were analyzed. Results Seventy-two (70.6%) children with adenotonsillar hypertrophy were sensitized to more than one allergen in the serum and/or adenotonsillar tissue. Thirty (29.4%) children had no IgE positivity to any allergen in both serum and adenotonsillar tissues. Fifty-five (53.9%) were sensitized to at least one allergen in the serum. Seventy (68.6%) were sensitized to at least one allergen in the adenotonsillar tissue. Seventeen (36.2%) of 47 children with specific immunoglobulin E-negative serum had specific immunoglobulin E-positive adenotonsillar tissues. The rate of specific immunoglobulin E was significantly higher in local tissues than in serum. The rate of inhalant allergen specific immunoglobulin E was significantly higher in the adenoids than in the tonsils. However, the rate of food allergen specific immunoglobulin E was significantly higher in the tonsils than adenoids. The lifetime prevalence of asthma and allergic rhinitis, recent symptoms or treatment of allergic rhinitis, and severity of nasal symptoms (rhinorrhea, sneezing, and nasal itching) were significantly higher in children with local atopy than with nonatopy. Conclusions These results confirm that allergic response may be a risk factor for adenotonsillar hypertrophy. Local allergic inflammation may play an important role in childhood adenotonsillar hypertrophy, and local atopy in adenotonsillar tissues can cause respiratory allergic symptoms in children.

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.

Total and allergen-specific immunoglobulin E in the serum and nasal mucosa of a nonallergic population

BACKGROUND

There has been a growing interest in measuring allergen-specific immunoglobulin E (sIgE) directly from the nasal mucosal epithelium of individuals with sinonasal disease. However, there is currently no normative data with which to estimate sensitivity, specificity, and the appropriate positive cutoff level for new testing methods.

METHODS

Twenty individuals with no history of sinonasal disease or food allergies underwent serum IgE testing and nasal mucosal brush biopsy (MBB) testing for total and sIgE to 7 common airborne allergens and 1 food allergen. The correlation between sIgE in serum and nasal samples was determined at both the 0.10-kU/L and 0.35-kU/L positive cutoff levels.

RESULTS

sIgE at the 0.35-kU/L cutoff level was detected for at least 1 allergen in 7 of 20 (35%) participants in both the serum and nose. At the 0.10-kU/L cutoff level, 8 of 20 (40%) and 19 of 20 (95%) participants had sIgE to at least 1 allergen in the serum and nose, respectively. At the 0.35-kU/L cutoff level, total serum IgE levels were significantly higher when at least 1 allergen was detected in the nose (p = 0.01). There was a strong association between sIgE in the serum and nasal mucosa (p < 0.0001) at both cutoff levels.

CONCLUSION

The significant association between serum and nasal samples for both total and sIgE suggests that nasal IgE and serum IgE are not independent of one another. Understanding levels of IgE in the nonallergic population will help answer the questions surrounding sensitization as new diagnostic tests for locally-present IgE become available.

Adenoids and clinical symptoms: Epidemiology of a cohort of 795 pediatric patients

OBJECTIVE

Adenoid hypertrophy (AH) is very common in children and can cause airway obstruction. The aim of this retrospective study was to investigate the relationship between AH and other factors, including age, possible related symptoms, and allergies.

METHODS

Seven hundred and ninety-five patients (460 males, 335 females; mean age=5.9 years; range age: 1-14 years) were seen in an ENT clinic for nasal symptoms. Nasal endoscopy was performed with a pediatric flexible endoscope. One hundred and sixty-nine patients had documented allergy sensitization. Patients were divided into two groups according to their age: group 1 included children aged 1-7 years, and group 2 included subjects aged 8-14 years.

RESULTS

Adenoid size was related to age (p<0.0001). A logistic regression model - performed to evaluate adenoid grade considering, as dependent variables, age, sex, and the presence or absence of symptoms - was statistically significant (p<0.001). Moreover, AH was more common (p=0.0104) in patients with allergy sensitization, in particular in patients aged 8-14 years (p=0.0043). Nasal obstruction (OR=3.27) significantly predicted AH, whereas major age was not associated with pathological AH (OR=0.81).

CONCLUSIONS

The present retrospective study described the relationship between AH and other demographic and clinical factors. In conclusion, our findings demonstrated a significant association among pathological AH, age, and nasal obstruction.

Impact of passive smoke and/or atopy on adenoid immunoglobulin production in children

The adenoids are exposed to a wide number and variety of microbes, environmental pollutants, and food antigens. Atopy and passive smoke may significantly affect immune responses, mainly in children. The aim of the present study was to investigate whether passive exposure to tobacco smoke and/or atopy could affect immunoglobulin production by adenoidal lymphocytes in a cohort of children presenting with adenoid hypertrophy. A total of 277 children (151 males and 126 females; median age 5.5 years), with adenoidal hypertrophy requiring adenoidectomy and or adeno-tonsillectomy, were consecutively enrolled in the study. Adenoid mononuclear cells were in vitro stimulated with LPS or CpG. When considering both the presence of smoke exposure and atopy, we observed that the CpG-induced decrease in IgA and IgM production was significantly associated with this combination of risk factors. In the T-independent immunoglobulin production assay we found a positive association between the two risk factors and IgA and IgM production. In particular, the presence of both risk factors, showed a significant increase in IgA and IgM production after stimulation. In conclusion, this is the first study that investigated the in vitro adenoidal B cell response after different stimuli in children, also evaluating possible exposure to passive smoke and/or an atopic condition.

Does Atopy Influence the Effectiveness of Treatment of Adenoid Hypertrophy with Mometasone Furoate?

Background

The effect of topical mometasone for adenoid hypertrophy treatment is well established. Nevertheless, the influence of atopy on this treatment remains ill defined.

Objective

This study aims to compare the effects of topical mometasone furoate treatment on the adenoid tissue between atopic and nonatopic children.

Methods

Fifty-one children with obstructive respiratory complaints underwent a semistructured clinical questionnaire on nasal symptoms, prick test, and nasoendoscopy. Nasoendoscopic images were digitalized, and both adenoid and nasopharyngeal areas were measured in pixels; the relative adenoid/ nasopharyngeal area was calculated. Patients were initially treated for 40 days with nasal saline solution. In a subsequent 40-day period, topical mometasone furoate (total dose, 100 μg/day) was used.

Results

Topical mometasone significantly improved nasal obstruction, snoring, and apnea and also significantly reduced the adenoid tissue area related to the nasopharynx (p < 0.0001). Treatment with this glucocorticoid was not influenced by atopy, neither for symptoms nor for adenoid area.

Conclusion

Topical mometasone furoate significantly reduced the adenoid tissue area and led to a supplementary improvement ofnasal symptoms. This improvement was similar for atopic and nonatopic patients.

Allergic airway diseases in childhood: an update

Complex multifactorial diseases such as allergic rhinitis and asthma are not only becoming an increasing burden to healthcare systems, but especially affect the life quality of children and families suffering from their allergic symptoms. Also physicians are challenged by the multifaceted diseases as their work involves not only the often difficult decisions on case-adapted diagnostics, treatment, and monitoring, but also possible preventive measures. This review gives an outline of the latest scientific developments related to the etiology, diagnosis, and management of allergic airway diseases in childhood, as well as prenatal and early life risk factors and strategies for prevention.

Adenoids in children: Advances in immunology, diagnosis, and surgery

Adenoids are strategically located for mediating local and regional immune functions as they are exposed to antigens from both the outside air and the alimentary tract. Recurrent or chronic respiratory infections can induce histomorphological and functional changes in the adenoidal immunological barrier, sometimes making surgical treatment necessary. Our aim in this review is to summarize the crucial points about not only the immunological histopathology of adenoidal tissue, especially in patients with adenoid hypertrophy, but also the most common and useful diagnostic techniques and surgical options.

A role for Waldeyer's ring in immunological response to allergens

OBJECTIVE

Adenoids, tubal tonsil, palatine tonsil, and lingual tonsil are immunological organs included in the Waldeyer's ring, the basic function of which is the antibody production to common environmental antigens. Adenoidal hypertrophy (AH) is a major medical issue in children, and adenoidectomy is still the most used treatment worldwide. The response of adenoids to allergens is a good model to evaluate their immunological function. This report assessed the immunological changes in adenoid tissues from children with allergic rhinitis (AR) undergoing sublingual immunotherapy (SLIT).

METHODS

Adenoid samples from 16 children (seven males, nine females, mean age 7.12 years) with AH and clinical indication to adenoidectomy were collected. Of them, five children were not allergic and 11 had house dust mite and grass pollen-induced AR. Among allergic children, in four AR was treated by antihistamines while in seven AR was treated by high-dose SLIT during 4-6 months. The evaluation addressed the T helper 1 (Th1), Th2, and Th3 cells by performing a PCR array on mRNA extracted from adenoid samples.

RESULTS

In non-allergic children, a typical Th1 pattern was found. SLIT induced a strong down-regulation of genes involved in Th2 and Th1 activation and function. In particular, in SLIT-treated allergic children IL-4, CCR2, CCR3, and PTGDR2 (Th2 related genes) and CD28, IL-2, and INHA (Th1 related genes) expression was reduced, compared with children treated with antihistamines.

CONCLUSIONS

These preliminary findings warrant investigation in trials including larger numbers of patients, but indicate that hypertrophic adenoids of allergic children have the typical response to the specific allergen administered by SLIT. This should suggest that one should reconsider the immunological role of adenoids.