Recurrent adenotonsillitis: a new concept

Risk of Hodgkin's disease subsequent to tonsillectomy: a population-based cohort study in Sweden

Although some studies have linked excess of Hodgkin's disease (HD) to tonsillectomy, the findings have not been consistent. In particular, risk of HD by age at tonsillectomy has not been fully evaluated, despite the notable change in immunologic function of the tonsils between childhood and adulthood. To evaluate the risk of HD and other lymphomas, associated with tonsillectomy according to age at surgery, a population-based cohort study was conducted. Using nationwide Swedish hospitalization records, 55,169 patients undergoing tonsillectomy with/without adenoidectomy (T/A) were identified during the period 1964-1983. By linkage with the nationwide Total Population, Migration, Cancer and Causes-of-Death registries, these patients were followed up for as long as 25 years. After exclusion of the first post-operative year, a total of 533 first primary-cancer cases was identified between 1965 and 1989. Small excess risk was observed for HD (20 cases, SIR = 1.4, 95% CI 0.9-2.2). HD risk was more pronounced among patients tonsillectomized before age 12 (7 observed vs. 1.7 expected, SIR = 4.1, 95% CI 1.6-8.4), but declined significantly with older ages at T/A. While our data suggest a small increase in HD among all patients undergoing T/A and a significant excess for those under age 12 at surgery, we cannot exclude the possibility that the excess may be due to factors underlying the disorders that led to surgery.

Immunohistochemical markers of tonsillar crypt epithelium

The crypt epithelium of human palatinal tonsils is a specialized squamous epithelium characterized by the presence of intraepithelial passages which are filled by non-epithelial cells. The passages are covered by the so-called M cells. This reticulated epithelium (reticulum = network) is a highly differentiated one. In the present study immunohistochemical markers were searched for the discrimination between the superficial mucosal squamous epithelium (from which the crypts were developed) and the reticulated crypt epithelium. The reticulated epithelium is replaced by simple squamous epithelium in the course of recurrent tonsillitis. The immunohistochemical characteristics of this metaplastic epithelium were also studied. The superficial epithelium expressed blood group antigens extensively, but these antigens were almost absent from the crypt epithelium. Epithelial membrane antigen was present only in the superficial layers of the surface epithelium. Abundant positivity was characteristic for the reticulated epithelium. The metaplastic foci in the crypts were identical with the surface squamous epithelium using these markers.

Immunopathological alterations in tonsillar disease

Inflammatory conditions continuing after the age of about 10 years usually seem to accelerate the aging process of palatine tonsils (PT). However, recurrent tonsillitis (RT) may significantly change the immunological competence of PT even before that age. The observed alterations may be irreversible since they were revealed in periods when the patients had been without inflammatory symptoms for at least 4 weeks. Altered immunological function may in fact contribute to recurrence of RT and a vicious circle may thereby develop. Nevertheless, considerable immunological activity persists in diseased tonsils so the functional changes cannot by themselves justify surgical removal of these organs.

Association of Epstein-Barr virus with acute exudative tonsillitis

This report is concerned with acute exudative tonsillitis as a pathologic response to the Epstein-Barr virus (EBV). The concept of a bacterial-viral etiology etiology for tonsillitis has been suggested, and previous studies implicate EBV as a major pathogen in exudative tonsillitis. A prospective study of 16 patients with this diagnosis was conducted. EBV serologic data plus viral and bacterial throat cultures were compiled and evaluated. EBV as a casual agent alone or concurrent with other organisms was seen in 56% (9) of the patients under study. EBV activation was associated with infection by other organisms in 19% (3) of the cases. The overall total incidence of EBV in association with severe acute exudative tonsillitis was 75% (12). The data further documents EBV as a significant causal or associative agent in acute exudative tonsillitis.

Tonsillectomy and adenoidectomy. Are there any indications?

Tonsillectomy and adenoidectomy have become quite controversial within the past two decades. Physicians disagree about the need for and benefits derived from these procedures, and well-designed studies to resolve the matter have been lacking. The authors describe conditions for which they believe each surgery is indicated.

Possible role of the anaerobe in tonsillitis

Anaerobic bacteria were isolated from all tonsils removed from children at routine tonsillectomy; 75.6% of specimens yielded moderate to heavy growth and 80% of tonsils contained more than one anaerobic species. This recovery rate fell to 56% after a 10-day course of metronidazole before tonsillectomy--in only 14.6% of cases were anaerobes isolated in significant numbers. Surface swabbing of the tonsils permitted recovery of a similar spectrum of anaerobic bacteria but resulted in an overall loss of both aerobic and anaerobic pathogens. A comparison was made between the flora of acutely inflamed tonsils and "healthy' tonsils: over 90% of both groups yielded anaerobic bacteria, but they were present in significant numbers in 56.2% of swabs taken from acutely inflamed tonsils compared with 24% of swabs from "healthy' children. The isolation rate for anerobic pathogens was 37.5% and 16% respectively.

Reduced lymphocyte activation in repeatedly inflamed human tonsils

Tonsils of 20 patients with recurrent tonsillitis were investigated. Activated lymphocytes, that is lymphocytes with increased nuclear birefringence, were found in only 3 cases. The lack of lymphocyte activation is supposedly due to reduced antigen stimulation. Since antigens arrive at the tonsillar lymphoid tissue via the follicle-associated cells of the crypt epithelium, the ultrastructure of this epithelium was also studied in 5 cases. Tonsils of three dogs were used for comparison. In the repeatedly inflamed human tonsils the follicle-associated, so-called M cells contained fewer intracytoplasmic tubules and vesicles than those of the dogs. Moreover the frequency of these cells seemed to be reduced. Most of the crypts of inflamed tonsils were lined with a non-reticulated, stratified squamous epithelium. A hypothesis is presented on the pathomechanism of recurrent tonsillitis and suggestions are put forward about its pathohistology.

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.

Surface tonsillar microflora versus deep tonsillar microflora in recurrent acute tonsillitis

One hundred patients suffering from recurrent acute tonsillitis were studied. One hundred tonsils were cultured. Surface bacteria were compared to deep bacteria. In 48 per cent of the cases a different pathogen was cultured from the interior of the tonsil as compared to the surface culture. This fact may explain recurrence of tonsillitis and makes the reliability of the conventional tonsillar culture questionable. Surgical extirpation of the tonsils seems to be the only treatment since deep bacteria remain unidentified and resist the antibiotic therapy that may affect only the surface microflora.