Tonsillar hyperplasia and recurrent tonsillitis: clinical-histological correlation

Tonsillectomy Versus Tonsillotomy in Pediatric Sleep-Disordered Breathing: A Systematic Review and Multi-subgroup Meta-analysis

OBJECTIVES

To evaluate the potential of tonsillotomy (TT) as an alternative to tonsillectomy (TE) for treating children with obstructive sleep-disordered breathing (oSDB).

DATA SOURCES

Two independent reviewers searched PubMed, the Cochrane Library, Embase, and additional sources to identify controlled studies comparing TT versus TE in pediatric patients with oSDB.

REVIEW METHODS

We evaluated post-surgery symptom relief, and short- and long-term postoperative benefits for children. Fixed-effect meta-analysis, sensitivity analysis, and subgroup analysis were conducted.

RESULTS

In our analysis of 32 studies with 9,430 children, the analysis revealed TT group had a similar therapeutic effect on improvement of OSA-18 as TE group (MD = 5.20, 95% CI: -32.67 to 43.07, p = 0.96). In terms of short-term outcome, the days to return to normal diet for TT group were shorter than that for TE group (MD = -2.49, 95%CI: -3.57 to -1.28; p < 0.001), less analgesics use (MD = -3.19, 95% CI = -3.44 to -2.93, p < 0.001), and lower postoperative secondary bleeding (RR = 0.33; 95%CI: 0.23 to 0.47; p < 0.001). But the risk of reoperation (OR = 8.28; 95%CI: 2.66 to 12.64; p < 0.001), oSDB recurrence (OR = 2.16; 95%CI: 1.20-3.86; p = 0.01), and postoperative infection (OR = 1.82; 95%CI: 1.34 to 2.47; p < 0.001) in TT group was significantly higher than that in TE group.

CONCLUSIONS

Tonsillotomy reduces postoperative pain and bleeding, speeding up recovery for children with oSDB, and improving their quality of life. Yet, the risk of recurrent infections from residual tonsil tissue, which may require reoperation, calls for a careful evaluation of the procedure's short-term gains against its long-term risks.

LEVEL OF EVIDENCE

NA Laryngoscope, 2024.

Comparison of innate lymphoid cells from tissue and blood in chronic tonsillitis and tonsillar hypertrophy

OBJECT

Recurrent tonsillitis and tonsillar hypertrophy are two common diseases in children for which tonsillectomy is the definitive solution. The underlying causes of both diseases are not fully known. The aim of this study was to identify the predominant innate lymphoid cells in both diseases of the palatine tonsils, which are known to play an important role in the immune system.

METHODS

Children who underwent tonsillectomy were divided into two groups as recurrent tonsillitis and tonsillar hypertrophy according to the indication for surgery. The proportions of innate lymphoid cell (ILC) groups and IFN-gamma, IL-10 and IL-17 secreting T lymphocyte cells were determined in tonsil and blood samples obtained during surgery. Local and peripheral immune responses were evaluated. Innate immune responses and acquired immune responses were compared.

RESULTS

The results of our study showed that the proportions of the innate lymphoid cell 1 group (ILC1) were similar in tonsil tissue in patients with recurrent tonsillitis and tonsil hypertrophy, with no statistically significant difference. It was observed that the innate lymphoid cell 2 group (ILC2) was the predominant group in tonsil hypertrophy, the innate lymphoid cell 3 group (ILC3) was the predominant innate lymphoid cell group in recurrent tonsillitis, and the proportion of IL-17 secreting T lymphocytes in blood and tonsillar mononuclear cells was higher in recurrent tonsillitis patients than in tonsil hypertrophy patients.

CONCLUSION

With the results obtained, the predominant innate lymphoid cells in the pathogenesis of both diseases were identified and local and peripheral responses were compared. These findings may be a guide for possible medical treatments for both diseases in the future.

Selected Immunohistochemical Assessment and Clinical Examinations in the Diagnosis of Palatine Tonsil Diseases

INTRODUCTION

The palatine tonsils are secondary lymphoid organs where immune processes occur, influencing the development of a targeted cellular and humoral response. The diseased tonsils are subject to immunological imbalances, including the activity of pro-inflammatory and anti-inflammatory factors. This leads to the development of palatine tonsil diseases, such as palatine tonsillitis and palatine tonsillar hypertrophy.

AIM

The main aim of the study was to evaluate the similarities and differences in the clinical and pathomorphological pictures of patients qualified for surgical treatment due to hypertrophy or inflammation of the palatine tonsils. The aim was achieved by demonstrating the relationship between the patient's medical history and physical examination and histopathological diagnosis of a given tonsillar disease, evaluating the usefulness of basic blood tests (leukocytosis, ASO, ESR, and CRP) in differential diagnosis, and assessing the immunohistochemical assessment of palatine tonsil tissue.

MATERIAL AND METHODS

The tonsils were stained with the following antibodies: IL-1, IL-2, IL-6, IL-8 IL-10, and IL-37 and CD25, CD40, and CD69, taking into account the histological division of the studied lymphatic tissue (epithelial, subepithelial, follicular, follicular center, and interfollicular). Patients aged between 19 and 70 years with tonsillitis or clinical signs of tonsillar hypertrophy were qualified for tonsillectomy/UPPP. Seventy-two males (68.6%) and thirty-three females (31.4%) were enrolled in the study. Histopathological and immunohistochemical assessment was performed on 105 palatine tonsils.

RESULTS

The diagnostic value of blood tests, including determination of ASO, ESR, CRP, and leukocyte level, proved to be a significant predictor of tonsil disease. In the pathomorphological assessment, 75% of the subjects who had simultaneously elevated ESR (>4.73) and leukocytosis (>6.96) and reduced ASO (<161.03) and CRP (<0.31) belonged to the tonsillitis group. The immunohistochemical assessment revealed a diverse profile of the markers tested depending on the diagnosed disease of the tonsils. The follicular center proved to be the region of palatine tonsil tissue for which the most statistically significant differences between the markers were found. Responses to CD-40 and IL-1 were observed in this region. The tissue of epithelial, follicular, and interfollicular regions each showed one statistically significant value for the studied chemokines and lymphokines. However, the lack of significant statistical differences for p < 0.05 between the study groups was only noted in the subepithelial region. It should be emphasized that for the data as a whole (calculated on the basis of the data for all regions together), no statistically significant differences were observed.

CONCLUSION

In conclusion, the results obtained are indicative of the presence of a specific immunohistochemical profile for palatine tonsil diseases. Significant discrepancies have been found in the clinical and pathomorphological assessment of tonsils qualified for tonsillectomy. Therefore, these methods should be considered complementary. The patient's medical history and physical examination, depending on the adopted clinical or histopathological classification, show a variation in the distribution of features that are the basis for allocation to a particular group.

Do tonsils regrow after partial tonsillectomy? - Histology of regrown tonsils and predisposing factors for tonsillar regrowth

OBJECTIVES

It has been suggested that after partial tonsillectomy, referred here as tonsillotomy (TT), the remaining tonsillar tissue might be altered, leading to scarring or chronic tonsillitis. The objectives were to compare the histology of regrown tonsillar tissues with native tonsils and to assess the incidence of reoperations and predictive factors for tonsillar regrowth after TT.

METHODS

Tonsillar tissues of 1) children that underwent TT and later requiring resurgery and 2) children operated on for the first time with TT were prospectively analysed. To assess the incidence of resurgery because of tonsillar regrowth and predictive factors for tonsillar regrowth, the data covering TTs and tonsillectomies performed in 2009-2020 were retrospectively retrieved.

RESULTS

Altogether 11 children formed the regrowth group, with the control group consisting of 19 children. In the histological analysis of tonsillar tissues, neutrophil infiltration in the epithelium and crypts and severe lymphoplasmacytic infiltration in the epithelium were significantly more frequent in samples of the regrowth group relative to the control group. The number of germinal centres was greater in the regrowth group. In the retrospective analysis of 3141 children, the incidence of resurgery after primary TT was 1.9%. Logistic regression analysis showed that age was the only significant predisposing factor for resurgery.

CONCLUSION

Inflammatory cells were present more often in regrown tonsillar tissues but there was no evidence of severe chronic inflammation or scarring in the regrown tonsils. The risk of resurgery after TT was low. Young age predisposed to tonsillar regrowth, no other risk factors were found.

FEATURES OF THE CONNECTIVE TISSUE COMPONENT OF THE PALATINE TONSILS IN PATIENTS WITH RECURRENT TONSILLITIS

OBJECTIVE

The aim: To explore the morphological changes of palatine tonsil at the levels of the epithelial layer and connective tissue; to determine the relative area of the connective tissue component in the tonsillar tissue (fibrosis) in patients with recurrent tonsillitis compared to the control.

PATIENTS AND METHODS

Materials and methods: This study presents a morphological assessment of the palatine tonsils of 10 people. Tonsils' material with surrounding tissue was fixed in 10% formalin solution. The samples were dehydrated in increasing ethanol concentrations, cleared in xylol, impregnated with paraffin. Microscopy was then performed with samples stained beforehand.

RESULTS

Results: In the samples of patients with recurrent tonsillitis pericapsular sclerosis was noted, along with thickening of interlobular septa and pronounced subepithelial fibrosis. A ratio of the dense connective tissue surface area to the total surface area of tonsil tissue was determined. The control group showed a statistically significant decrease in the degree of sclerosis of the tonsil stroma.

CONCLUSION

Conclusions: Multiple changes were found in the tonsils of patients with recurrent tonsillitis at the level of the epithelial layer that manifested in structural alterations. Significant and irreversible changes were also observed in the connective stroma of the tonsil - pericapsular sclerosis, thickening of interlobular septa, and pronounced subepithelial fibrosis. A statistically significant increase in the relative surface area of the connective tissue component of the tonsil (fibrosis) by a factor of 1,26 was noted in patients with recurrent tonsillitis compared to the results of the control group of patients.

3T MRI characteristics of the palatine tonsil in brachycephalic dogs

OBJECTIVE

Investigation of the MRI characteristics of the palatine tonsil in brachycephalic dogs in 3T high-field system.

MATERIAL AND METHODS

Eighty-five brachycephalic dogs and 37 normocephalic dogs were divided into five groups: group 1 French bulldogs (FBs) with neurological clinical signs (n = 37), group 2 FBs with brachycephalic obstructive airway syndrome (BOAS) (n = 22), group 3 pugs with neurological clinical signs (n = 17), group 4 pugs with BOAS (n = 9) and group 5 normocephalic dogs (n = 37). Cross-sectional area and volume measurements were performed, and tonsillar margination and contour, shape, signal intensity and homogeneity/heterogeneity of the palatine tonsils were evaluated and compared.

RESULTS

Cross-sectional area and volume measurements of the tonsils showed no significant differences between brachycephalic and normocephalic dogs with the exception of the dogs of group 2 (FB BOAS), which showed relatively high volume and large cross-sectional area in comparison to other groups. In 87% of the brachycephalic animals, the tonsils were well defined. A smooth contour was detectable in 91.8% and a rounded shape in 94.7% of brachycephalic dogs. Signal intensity was assessed as hyperintense in relation to the musculature and iso- to hyperintense to the soft palate. Heterogeneous appearance was described in 86.9% of the brachycephalic animals.

CONCLUSIONS

The MRI characteristics of the tonsils of brachycephalic dogs do not differ considerably from those of normocephalic dogs. In FBs with distinct clinical signs of obstructive airway syndrome, increase in cross-sectional area and volume of the tonsils was detected.

Role of Tonsillar Chronic Inflammation and Commensal Bacteria in the Pathogenesis of Pediatric OSA

Immune responses at the boundary between the host and the world beyond are complex and mucosal tissue homeostasis relies on them. Obstructive sleep apnea (OSA) is a syndrome suffered by children with hypertrophied tonsils. We have previously demonstrated that these tonsils present a defective regulatory B cell (Breg) compartment. Here, we extend those findings by uncovering the crucial role of resident pro-inflammatory B and T cells in sustaining tonsillar hypertrophy and hyperplasia by producing TNFα and IL17, respectively, in ex vivo cultures. Additionally, we detected prominent levels of expression of CD1d by tonsillar stratified as well as reticular epithelium, which have not previously been reported. Furthermore, we evidenced the hypertrophy of germinal centers (GC) and the general hyperplasia of B lymphocytes within the tissue and the lumen of the crypts. Of note, such B cells resulted mainly (IgG/IgM)⁺ cells, with some IgA⁺ cells located marginally in the follicles. Finally, by combining bacterial culture from the tonsillar core and subsequent identification of the respective isolates, we determined the most prevalent species within the cohort of OSA patients. Although the isolated species are considered normal oropharyngeal commensals in children, we confirmed their capacity to breach the epithelial barrier. Our work sheds light on the pathological mechanism underlying OSA, highlighting the relevance taken by the host immune system when defining infection versus colonization, and opening alternatives of treatment.

Comparative clinicopathological aspects of chronic tonsillitis and adenoiditis in children

Chronic palatal and nasopharyngeal inflammations are common lesions in pediatric pathology, with major effects on children’s development. The study included 34 cases of chronic tonsillitis and adenoiditis for which we quantified immunohistochemically and analyzed the distribution of inflammatory elements in the follicular, extrafollicular and epithelial compartments, in relation to the composite histological scores and the clinico-epidemiological profile of the lesions. The cases were more frequent under the age of 10, in female patients, coming from urban areas, with the diagnosis of tonsillitis. B-lymphocytes have been associated with follicular areas in tonsillitis and epithelial areas in adenoiditis. In all compartments, T-lymphocytes were more frequently associated with tonsillitis and plasma cells associated with adenoiditis. Macrophages and dendritic cells had a relatively uniform distribution for the three compartments in all cases. The results obtained indicate different inflammatory phenotypes for chronic tonsillitis and adenoiditis, an aspect that may be useful for stratifying patients for optimal therapy.

Lingual salivary gland hypertrophy and decreased acinar density in chagasic patients without megaesophagus

Although the salivary glands present several functions, there are few studies evaluating these glands in Chagas disease (CD). This study aimed to compare the percentage of collagen, the presence of inflammation, the density of chimase and tryptase mast cells, the area and density of lingual salivary gland acini in autopsied individuals with and without (CD). We analyzed 400 autopsy reports performed in a tertiary public hospital from 1999 to 2015 and selected all the cases in which tongue fragments were collected (27 cases), 12 with chronic CD without megaesophagus (CH) and 15 without CD (non-chagasic - NC). The histological sections of the tongue were stained by Picrosirius red for collagen evaluation and Hematoxylin-eosin for morphometric evaluation of salivary gland acini and inflammation. Anti-chimase and anti-tryptase antibodies were used for the immunohistochemical evaluation of mast cells. The chagasic patients presented higher volume and lower density of salivary glands acini. There was no difference in the collagen percentage, inflammation and density of mast cell chymase and tryptase between the groups. Although we did not observe a significant difference between the groups regarding the collagen percentage, inflammatory process and mast cell density, our results suggest that even without megaesophagus, chagasic patients present hypertrophy of the lingual salivary glands and lower acinar density probably due to mechanisms independent of the esophagus-glandular stimulus.

Study of adenotonsillectomy specimens: An institutional experience

OBJECTIVE

Waldeyer's lymphatic ring consists of group of tonsils located over the posterior oropharyngeal wall. The palatine tonsils are largest tonsil. The present study was aimed to evaluate the significance of lymphoid hyperplasia, lymphocyte infiltration with and without defect in the surface epithelium in chronic tonsillitis (CT) and chronic adenotonsillar hypertrophy (CAH) in resected tonsillectomy and adenotonsillectomy specimens.

MATERIALS AND METHODS

A total of 85 patients were included in the study. Fifty-one cases underwent bilateral tonsillectomy and 34 cases underwent adenotonsillectomy.

RESULTS

The lymphoid hyperplasia was higher in CAH (30/34; 88.24%) as compared to CT (26/50; 52%). Lymphocyte infiltration with or without defect in the surface epithelium was common in CT. The histopathologic criteria of lymphoid hyperplasia and lymphocyte infiltration with or without defect in the surface epithelium showed a statistically significant difference between CT and CAH.

CONCLUSION

CT and CAH may be differentiated on the basis of reliable histopathological criteria. Punch biopsy can be performed to avoid CT complication if the clinical diagnosis is true. Choristomas can be clinically confused with true neoplasms, if large in size.

Tonsillar cytokine expression between patients with tonsillar hypertrophy and recurrent tonsillitis

Background

Tonsils provide an innovative in vivo model for investigating immune response to infections and allergens. However, data are scarce on the differences in tonsillar virus infections and immune responses between patients with tonsillar hypertrophy or recurrent tonsillitis. We investigated the differences in virus detection and T cell and interferon gene expression in patients undergoing tonsillectomy due to tonsillar hypertrophy or recurrent tonsillitis.

Methods

Tonsils of 89 surgical patients with tonsillar hypertrophy (n = 47) or recurrent tonsillitis (n = 42) were analysed. Patients were carefully characterized clinically. Standard questionnaire was used to asses preceding and allergy symptoms. Respiratory viruses were analysed in tonsils and nasopharynx by PCR. Quantitative real-time PCR was used to analyse intratonsillar gene expressions of IFN-α, IFN-β, IFN-γ, IL-10, IL-13, IL-17, IL-28, IL-29, IL-37, TGF-β, FOXP3, GATA3, RORC2 and Tbet.

Results

Median age of the subjects was 15 years (range 2–60). Patients with tonsillar hypertrophy were younger, smoked less often, had less pollen allergy and had more adenovirus, bocavirus-1, coronavirus and rhinovirus in nasopharynx (all P < 0.05). Only bocavirus-1 was more often detected in hypertrophic tonsils (P < 0.05). In age-adjusted analysis, tonsillar hypertrophy was associated with higher mRNA expressions of IL-37 (P < 0.05).

Conclusions

Intratonsillar T cell and interferon gene expressions appeared to be relatively stable for both tonsillar hypertrophy and recurrent tonsillitis. Of the studied cytokines, only newly discovered anti-inflammatory cytokine IL-37, was independently associated with tonsillar hypertrophy showing slightly stronger anti-inflammatory response in these patients.

Electronic supplementary material

The online version of this article (10.1186/s13601-018-0205-z) contains supplementary material, which is available to authorized users.

Allergy genuflection? It's surmount with special focus on ear, nose and throat

The system that protects body from infectious agents is immune system. On occasions, the system seldom reacts with some foreign particles and causes allergy. Allergies of the ear, nose and throat (ENT) often have serious consequences, including impairment and emotional strain that lowers the quality of life of patients. This is further responsible for the common cold, cough, tonsillitis, dermal infection, chest pain and asthma-like conditions which disturb one's day to day life. The present review enlightens some common ENT allergies which one can suffer more frequently in one's lifetime, and ignorance leads to making the condition chronic. Information regarding pathophysiology and the management of ENT allergy by this review could help clinicians and common people to better understand the circumstances and treatment of ENT allergy.

Characterization of tonsillar IL10 secreting B cells and their role in the pathophysiology of tonsillar hypertrophy

The comprehension of unconventional immune functions of tonsillar B cells, their role in tolerance induction and protective immune responses, is crucial to unveil the dynamic interactions of the upper aero digestive tract with polymicrobial commensal flora and pathogens, in health and disease. Here, we describe the kinetics of IL10 intracellular expression and compare it with that of cytokines known to be produced by tonsillar B cells. Additionally, we detected a relevant proportion of IL17-expressing tonsillar B cells, which has not previously been reported. We immunophenotyped tonsillar IL10-expressing B cells (B10) and observed IL10 production in activated B cells at every developmental stage. Finally, we identified a relationship between decreased B10 percentages, increased proportion of the germinal centre (GC) population and hypertrophied tonsils (HT). Our findings provide greater insight into the role of B10 in GC reactions and characterized their involvement in the pathogenesis of tonsillar dysfunction.

Hyperplasia and the degree and activity of inflammation in chronic recurrent tonsillitis: a histopathological study

Postoperative haemorrhage following tonsillectomy occurs in 5.98% of all cases with up to 10 deaths reported annually in Germany. When comparing tonsillectomy (TE) and tonsillotomy (TT), the same long-term frequency of ENT infections is displayed in children and young adults. However, taking postoperative haemorrhaging into account, TT is more favourable. Chronic tonsillitis is one of the most common indications for TE in the adult population; however, a histopathological characterization may reveal objective criteria and provide a foundation for routinely performing TT in adults too. Three essential parameters hyperplasia (HP), grade of inflammation (GOI) and activity of inflammation (AOI), which are responsible for, and associated with a clinically relevant disease were histopathologically examined in the tonsils of 100 adult patients with chronic recurrent tonsillitis. The parameters were analysed and compared separately in the pharyngeal and basal parts of the tonsils as well as in three sections (upper and lower pole of the tonsil, middle part) as this may influence the indication for TT. The comparison of the basal and pharyngeal portions displayed a significant difference in the GOI and the HP in all three sections: grade 2 HP as well as GOI were more commonly found in the basal than pharyngeal portions (p > 0.001). AOI (grade 2) displayed the same properties in the middle section (p < 0.002), but did not reach statistical significance in the cranial and caudal sections (p = 0.107 and p = 0.186). An overabundance of grade 1 GOI, AOI, and HP was seen in the pharyngeal sections. The results show that two out of three relevant parameters that demonstrate histopathological changes in recurrent inflamed tonsils have a significantly stronger presence in the basal section of the tonsil as opposed to the pharyngeal section. The processes initiated by inflammation next to the surface responsible for a clinically relevant recurrent tonsillitis seem to cause stronger reactions in the deep follicular portion of the tonsils.

Enzyme-labeled Antigen Method: Development and Application of the Novel Approach for Identifying Plasma Cells Locally Producing Disease-specific Antibodies in Inflammatory Lesions

In chronic inflammatory lesions of autoimmune and infectious diseases, plasma cells are frequently observed. Antigens recognized by antibodies produced by the plasma cells mostly remain unclear. A new technique identifying these corresponding antigens may give us a breakthrough for understanding the disease from a pathophysiological viewpoint, simply because the immunocytes are seen within the lesion. We have developed an enzyme-labeled antigen method for microscopic identification of the antigen recognized by specific antibodies locally produced in plasma cells in inflammatory lesions. Firstly, target biotinylated antigens were constructed by the wheat germ cell-free protein synthesis system or through chemical biotinylation. Next, proteins reactive to antibodies in tissue extracts were screened and antibody titers were evaluated by the AlphaScreen method. Finally, with the enzyme-labeled antigen method using the biotinylated antigens as probes, plasma cells producing specific antibodies were microscopically localized in fixed frozen sections. Our novel approach visualized tissue plasma cells that produced 1) autoantibodies in rheumatoid arthritis, 2) antibodies against major antigens of Porphyromonas gingivalis in periodontitis or radicular cyst, and 3) antibodies against a carbohydrate antigen, Strep A, of Streptococcus pyogenes in recurrent tonsillitis. Evaluation of local specific antibody responses expectedly contributes to clarifying previously unknown processes in inflammatory disorders.

Application of an enzyme-labeled antigen method for visualizing plasma cells producing antibodies against Strep A, a carbohydrate antigen of Streptococcus pyogenes, in recurrent tonsillitis

Streptococcus pyogenes is the main causative pathogen of recurrent tonsillitis. Histologically, lesions of recurrent tonsillitis contain numerous plasma cells. Strep A is an antigenic carbohydrate molecule on the cell wall of S. pyogenes. As expected, plasma cells in subjects with recurrent tonsillitis secrete antibodies against Strep A. The enzyme‐labeled antigen method is a novel histochemical technique that visualizes specific antibody‐producing cells in tissue sections by employing a biotin‐labeled antigen as a probe. The purpose of the present study was to visualize plasma cells producing antibodies reactive with Strep A in recurrent tonsillitis. Firstly, the lymph nodes of rats immunized with boiled S. pyogenes were paraformaldehyde‐fixed and specific plasma cells localized in frozen sections with biotinylated Strep A. Secondly, an enzyme‐labeled antigen method was used on human tonsil surgically removed from 12 patients with recurrent tonsillitis. S. pyogenes genomes were PCR‐detected in all 12 specimens. The emm genotypes belonged to emm12 in nine specimens and emm1 in three. Plasma cells producing anti‐Strep A antibodies were demonstrated in prefixed frozen sections of rat lymph nodes, 8/12 human specimens from patients with recurrent tonsillitis but not in two control tonsils. In human tonsils, Strep A‐reactive plasma cells were observed within the reticular squamous mucosa and just below the mucosa, and the specific antibodies belonged to either IgA or IgG classes. Our technique is effective in visualizing immunocytes producing specific antibodies against the bacterial carbohydrate antigen, and is thus a novel histochemical tool for analyzing immune reactions in infectious disorders.