Spatially visualized single-cell pathology of highly multiplexed protein profiles in health and disease

Deep molecular profiling of biological tissues is an indicator of health and disease. We used imaging mass cytometry (IMC) to acquire spatially resolved 20-plex protein data in tissue sections from normal and chronic tonsillitis cases. We present SpatialViz, a suite of algorithms to explore spatial relationships in multiplexed tissue images by visualizing and quantifying single-cell granularity and anatomical complexity in diverse multiplexed tissue imaging data. Single-cell and spatial maps confirmed that CD68+ cells were correlated with the enhanced Granzyme B expression and CD3+ cells exhibited enrichment of CD4+ phenotype in chronic tonsillitis. SpatialViz revealed morphological distributions of cellular organizations in distinct anatomical areas, spatially resolved single-cell associations across anatomical categories, and distance maps between the markers. Spatial topographic maps showed the unique organization of different tissue layers. The spatial reference framework generated network-based comparisons of multiplex data from healthy and diseased tonsils. SpatialViz is broadly applicable to multiplexed tissue biology.

Geographical differences in tonsillar carriage rates of Fusobacterium necrophorum - A cross-sectional study in Sweden and Zambia

While Fusobacterium necrophorum historically has been considered normal tonsillar flora, recent studies from Europe and the US have suggested that carriage occur transiently in adolescence and young adulthood. However, no studies originating from Africa exist. In this cross-sectional study of tonsillar carriage of F. necrophorum, we aimed to investigate geographical differences in tonsillar carriage rates of F. necrophorum in healthy participants aged 15-25 years in Sweden and Zambia and further investigate the age distribution of tonsillar carriage in Zambia. Specimens were obtained by tonsillar swabs and analyzed with real-time PCR for F. necrophorum. In participants aged 15-25 years, tonsillar carriage was more common in Sweden 21/100 (21%) than in Zambia 6/192 (3%), p < 0.001. In Zambian participants aged above 25 years tonsillar carriage was rare 1/76 (1%). In conclusion, the high rate of tonsillar carriage in participants aged 15-25 years in Sweden has implications on the interpretation of tonsillar findings in patients with pharyngotonsillitis. Interestingly, a geographical difference was found with tonsillar carriage rarely identified in Zambia.

Assessment of Tonsil Volume With Transcervical Ultrasonography in Both Children and Adults

OBJECTIVES

To investigate the success of ultrasonography (USG) in the objective measurement of palatin tonsil volume in both children and adults and to compare those results with clinical findings.

METHODS

Eighty-five patients, who were scheduled to undergo tonsillectomy with the indications of recurrent tonsillitis and obstructive sleep apnea syndrome, were included in the study. The tonsil grades of the patients were recorded according to the Friedman tonsil grading. The tonsil size and volume were measured with transcervical USG. After tonsillectomy, the volumes of the tonsils were calculated by the displacement method. The correlation between the obtained data was evaluated. In all analyses, P < .05 was accepted as a statistical level of significance.

RESULTS

Fifty children and 35 adults were included in the study. In children, the mean actual volume ± SD of 100 tonsils was measured as 3.5 ± 1.45 mL, and the USG volume was 3.67 ± 1.59 mL; a high correlation was found between both methods (r = 0.842; P < .05). In adults, the mean actual volume of 70 tonsils was measured as 5.15 ± 2.25 mL, and the USG volume was 5.71 ± 2.98 mL; a moderate correlation was found between the methods (r = 0.589; P < .05). In children, a moderate correlation was found between the Friedman grading and the USG (r = 0.532; P < .05), and actual (r = 0.549; P < .05) tonsil volumes. In adults, a low correlation was found between the Friedman grading and the USG (r = 0.363; P < .05) and actual (r = 0.384; P < .05) tonsil volumes.

CONCLUSIONS

Ultrasonography is a useful, accessible, and noninvasive imaging method for objective measurement of tonsil volume in adults and children.

Sore Throat Assessment Tool-10 for patients with acute pharyngo-tonsillitis

INTRODUCTION

The aim of this study was to develop and validate a patient-based questionnaire for the assessment of sore throat symptoms. The questionnaire can be used to quantify the effects of different treatments in patients with acute pharyngo-tonsillitis (APT).

METHODS

A 13-item questionnaire was constructed using a five-point Likert scale. Adult patients with APT consulting one of the participating general practitioners answered the survey. Healthy students served as controls.

RESULTS

A total of 77 sore throat patients and 103 healthy controls were included. Ten items had moderate to high (> 0.25) inter-item correlations and high mean scores (> 3.0) among patients and were included in the final tool, the Sore Throat Assessment Tool (STAT)-10. The patients' mean STAT-10 score was 36.5 (95% confidence interval (CI): 34.8-38.2) at the time of inclusion compared with 10.4 (95% CI: 10.2-10.6) for controls (p < 0.001). Cronbach´s alpha coefficient for the questionnaire was 0.87. The standard error of measurement was 2.99, the intraclass correlation 0.92 and the Spearman correlation test-retest reliability 0.87. The STAT-10 scores increased with Centor scores (p = 0.018).

CONCLUSIONS

The reliability and validity of the STAT-10 were very high. The STAT-10 is the first validated tool for measuring the intensity and duration of symptoms from the perspective of sore throat patients and for quantifying and comparing different treatment modalities in APT patients.

FUNDING

This study received funding from The Lundbeck Foundation (Grant #R185-2014-2482), Fonden for Lægevidenskabens Fremme, and Hans Skouby´s Fond.

TRIAL REGISTRATION

The study was approved by the Danish Data Protection Agency (2015-57-0002).

[The specific pathogenetic features of the development of chronic tonsillar pathology]

The authors discuss the mechanisms underlying the development of chronic tonsillar pathology confirmed by the methods of histological, autoradiographic, and bacteriological diagnostics. The new aspects of vital activity of microorganisms in the parenchymal tissue of the palatine tonsils are highlighted that account for the low effectiveness of the conservative therapy of chronic tonsillitis and give evidence of the necessity of the surgical treatment of this condition.

[The use of the enzymes for the enhancement of the effectiveness of antimicrobial photodynamic treatment of the patients presenting with chronic tonsillitis]

The objective of the present study was to enhance the effectiveness of the treatment of the patients presenting with various forms of chronic tonsillitis (CT) by means of antimicrobial photodynamic therapy (APDT). The study included 48 patients at the age from 18 to 55 years divided into three groups; all of them suffered from various forms of CT. Group 1 was comprised of 12 patients given a course of traditional conservative therapy. Group 2 consisted of 17 patients treated by APDT while group 3 included 19 patients in whom a course of antimicrobial photodynamic therapy was preceded by the treatment of the mucous membrane of the palatine amygdalae with a lidase solution. The microbiological testing was performed on days 5, 12, and 24 after APDT and also within the next 6-9 months. The results of the microbiological and clinical studies give evidence of the possibility to improve the effectiveness of the treatment of chronic tonsillitis by means of antimicrobial photodynamic therapy with the use of the preventive treatment of palatine tonsillar mucosa with a lidase solution. Such treatment was found to facilitate degradation of theintercellular matrix of the biofilm and reduced its resistance to the photodynamic impact.

[Chronic tonsillitis, etiological and pathogenetic aspects of the development of metatonsillar complications]

The objective of the present study was to summarize the data of the current literature publications concerning the tonsillar biotope under the normal conditions and in the course of the development of the pathological process. Specific microbiological characteristics of the potential causative agents of tonsillar pathology are considered. The structural, immunological, and genetic prerequisites for the for progress of infection are discussed with special reference to the morphological and functional changes in the tissue of palatine tonsils associated with different forms of the disease and the mechanisms underlying immunopathological conditions and metatonsillar complications.

[A rare case of thalassemia concomitant with chronic decompensated tonsillitis]

The present paper reports a rare combination of Cooley's disease (thalassemia B) and the decompensated variant of chronic tonsillitis in a 14-year old girl. The patient presented with the severe form of hypochromic anemia and degenerative changes of erythrocytes. She was treated by means of bilateral tonsillectomy associated with the high risk of postoperative hemorrhage. In the preoperative period, the child received drop intravenous infusion of tranexam at a dose of 15 mg/kg body weight together with hemostatic agents. Hemorrhage during the surgical intervention was stopped by pressing tampons impregnated with tranexamic acid known to exert local and systemic hemostatic and antifibrinolytic action. The patient was discharged from the hospital for the further treatment of the primary disease.

[The morphofunctional prerequisites for the development of exudative otitis media in the children presenting with chronic adenoiditis]

The objective of the present study was to elucidate the structural and functional mechanisms underlying disturbances of the protective nasolaryngeal barrier with special reference to the following histological and immunohistochemical characteristics of the pharyngeal tonsils (CD4, CD20, CD68, IgA, P53, BCL2, Ki67, TGF-beta) in the children aged 3-6 years and presenting with complicated (n=20) or uncomplicated (n=20) chronic adenoiditis (CA). It was shown that adenoids of the patients with complicated chronic adenoiditis less frequently exhibit markers of active inflammation, such as hyperemia, intraepithelial infiltration, and hemosiderophages. Also, they have the smaller mean area of lymphoid follicles and the number of functional intrafollicular macrophages suggesting impaired immunological reactivity. Lymphoid follicles of the pharyngeal tonsils in the children with uncomplicated chronic adenoiditis show up enhanced density of B-lymphocytes (CD20) and CD69-positive cells which may suggest functional tension. However, density of IgA-producing lymphocytes responsible for the protection of nasolaryngeal mucosa is identical in the patients with complicated and uncomplicated chronic adenoiditis. Taken together with the decreased number of T-helpers (CG4), this finding indicates the compromised immunological response in the children with this pathology. It is concluded that the structural characteristics of pharyngeal tonsils revealed in the present study may provide a basis for the disturbances of congenital and adaptive immunity; moreover, they can serve as the predictors of complications of chronic adenoiditis.

[The microbiocenosis of intestine and immune status of children of primary school age]

The article deals with the study of species and quantitative structure of microbiocenosis of intestine and characteristics of immune status in children aged 8-10 years. In children with chronic tonsillitis pharyngitis and bronchitis and with diseases of gastro-intestinal tract (biliary dysfunction, chronic gastroduodenitis and gastritis) the microbe imbalance of various degree of manifestation was established which was prevailing in cases of children with pathology of gastrointestinal tract. The increase of quantity of opportunistic microflora induces the production of both immunoglobulins and cytotoxic lymphocytes and cells-natural killers.

[Influence of сycloferon on the сytokine blood profile and production of proinflammatory сytokines in the cultures of mononucleares of peripheral blood of the patients with chronic tonsillitis]

The 88 patients with chronic tonsillitis (CT) was investigated. The 46 patients (basic group) got the modern immunoactive preparation cycloferon and 42 patients (comparison group) - only the generally accepted therapy. During immunological researches on a background clinical manifestation of СT the increase proinflammatory cytokines (CK) (TNFα, IL-1Β) in the serum, and also increase the level of spontaneous products of these CK in the cultures mononucleares of periferal blood was detected. At general accepted treatment took place increase level proinflammatory CK at serum on background decline stimulated product of CK at mononucleares cultures. Aрplication of cycloferon at the treatment of CT provided to normalization cytokines profile of the blood and production of CK in the cultures mononucleares.

[The application of a CO(2)-laser for tonsillectomy in the patients presenting with chronic decompensated tonsillitis as an alternative to the traditional methods of surgical treatment]

AIM OF THE STUDY

to estimate the clinical efficiency and advantages of the surgical treatment of palatal tonsils with the use of a CO(2)-laser in comparison with the traditional methods of tonsillectomy.

METHODS

A total of 175 patients presenting with decompensated tonsillitis were available for the observation of which 79 were operated with the use of a CO(2)-laser. The control group was comprised of the patients undergoing conventional tonsillectomy.

RESULTS

The study confirmed the high clinical efficiency of the ablation of palatal tonsils using the CO(2)-laser and its advantages in terms of reduced duration of the postoperative period, requirements for analgesic and antibacterial medications, recovery of the swallowing function and speech.

[The use of immunocorrection therapy for the combined treatment of the inflammatory diseases of the pharynx]

The objective of the study. To estimate the efficacy of the combined treatment of the patients presenting with chronic tonsillitis, acute and chronic pharyngitis with the use of traditional methods supplemented by the immunocorrective preparation imudon. A total of 320 patients with inflammatory pharyngeal diseases were examined and treated. It was shown that the introduction of imudon therapy in the combined treatment of chronic tonsillitis, acute and chronic pharyngitis produces a more pronounce and stable beneficial effects than conventional therapy.

[The state of palatine tonsils in the patients presenting with the deviation of the nasal septum]

The objective of the present study was to further improve diagnostics and treatment of chronic tonsillitis (ChT). It included 100 patients presenting with disturbances of the nasal breathing that resulted in the deviation of the nasal septum and hypertrophy of the inferior turbinate bones. The signs of the simple form of chronic tonsillitis were detected in the 87 patients enrolled in the study. The patients who enjoyed the normalization of the nasal breathing after the surgical intervention had a more favourable clinical course of chronic tonsillitis compared with the patients given no such treatment. The results of the study provide an additional information concerning the relationship between the disturbances of the basal bleeding and the development of changes in palatine tonsils; moreover, they allow determining early indications for the surgical treatment for the correction of the deviation of the nasal septum.

[Improved diagnosis of the severity of chronic decompensated tonsillitis]

Results of examination and treatment of 111 patients were used to evaluate the severity of chronic decompensated tonsillitis based on the following parameters of endotoxicosis: leukocytic intoxication index, content of medium molecular-weight peptides in blood, and erythrocyte sorption capacity. These results provided additional information about the functional state of palatine tonsils and severity of tonsillogenic intoxication; moreover they made it possible to evaluate efficiency of conservative treatment and determine indications for surgical intervention. Taken together, these data may be used to avoid subjective conclusions as regards the degree of decompensation in patients with chronic tonsillitis.

[Treatment of chronic tonsillitis in singers]

A total of 74 professional vocalists aged from 20 to 64 years with different forms of chronic tonsillitis were examined. Results of the study were used to develop recommendations for the treatment of chronic tonsillitis in patients of this category.

[Vegetative adaptation in children presenting with chronic adenoiditis]

Publications reporting the comprehensive analysis of the psychovegetative status in children with chronic adenoiditis are practically lacking in the literature. The objective of the present work was to study the functional state of the vegetative nervous system (vegetative nerve tone, vegetative reactivity, and vegetative regulation of vital activity) and manifestations of vegetative disorders in the clinical picture of chronic adenoiditis in preschool children.

[On certain aspects of the problem of chronic tonsillitis]

Based on the current literature data and the results of original studies on the role of non-infectious (atopic) allergy in pathogenesis of chronic tonsillitis (CT), the author considers it unjustified under the current state of the art to characterize CT as an infectious allergic disease. He maintains that the classification of chronic tonsillitis proposed by Preobrazhensky and Pal'chun remains the most acceptable one for the practical purposes.

[Peripheral T cell subsets in chronic tonsillitis patients]

OBJECTIVE

To investigate the characteristics of T lymphocytic subsets in chronic tonsillitis patients for evaluation of their clinical implication.

METHOD

Fresh peripheral blood samples were obtained from 54 chronic tonsillitis patients and 52 healthy counterparts. CD4+ and CD8+ T lymphocyte subsets including the naive (CD45RA+), memory (CD45RO+), functional (CD28+), activated (HLA-DR+, CD25+) and apoptosis (CD95+) T lymphocytes, were analyzed by flow cytometry, respectively. The clinical data such as serum Cystatin C con centration, ASO and ESR were simultaneously recorded from each chronic tonsillitis patient.

RESULT

The CD4+ T cells, the rate of CD4+/CD8+ and CD4+ CD45RA+ /CD4+ CD45RO+, the CD4+ CD45RA+ T cells and the CD4+ CD25+ T cells in chronic tonsillitis were significantly lower than those of the control group (P < 0.05) while an obviously increasing percentage of memory (CD45RO+) and apoptosis (CD95+) T lymphocytes in chronic tonsillitis patients, and there were significant differences between the patients with chronic tonsillitis and the healthy volunteers (P < 0.05). Furthermore, in the chronic tonsillitis patients, Serum Cystatin C level was negatively correlated with CD4+ CD45RA+ T(P < 0.05), and not significantly correlated with other T lymphocyte subtypes (P > 0.05).

CONCLUSION

Immune disorder is present in the peripheral blood of chronic tonsillitis patients. Our data may provide valuable information for evaluation of disease progression of chronic tonsillitis patients.

The influence of tonsillitis on oral and throat muscles in adults

OBJECTIVES

Surface electromyography (sEMG) was performed on randomly chosen adults with acute and recurrent tonsillitis to trace changes in muscle activity.

STUDY DESIGN AND SETTING

Randomized prospective study.

METHODS

Activity of masseter (MS), submental (SUB), and infrahyoid muscles (INF) were examined and statistically analyzed during deglutition being compared to normative databases.

RESULTS

For acute tonsillitis, the duration of muscle activity during deglutition was normal with normal amplitude, except for INF muscles. When the acute episode was over, no peculiarities remained. For recurrent tonsillitis, the duration of activity and SUB amplitude remains normal and activity of MS and INF became increased, and this abnormality remained during the remissions.

CONCLUSION

Acute and recurrent tonsillitis affect muscle activity significantly by involving additional muscles (mainly infrahyoid) in swallowing. Acute tonsillitis triggers temporary electric hyperactivity of infrahyoid muscles. Recurrent tonsillitis affects MS and INF even during periods of remission (fixed pathological changes).

SIGNIFICANCE

This data might justify patients' complaints during the period of remission and can be used for comparison purposes to trace possible complications of tonsillitis.

The influence of tonsillitis on oral and throat muscles in children

OBJECTIVES

Surface electromyography (sEMG) studies were performed on 80 children with acute tonsillitis (AT) and 110 children with recurrent tonsillitis (RT), age 4-12 years, to trace sEMG changes of duration and amplitude of muscle activity during swallowing and continuous drinking.

STUDY DESIGN

Prospective observational study of randomly chosen patients compared to normative database.

METHODS

Timing and amplitude (in muV) of activity of masseter, submental and infrahyoid muscles were evaluated during voluntary single swallows of saliva ("dry" swallow), water swallows, swallows of excessive amount of water (up to 15 ml), and continuous drinking of 50 ml of water. These parameters were measured for two age groups for both conditions: 4-8 and 9-12 years old. The previously established normative database was taken for control.

RESULTS

AT presents prolonged duration of swallowing and electric hyperactivity of infrahyoid muscles but this activity returns to normal after recovery. RT affects masseter and infrahyoid muscles even during periods of remission but do not affect duration of swallowing activity.

CONCLUSION

AT and RT in children age 4-12 years affects muscle activity during swallowing significantly by involving additional muscles (mainly infrahyoid) in this process. AT presents temporary electric hyperactivity of infrahyoid muscles. RT affects masseter and infrahyoid muscles even during periods of remission (pathologic changes are fixed). Abnormally high electric activity of masseter and infrahyoid muscles in patients with RT might serve as an additional indicator for tonsillectomy. Surface EMG of swallowing is a simple, non-invasive and reliable method for diagnostic and preoperative evaluation of dysphagia complaints associated with tonsillitis.

Comparative study of bacteriology in recurrent tonsillitis among children and adults

INTRODUCTION

Diagnosis and treatment of acute tonsillitis are one of the most common problems seen at an otorhinolaryngology clinic in both adult and paediatric populations. Much has been written about bacteriology of recurrent tonsillitis but it remains a controversial topic. Despite the fact that tonsillitis is so common, consensus seems to be lacking as to the main causative organism and the differences between children and adults. The tonsillar core bacteriology of 233 patients with recurrent tonsillitis who underwent tonsillectomy from January 2000 to June 2003 is presented.

METHODS

The patient population was divided into two groups, namely: the paediatric group and the adult group. 132 patients, whose age was more than 12 years, were in the adult group. 101 patients aged between two and 12 years, were in the paediatric group. The bacteriology of the children and adults were tabulated according to their species, and were compared.

RESULTS

138 patients grew single pathogenic bacteria in their tonsillar core culture, 52 grew two different pathogenic bacteria, and the rest (43) grew normal bacterial flora. Staphylococcus aureus was the most commonly-isolated bacterium and accounted for 40.9 percent of the total cultures isolated; its prevalence was the same in the adults and children. Beta-haemolytic Streptococcus was isolated in 23 percent of subjects, and was predominantly from group A (Streptococcus pyogens). Group A beta-haemolytic Streptococci was more prevalent in children. Pseudomonas aeruginosa, which rarely cause pathogenicity in tonsils, was cultured from nine (3.8 percent) of our study subjects.

CONCLUSION

This study showed that Staphylococcus aureus is the most common pathogenic bacteria cultured both in adults and children. Klebsiella pneumonia, Streptococcus pneumonia, Escherichia coli and Enterobacter are more prevalent in adults. Haemophilus influenza and Streptococcus pyogens are more prevalent in children. Pseudomonas aeruginosa is not a rare causative organism in recurrent tonsillitis. Since the mechanism of activation of infection in recurrent tonsillitis is unknown, knowing the bacteriology does not help us to treat the disease. However, it may be a stepping stone to eventually understanding whether the bacteria play a role in reactivating recurrent infections. From previous and current studies, there is no relationship between bacteriology and recurrent infections.

Morbidity in patients waiting for tonsillectomy in Cardiff: a cross-sectional study

Objective: Our aim was to determine the morbidity of patients awaiting tonsillectomy.

Design: The study comprised a questionnaire survey of 379 children and 278 adults waiting over 12 months for tonsillectomy.

Outcome measures: These comprised frequency of infection, sickness absence and continuing desire for surgery.

Results: Response rates were 70 per cent (children) and 60 per cent (adults). Morbidity was similar in adults and children, and in those waiting more or less than two years. In the six months prior to the study, 86 per cent of children and 83 per cent of adults had had tonsillitis. Sixty per cent of children and 50 per cent of adults had had three or more episodes. Sixty-two per cent of children and 59 per cent of adults had had at least one long episode of tonsillitis, and 29 per cent of children and 24 per cent of adults had had more than three long episodes. Eighty-nine per cent of children had missed school at least once, compared with 71 per cent of adults missing work at least once (p = 0.01). The frequency of infection was significantly associated with patients' desire for surgery (p < 0.001).

Conclusions: Patients awaiting tonsillectomy experience considerable morbidity. This study does not support the hypothesis that untreated patients will ‘outgrow’ their condition.

Effect of adenotonsillitis on peak exploratory flow rate in children

Peak Exploratory Flow Rate (PEFR) is a simple, economical, reproducible, non-invasive test, which can be quickly performed with ease. PEFR was assessed in 36 children with adenotonsillar enlargement with mean age 10.75 years and equal number of age and sex matched normal children who acted as controls. PEFR was found to be 250. 61 +/- 66.92 lt/min in controls and 216.85 +/- 59.76 lt/min in children with adenotonsillar enlargement signifying impairment of PEFR in children in the second group.

The role of bacterial interference in otitis, sinusitis and tonsillitis

Bacterial interactions that include antagonism (interference) and synergism help maintain balance between the members of the normal endogenous flora. Alpha-streptococci that predominate in the normal respiratory tract flora attracted most attention in studies of bacterial interference. Other organisms that possess interfering characteristics in upper respiratory tract infections (URTIs) are nonhemolytic streptococci, and Prevotella and Peptostreptococcus spp. The production of bacteriocins by some microorganisms is one of the important mechanisms of interference. The role of bacterial interference in the development of URTI and its effect on the eradication of these infections is discussed. These infections include pharyngo-tonsillitis, otitis media, and sinusitis. Treatment with various antimicrobial agents can affect the balance between members of the oro-pharyngeal bacterial flora and interfering organisms. Implantation into the indigenous microflora of low virulence bacterial strains that are potentially capable of interfering with colonization and infection with other more virulent organisms has been used in preliminary studies as a means of coping with the failure of antimicrobials in the treatment of several URTI.

Spontaneous resolution of acquired tonsillar herniation caused by isolated cerebellar tonsil inflammation: case report

OBJECTIVE AND IMPORTANCE

Chiari I malformation is a well-known disease involving caudal descent of the cerebellar tonsils and is generally considered to be a congenital condition. Acquired Chiari I malformations as a result of various causes are well described. An unusual case is reported in which regression of an acquired Chiari I malformation caused by isolated cerebellar tonsil inflammation in a patient with infectious mononucleosis was observed after conservative treatment. This supports the view that the cause of tonsillar herniation should be considered as an important factor in patient selection for surgical decompression.

CLINICAL PRESENTATION

A 6-year-old boy presented with a 1-week history of progressive occipital headache, neck pain, and dysequilibrium. A neurological examination revealed hyperreflexia in all extremities; he also had a fever, pharyngitis, and cervical adenopathy. A magnetic resonance imaging study demonstrated isolated right cerebellar tonsil enhancement and herniation into the foramen magnum. Further laboratory findings disclosed Epstein-Barr virus infection.

INTERVENTION

The patient underwent conservative treatment for systemic illness, and he was asymptomatic after 3 weeks. A follow-up magnetic resonance imaging study obtained 2 months after discharge demonstrated resolution of the tonsillar herniation.

CONCLUSION

Because the patient presented with infectious mononucleosis and cerebellar tonsillar herniation, direct treatment of decompression was considered unnecessary. Thus, caution in patient selection for surgical treatment is suggested in such unique cases.

Induction of macrophage migration inhibitory factor precedes the onset of acute tonsillitis

We investigated the serum macrophage migration inhibitory factor (MIF) levels of palmoplantar pustulosis patients, before and after the tonsillar provocation test. Higher serum MIF levels of palmoplantar pustulosis patients were decreased after the tonsillar provocation test (n=29). To confirm these phenomena, two patients with acute tonsillitis had their changes in body temperature, C-reactive protein (CRP) and serum MIF levels examined during the course of their illness. Surprisingly, increased MIF preceded fever and CRP elevation, and MIF subsequently decreased at the onset of fever and CRP elevation. Since MIF is an initiator of other proinflammatory cytokines, we suggest that the induction of MIF may precede other inflammatory conditions.

Differential expression of cysteinyl leukotriene receptors 1 and 2 in tonsils of children with obstructive sleep apnea syndrome or recurrent infection

BACKGROUND

Recurrent tonsillitis and sleep apnea are the major indications for tonsillectomy in children. We hypothesized that the recurrent vibration in the upper airway of snoring children would promote inflammatory changes in the tonsillar tissue and would lead to the up-regulation of cysteinyl leukotriene (LT) receptors (Rs).

OBJECTIVE

To assess the expression patterns of the human LT-Rs in children undergoing tonsillectomy, and compare those patterns in children having recurrent throat infections (RIs) and children with obstructive sleep apnea syndrome (SA).

METHODS

Tonsillar tissue from 17 children with SA and 13 with RIs was subjected to quantitative polymerase chain reaction using specific primers for LT1-R and LT2-R, and to immunohistochemistry and Western blotting for protein expression of LT1-R and LT2-R.

RESULTS

Messenger RNA encoding for the expression of LT1-R and LT2-R was detected in the tonsils of all children. Immunoblots revealed significantly higher expressions of LT1-R and LT2-R in the tonsils of children with SA. The topographic pattern of both receptors differed among the tonsils of children with SA and RI.

CONCLUSION

LT1-R and LT2-R are expressed in pediatric tonsillar tissue, are more abundant in SA patients, and demonstrate a specific topographic pattern of expression. These findings suggest that an inflammatory process involving LT expression and regulation occurs in children with SA.

Immunolocalization of inducible nitric oxide synthase and 3-nitrotyrosine in recurrently inflamed, human palatine tonsils

The purpose of this study was to evaluate the possible involvement of nitric oxide and its toxic metabolite--peroxynitrite--in the pathogenesis of recurrent tonsillitis. Tonsil specimens with recurrent inflammation were obtained from patients who required tonsillectomies as surgical treatment for their conditions. The relatively normal tonsils were obtained from patients who underwent uvulo-palato-pharyngoplasty for habitual snoring or obstructive sleep apnea. The sites of inducible nitric oxide synthase (iNOS) expression in the tonsil specimens were examined with an immunohistochemical technique. The possible production of peroxynitrite was evaluated by immunolabeling of 3-nitrotyrosine (3-NT) as its biological footprint. Each section was given a score of 0 to 4 according to the labeling intensity seen, with the highest number representing the highest labeling intensity. We found that tonsils with recurrent inflammation had iNOS expression mainly in the mucosal epithelium, subepithelial regions and vascular endothelium. The parenchyma of the tonsils, where T- and B-cell clones are located, showed little iNOS immunoreactivity. The accumulation of 3-NT had a similar distribution pattern to that of iNOS expression. However, the normal tonsils showed limited iNOS expression on mucosal epithelium and rare 3-NT accumulation. Recurrently inflamed tonsils had significantly higher labeling scores for both iNOS and 3-NT compared to normal tonsils. Further, a higher iNOS score correlated with a higher 3-NT accumulation. These data suggest that iNOS expression and the formation of peroxynitrite may have an important role in the pathogenesis of recurrent tonsillitis.

[The evaluation of the palatine tonsil function in patients with chronic tonsillitis]

The authors review the results of the research performed in patients with chronic tonsillitis in 1997-1999. Immunological activity of their palatine tonsils was evaluated according to the original technique which demonstrated relations between external functional activity of the palatine tonsils and age as well as symptoms of chronic tonsillitis. Additional information is presented on interrelations between lymphocytopoietic production of the palatine tonsils and hormonal status, metabolism, ecological and physical factors. The study of lifetime activity of the palatine tonsils is necessary for examination of local immunity of the mucous membranes of the lymphoid pharyngeal ring.

Increased urinary excretion of macrophage-colony-stimulating factor (M-CSF) in patients with IgA nephropathy: tonsil stimulation enhances urinary M-CSF excretion

Upper respiratory tract infection including chronic tonsillitis is considered to be involved in the onset and/or the progression of IgA nephropathy. It is well known that deterioration of urinary findings occurs after episodes of upper respiratory tract infection in patients with IgA nephropathy. We previously showed that the expression of macrophage-colony-stimulating factor (M-CSF) is increased in the glomeruli of patients with IgA nephropathy and correlated with glomerular mesangial proliferation, suggesting that M-CSF plays an important role in the progression of IgA nephropathy. In the present study, we measured the serum and urinary concentrations of M-CSF in patients with IgA nephropathy associated with chronic tonsillitis. Furthermore, we evaluated the effects of the local provocation test of tonsils (mechanical tonsil stimulation) on the serum and urinary concentrations of M-CSF in the following three groups: (1) IgA nephropathy with severe mesangial proliferation, (2) IgA nephropathy with mild mesangial proliferation, and (3) patients with chronic tonsillitis without renal disease. The serum and urinary levels of M-CSF in the groups with severe and mild IgA nephropathy were significantly higher than those in the chronic tonsillitis group. The urinary M-CSF level but not the serum M-CSF level was positively correlated with the degrees of mesangial proliferation and glomerular M-CSF expression in the renal biopsy specimens. The urinary M-CSF concentration was significantly increased after tonsillitis stimulation in both mild and severe IgA nephropathy groups. Enhanced urinary excretion of M-CSF prolonged for 7 days after tonsil stimulation in the severe IgA nephropathy group; in contrast, the urinay M-CSF level was increased for only 2 days after tonsil stimulation in the mild IgA nephropathy group. The urinary M-CSF level was not changed in the chronic tonsillitis group after tonsil stimulation. The serum concentrations of M-CSF were not changed after tonsil stimulation in these three groups. Our present results suggest that tonsil stimulation contributes to the progression of IgA nephropathy via enhancement of glomerular production of M-CSF. The urinary excretion of M-CSF may be a useful predictor to evaluate the relevance of chronic tonsillitis to the disease and the indication of tonsillectomy in patients with IgA nephropathy.

Relationship between clinical history, coagulation tests, and perioperative bleeding during tonsillectomies in pediatrics

STUDY OBJECTIVE

To determine the value of clinical history and preoperative coagulation tests.

DESIGN

Prospective, multicenter clinical investigation.

SETTING

Twenty-four centers over a one-year period.

PATIENTS

1,706 children scheduled for tonsillectomy. In 1, 479 out of 1,706 children, studied age was ranged from 9 months to 15 years. Indications for surgery were tonsillar infection 54%, sleep apnea 33%, or both 13%. Surgical dissection was performed in 1, 284 cases (88%) and sluder technique in 172 cases (12%).

MEASUREMENTS AND MAIN RESULTS

Clinical history of bleeding, preoperative coagulation tests, and perioperative bleeding were recorded. Clinical history of bleeding was positive in 13 patients; clinical history cannot predict abnormal coagulation tests. Coagulation tests were abnormal in 57 children (4%). Only 8 patients had disease-induced bleeding; five children had a preoperative correction of the deficiency in factor of coagulation or received desmopressin acetate prior to surgery in the case of von Willebrand's disease. Bleeding that occurred during the intraoperative period was assessed as abnormal by the surgeon in 101 children (7%) and during the postoperative period in 50 children (3%). Univariate analysis showed a relationship between intraoperative bleeding and age (p < 0.001), sluder technique (p < 0. 001), and abnormal preoperative coagulation tests (p < 0.05). Multivariate analysis showed the probability that bleeding was linked to the center where the surgery took place, the technique used, i.e., sluder technique, and the child's age, i.e., the older children.

CONCLUSIONS

Preoperative assessment based on the history of bleeding cannot predict abnormal laboratory tests. Neither the history of bleeding or laboratory tests can predict postoperative bleeding.

Amoxicillin for fever and sore throat due to non-exudative pharyngotonsillitis: beneficial or harmful?

OBJECTIVES

To determine duration of signs and symptoms and adverse reactions after treatment with amoxicillin of patients with fever and sore throat due to non-exudative pharyngotonsillitis.

DESIGN

This was a randomized, double-blinded, placebo-controlled trial. Outpatients at four medical centers were enrolled. Patients over 5 years of age presented with fever and sore throat for less than 10 days due to non-exudative pharyngotonsillitis. Cases with any of the following symptoms or illness were excluded: earache, nasal discharge with foul smell, rheumatic fever, valvular heart disease, renal disease, and penicillin hypersensitivity. Amoxicillin or identical placebo at the dosage of 50 mg/ kg per day was given three or four times daily for 7 days.

RESULTS

There were 1217 patients enrolled in this study. Some were lost to follow-up, which is the reason for the variability in number of cases in these analyses. After therapy, duration of fever was 2.46 and 2.48 days (P = 0.78) and of sore throat 3.01 and 3.04 days (P = 0.80) in amoxicillin (n = 431) and placebo (n = 436) groups, respectively. Complications were clinically documented in 13 (2.5%) and 16 (3.0%) cases in amoxicillin (n = 527) and placebo (n = 524) groups (P = 0.56). Two cases (0.46% and 0.46%) from each group (n= 433 and 431) were positive by antistreptolysin O antibody determination. The history of carditis and abnormal urinalysis after treatment were not obtained.

CONCLUSIONS

Amoxicillin therapy for non-exudative pharyngotonsillitis conferred no beneficial or harmful effect.

Pediatric outcomes research: development of an outcomes instrument for tonsil and adenoid disease

We describe the design and validation process of a disease-specific health status instrument for use in children with tonsil and adenoid disease. This instrument is reliable and valid and should be useful in future outcomes research on tonsil and adenoid disease. Some of the unique issues and challenges regarding outcomes research in pediatric patients are also discussed.

[Metabolism and the functional activity of the thyroid in patients with chronic tonsillitis and excess body weight]

Clinical and laboratory tests were conducted in 138 females of reproductive age with chronic decompensated tonsillitis (CDT) with normal and excessive body mass. Improper diet of the obese patients was responsible for specific manifestations of CDT, disturbances of lipid, carbohydrate and mineral metabolism, thyroid function.

Initial events in the pathogenesis of acute tonsillitis caused by Streptococcus pyogenes

Bacterial and epithelial cell samples were obtained, within 24 h of onset of pharyngeal symptoms, from the palatine tonsils of nine patients (four female and five male; age range 10-40 years, median age 23) with acute tonsillitis, culture-positive for Streptococcus pyogenes. The specimens were examined using fluorescein isothiocyanate- (FITC) and gold-labelled antiserum to S. pyogenes and fluorescence, scanning electron and transmission electron microscopy. S. pyogenes could be identified both in the mucous layer covering the tonsils and attached to the surface epithelial cells. Long chains of coccus-shaped bacteria could be seen encroaching on the epithelial cell borders. S. pyogenes can apparently penetrate the mucous barrier, attach to the epithelial cells, spread from cell to cell and possibly penetrate into the outermost layer of the epithelial cells. These events in turn provoke cytokine production and/or complement activation, which induce inflammatory reaction in the tonsillar tissue.

[Evaluation of granulocyte (PMNL) function in patients with chronic inflammation of the middle ear and palatine tonsils]

The evaluation of granulocytes function (PMN) in patients with chronic inflammation of middle ear and palatine tonsils. There were 39 people examined and divided into: 28 patients with chronic inflammation of middle ear and palatine tonsil, 11 healthy persons. The function of granulocytes in patients with chronic inflammation of middle ear and palatine tonsil were changed more in comparison with the healthy people.

The effect of tonsillectomy on eustachian tube function

A two-part study was designed to investigate the effect of tonsillectomy on eustachian tube function and to identify if any change is related to postoperative pain. Middle ear pressure was measured by tympanometry and results were classified as type A (+50 daPa to -99 daPa), type B (flat) or type C (-100 daPa to -350 daPa). Thirty-one patients with type A tympanograms, undergoing tonsillectomy enrolled in study A. Patients had tympanometry the next day and filled in a questionnaire incorporating visual analogue pain scores. In study B, 30 patients underwent a similar protocol and were followed up at 1 week tympanometry and a questionnaire. A control group of 26 patients undergoing appendicectomy was recruited. Follow-up was available on 23 patients from study B. Combining A and B, on the first postoperative day 39% of patients developed type C tympanograms. No member of the control group developed any change in middle ear pressure. There was no significant relationship between pain scores for throat pain or otalgia and the development of negative middle ear pressure. By day 7 all patients had type A tympanograms. Otalgia was a delayed symptom significantly associated with increased throat pain. Transient negative middle ear pressure commonly occurs following tonsillectomy.

Tonsillitis, tonsillectomy and weight disturbance

To determine the relationship between tonsillitis, tonsillectomy and abnormalities in body weight, we have analyzed pre- and post-operative weights in a population of 55 children who underwent adenotonsillectomy in our department. Pre-operative mean weight was 9.8% heavier than the standard mean normal weight for age and post-operative mean weight was 22% greater than standard mean weight for age. The mean weight gain during the follow-up period was 12% greater than that which would be normally expected (p < 0.001). This study suggests that children undergoing tonsillectomy are slightly heavier than their peers and that following the procedure this discrepancy increases.

Posttransplant lymphoproliferative disease presenting as sudden respiratory arrest in a three-year-old child

Posttransplant lymphoproliferative disease (PTLD) is an occasional complication of pediatric organ transplantation that, heretofore, has not been associated with airway obstruction. We report the first documented case of PTLD associated with complete airway obstruction resulting in sudden respiratory arrest and death in a 3-year-old child. This is contrasted to a subsequent case of PTLD wherein heightened clinical suspicion and prompt tonsillectomy resulted in a definitive diagnosis and improved outcome. The early clinical hallmarks of PTLD are a mononucleosis-like syndrome, tonsillar enlargement, and positive Epstein-Barr virus seroconversion. The potential for a fatal outcome of PTLD involving Waldeyer's ring components warrants early recognition and aggressive treatment.