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Concept: Tonsillitis


BACKGROUND: Nanotechnology is receiving enormous funding. Very little however is known about the health dangers of this technology so far. Chronic tonsillitis is one of a number of diseases called idiopathic. Among other factors, the tonsils are exposed to suspended particles in inhaled air including nano particles. The objective of this study was to detect and evaluate metallic particles in human tonsil tissue diagnosed with chronic tonsillitis and in amniotic fluid as a comparison. METHODS: Scanning electron microscopy with energy dispersive X-ray spectroscopy (SEM-EDX) was used for identification of solid particles in a total of 64 samples of routinely analyzed biopsy and cytologic material. RESULTS: Almost all samples were found to contain solid particles of various metals. The most frequent, regardless of diagnosis, were iron, chromium, nickel and aluminium. The size, determined using SEM, varied from around 500 nm to 25 µm. The majority formed aggregates of several micrometers in size but there were a significant number of smaller (sub-micrometer or nano-sized) particles present. The incidence of metallic particles was similar in child and adult tissues. The difference was in composition: the presence of several metals in adults was due to occupational exposure. CONCLUSIONS: The presence of metallic particles in pathologically altered tissues may signal an alternative causation of some diseases. The ethiopathogenic explanation of these diseases associated with the presence of nano-sized particles in the organism has emerged into a new field of pathology, nanopathology.

Concepts: Iron, Metal, Scanning electron microscope, Energy-dispersive X-ray spectroscopy, Tonsil, Tonsillectomy, Tonsillitis, Tonsillolith


OBJECTIVES: It has been suggested that bacterial biofilms are involved in chronic tonsillar disease, but there is a lack of strong evidence concerning their etiopathogenic role in childhood chronic tonsillar infections. The aim of this study was to assess the presence of biofilm-producing bacteria (BPB) in tonsillar bioptic specimens taken from children with recurrent exacerbations of chronic hyperplastic tonsillitis, and to evaluate the possible relationship between them and the patients' demographic and clinical characteristics. METHODS: 22 children (68.2% males; median age 6.5 years, range 3-13) with recurrent exacerbations of chronic hyperplastic tonsillitis were included. The presence of tonsillar BPB was assessed by means of the spectrophotometric analysis of tonsillar bioptic specimens taken during tonsillectomy between episodes of tonsillar infection. RESULTS: BPB were found in 50.0% of the 44 tonsillar specimens, and Staphylococcus aureus was the most frequent pathogen (81.8%). There was a significant relationship (p=0.02) between the grade of tonsillar hyperplasy (GTH) and the presence of tonsillar BPB, with an increased relative risk (RR=4.27, standard error=2.57, p<0.01) of tonsillar BPB development in children with GTH scores of >2. CONCLUSIONS: The findings of this study: (1) confirm the presence of tonsillar BPB in children with recurrent exacerbations of chronic tonsillar infections; (2) suggest that GTH is an important indicator of the presence of tonsillar BPB; and (3) raise the question as to whether tonsillar biofilm is a causative factor or just a consequence of recurrent exacerbations of chronic hyperplastic tonsillitis.

Concepts: Bacteria, Staphylococcus aureus, Infection, Staphylococcus, Biofilm, Tonsil, Tonsillectomy, Tonsillitis



The association of tonsillectomy, a common surgical procedure involving the removal of a majority of the palatine tonsillar tissue, with risk of tonsil cancer specifically or oropharyngeal cancers overall is not known. In this issue of Cancer Prevention Research, Fakhry and colleagues conduct an analysis within the Danish Cancer Registry and show that tonsillectomies were associated with significantly reduced risk of tonsil cancer, but were unrelated to risk of base of tongue cancers. This editorial discusses the implications of the results by Fakhry and colleagues for key prevailing questions in the field related to risk, rising incidence, secondary prevention, and treatment of oropharyngeal cancers. Cancer Prev Res; 1-3. ©2015 AACR. See related article by Fakhry et al., p. xxx.

Concepts: Chemotherapy, Oral cancer, Tonsil, Tonsillectomy, Tonsillitis


IMPORTANCE Tonsillectomy is one of the most commonly performed otolaryngology procedures. The safety of this procedure in adults is based on small case series. To our knowledge, we report the first population-level analysis of the safety of adult tonsillectomies in the United States. OBJECTIVE To characterize the mortality, complication, and reoperation rate in adult tonsillectomy. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of 5968 adult patients who underwent tonsillectomy with records in the database of the American College of Surgeons National Surgical Quality Improvement Program (2005 to 2011). INTERVENTION Tonsillectomy. MAIN OUTCOMES AND MEASURES Outcomes of interest included mortality, complications, and reoperation in the 30-day postoperative period. Statistical analysis included χ2 test, t test, and multivariate logistic regression. RESULTS The 30-day mortality rate was 0.03%, the complication rate was 1.2%, and the reoperation rate was 3.2%. Most patients had a primary diagnosis of chronic tonsillitis and/or adenoiditis (82.9%), and the most common complications were pneumonia (27% of all complications), urinary tract infection (27%), and superficial site infections (16%). Patients who underwent reoperation were more likely to be male (54.0% vs 32.4%; P < .001), white (84.8% vs 75.3%; P = .02), or inpatients (24.3% vs 14.3%; P < .001) and to have postoperative complications (5.3% vs 1.1%; P < .001) than those who did not return to the operating room. On multivariate analysis, male sex (odds ratio [OR], 2.30 [95% CI, 1.67-3.15]), inpatient status (OR, 1.52 [95% CI, 1.04-2.22]), and the presence of a postoperative complication (OR, 4.58 [95% CI, 2.11-9.93]) were independent risk factors for reoperation. CONCLUSIONS AND RELEVANCE In the United States, adult tonsillectomy is a safe procedure with low rates of mortality and morbidity. The most common posttonsillectomy complications were infectious in etiology, and complications were independently associated with the need for reoperation.

Concepts: Cohort study, Epidemiology, Urinary tract infection, Medical statistics, Actuarial science, Tonsil, Tonsillectomy, Tonsillitis


Benign enlargement of the lingual tonsils due to various causes may cause symptoms that warrant treatment. Conventional lingual tonsillectomy remains a challenging procedure, and there is no established standard procedure. We aimed to review the patients receiving different methods of lingual tonsil surgery for various indications at our institute.

Concepts: Tonsil, Tonsillectomy, Tonsillitis, Tonsillolith


Objective To investigate the readmission rates due to postoperative hemorrhage in relation to tonsil surgery clinical practice in a national population. Study Design Retrospective longitudinal population-based cohort study. Setting Based on register data from the Swedish National Patient Register (NPR). Subjects and Methods All benign tonsil operations (256 053) performed in Sweden from 1987 to 2013 were identified through a search in the NPR. For all identified cases, data on gender, age, date of surgery, indication, type of surgery, level of care, length of stay (LOS) for inpatient surgery, readmission and reoperation because of postoperative bleeding (within 31 days) were collected. Results Overall frequency of readmission for hemorrhage was 2.61%, and the reoperation rate for hemostasis was 0.84%. The longitudinal analysis showed an increase from 1% (1987) to 5% (2013) in readmissions caused by hemorrhage. Tonsillectomies, surgery performed for infectious disease, and surgery on adult patients (age >18 years) showed readmission rates approaching 10% (2013). Male gender, increasing age, tonsillectomy, infectious indication, and recent year of surgery were identified as risk factors for readmission and reoperation due to hemorrhage. An increasing share of patients readmitted for hemorrhage underwent reoperation for hemostasis: 18% (1987) versus 43% (2013). Conclusion Readmissions for hemorrhage have increased by a factor of 5 in Sweden from 1987 to 2013. The design of the study and the data in NPR do not allow determination of the true reasons behind the alarming results.

Concepts: Cohort study, Experimental design, Epidemiology, Clinical trial, Bleeding, Swedish language, Tonsillectomy, Tonsillitis


Adenotonsillectomy (ADT) is one of the most widely used procedures in the treatment of paediatric recurrent acute tonsillitis (RAT) and obstructive sleep apnoea syndrome (OSAS), both of which have significant repercussions on the patients' quality of life (QoL). The purpose of our review of literature was to highlight the great variety of tools that are currently used to evaluate QoL in children, to examine data available on their efficacy and the feasibility of their use in daily clinical practice, and to determine possible limitations related to an indirect and subjective assessment of QoL in children.Although the use of different parameters makes it difficult to compare the published studies, an analysis of the evidence currently available in the literature suggests that ADT has a generally positive impact on the QoL (especially in case of OSAS). It also highlights the importance of combining tonsillectomy and adenoidectomy in the treatment of OSAS, and documents the comparability of tonsillectomy and tonsillotomy in improving obstructive symptoms. In conclusion, our findings suggest that literature supports that ADT is associated with positive changes in QOL; however further studies using comparable standardised criteria are necessary to confirm the size and duration of this benefit.

Concepts: Sleep, Sleep apnea, Obstructive sleep apnea, Pediatrics, Hypopnea, Sudden infant death syndrome, Tonsillectomy, Tonsillitis


Peritonsillar abscess (PTA) is traditionally considered only a purulent complication of acute tonsillitis (AT), but may be related to infection of minor salivary glands. We analysed the presence of peritonsillar minor salivary glands and inflammation patterns in 114 adult tonsils representing three patient groups: recurrent AT, chronic tonsillitis (CT), and PTA. Samples acquired from elective tonsillectomies were stored in formalin, and after preparation were microscopically examined for inflammation and fibrotic changes. Clinical features and histological characteristics were compared between the groups. Of all tonsils, the minor salivary glands were present in 77 (67.5%). Glands located near the tonsillar tissue showed signs of infection in 73 (94.8%), while only 3 (15.0%) of 20 glands located deeper in the peritonsillar space were infected. Compared to patients with recurrent AT and CT, those with PTA more often presented with periductal inflammation, p < 0.011 (PTA 82.1%, AT 42.9%, and CT 63.6%). The majority of our 114 tonsillectomy specimens, collected from patients with AT, CT, or PTA, presented with infected minor salivary glands, and inflammation of the peritonsillar space glands was evident. To further elucidate the association between these glands and PTA, tonsillar samples should be collected and analysed from patients during the acute phase of infection.

Concepts: Infection, Glands, Pus, Salivary gland, Tonsil, Tonsillectomy, Tonsillitis, Tonsillolith


The palatine tonsils, localized in the oropharynx, are easily accessible secondary lymphoid tissue in humans. Inflammation of the palatine tonsils, local and chronic in case of chronic tonsillitis (CT) or acute in the presence of a peritonsillar abscess (PTA), ranks among the most common diseases in otolaryngology. However, the functionality of tonsillar immune cells, notably T-cells, in the context of these immune pathologies is poorly understood. We have examined the functional status of human tonsillar T-cells in CT and compared it to the acute inflammatory setting of a PTA. Patients presenting with CT (n = 10) or unilateral PTA (n = 7) underwent bilateral tonsillectomy and a subgroup of 8 patients underwent additional blood sampling. T-cells were purified via automated magnetic selection and subjected to flow cytometry-based immunophenotyping. In addition, the response to T-cell receptor (TCR) stimulation was assessed at the level of proximal signaling, activation marker expression and proliferation. We observed no difference between the percentage of T helper (CD4(+)) cells from tonsil tissue in CT and PTA, but observed a trend towards a higher percentage of T helper cells in the blood of patients with PTA versus CT, probably reflecting an acute, systemic bacterial infection in the former cohort. Tonsils from CT harbored more PD-1(+) CD4(+) T-cells, pointing to T-cell exhaustion due to chronic infection. This notion was supported by functional studies that showed a tendency to weaker TCR responses of tonsillar T-cells from CT. Intriguingly, tonsillar T-cells recurrently featured a dampened response to T-cell receptor stimulation at the level of receptor proximal signaling steps compared to peripheral T-cells. In sum, our study documents distinct differences in tonsillar T-cell class distribution and function between the various pathological conditions. Our observations are consistent with the concept that tonsillar T-cells react to infections by eliciting specific immunological responses in chronic versus acute settings of inflammation.

Concepts: Immune system, Inflammation, White blood cell, T helper cell, Lymphatic system, Tonsil, Tonsillectomy, Tonsillitis