Assessment of adenotonsillar size and caregiver-reported sleep symptoms among 3–6 year old children undergoing adenotonsillectomy

IntroductionAdenotonsillectomy remains the accepted first-line treatment for obstructive sleep apnea syndrome (OSAS) in children. Tonsillar size may be especially relevant in risk stratification as it may impact symptoms of sleep disordered breathing (SDB). This study assesses correlations among subjective tonsillar grading, measured tonsillar size, and degree of adenoid obstruction in patients age 3–6 years with caregiver-reported symptoms.MethodsChildren 3–6 years old undergoing adenotonsillectomy for OSAS were enrolled prospectively. The subjective tonsillar grade and degree of adenoid obstruction were recorded on physical examination by the otolaryngologist, and the objective tonsillar size was obtained from pathology reports. Spearman's rho was used to assess agreement among measures of tonsillar size and adenoid obstruction; and to correlate these measures with caregiver-reported SDB symptoms obtained from a pre-operative standardized questionnaire.ResultsThe cohort included 103 boys and 97 girls of median age 4.8 (interquartile range [IQR]: 3.9, 5.9) years. Median subjective tonsillar grade was 3+ (IQR: 3+, 4+) while median tonsillar size was 2.7 cm (IQR: 2.5, 3) and median adenoid obstruction was 60% (IQR: 50%, 80%). The subjective tonsillar grade and measured tonsillar size were strongly correlated (ρ = 0.31, p < 0.001), whereas adenoid obstruction was uncorrelated with either subjective tonsillar grade (ρ = 0.01, p = 0.860) or measured size (ρ = −0.05, p = 0.497). Tonsillar grade was positively correlated with 3 common caregiver-reported SDB symptoms (loud snoring, trouble breathing at night, and daytime sleepiness). Objective tonsillar size was positively correlated only with difficulty organizing tasks or activities, and adenoid obstruction was positively correlated only with stopping breathing during sleep.ConclusionSubjective tonsillar grading by the otolaryngologist achieved better correlation than measured tonsillar size or degree of adenoid obstruction with caregiver-reported SDB symptoms in children 3–6 years of age undergoing adenotonsillectomy.     

The lateral neck radiograph in adenotonsillar hyperplasia

In this study we have considered whether the lateral neck radiograph is useful in predicting the degree of airway obstruction, and whether supine and erect views are more useful than a single film. We evaluated the supine and erect lateral neck radiographs of 50 patients with upper airway obstruction due to enlarged tonsils and adenoids. Our results show that the supine radiograph, which is technically easier to perform, is entirely satisfactory for appraising the size of the tonsils and adenoids, but that neither view tells us much about the degree of airway obstruction during sleep.     

Prevalence of Epstein-Barr virus in tonsils and adenoids of United Arab Emirates nationals

Objective

Given that Epstein-Barr virus (EBV) often inhabits human tonsils and adenoids, it remains to be distinctively determined its prevalence and in which cell and microenvironment the virus is present.

Methods

To determine the prevalence of EBV in the tonsils and adenoids of the United Arab Emirates (UAE) nationals and to provide a basis for understanding the origin and biology of EBV-infected cells, the immunophenotype of all EBV-infected cells in 46 tonsils and 46 adenoids was determined by EBER in situ hybridization and immunohistochemistry with monoclonal antibodies to T cells (CD3), B cells (CD20), and epithelial cells (cytokeratin AE1/AE3), as well as immunostaining with antibodies to EBV latent membrane protein-1 (LMP-1).

Results

EBV was found in 43% of tonsillectomy specimens and 15% of adenoidectomy specimens. All EBV-infected cells were found to be B lymphocytes. About 90% of the infected B cells are found in the interfollicular regions of tonsils and adenoids and the remaining 10% are found within the follicles. There is no significant association between EBV infection, age (P = 0.324) and gender (P = 0.442).

Conclusion

EBV is associated with tonsillar hypertrophy and is prevalent in 43% of our cases. EBV is only detected in B lymphocytes and we believe that B lymphocytes are sites of primary infection and latency. In situ hybridization is the gold standard for the detection of EBV in tissue.     

Evaluation of tonsils and adenoids in sleep apnea syndrome

Peripheral Sleep Apnea syndrome has been associated with enlarged tonsils and adenoids as well as other abnormalities which may cause upper airway obstruction in children. A multidisciplinary approach is used at the Sleep Disorder Center of Cincinnati General Hospital to evaluate the role of tonsils and adenoids in sleep apnea. Polysomnographic techniques combined with cine sleep studies of the upper airway document the degree, site and type of obstruction. This presentation highlights the entity of obstructive sleep apnea and provides a rational clinical approach in the management of these patients.     

Correlations Between the Adenotonsillar Microbiome and Clinical Characteristics of Pediatric Patients With Snoring

ObjectivesFew studies have reported combined analyses of the microbiome of the adenoids and tonsils in pediatric patients with snoring, and correlations of the adenotonsillar microbiome with clinical characteristics have not been evaluated to date. The aim of this study was to characterize the adenotonsillar microbiome and to determine its correlations with the subjective symptoms of pediatric patients with snoring and with levels of regional mucosal immune molecules.MethodsTwenty-four children who underwent tonsillectomy with adenoidectomy owing to snoring were enrolled in this cross-sectional study conducted between August 2017 and December 2018. The microbiome of the adenoids and tonsils was characterized, and its alpha- and beta-diversity was determined. Clinical characteristics, including subjective discomfort during sleep (assessed using the obstructive sleep apnea-18 questionnaire), the presence of allergic rhinitis, concentrations of heat shock protein (Hsp)27, Hsp70, and interleukin-8 (IL-8) in lavage fluids, and white blood cell (WBC) counts, were measured.ResultsAt the phylum level, the microbiome was not significantly different between the adenoids and tonsils; the alpha and beta indices were likewise not significantly different between these two regions. The alpha-diversity of the entire adenotonsillar microbiome was associated with sex, emotional stress, and IL-8 levels in the tonsil lavage fluids. Beta-diversity was associated with Hsp27 levels in the tonsil lavage fluids and WBC counts. Multiple allergen simultaneous test results were not significant, although total serum immunoglobulin E levels were significantly associated with the beta-diversity of the adenotonsillar microbiome.ConclusionThe data reported herein suggest, for the first time, that the adenotonsillar microbiome interacts with the regional mucosal immune system. The observed association of the microbiome with subjective discomfort is a novel finding that warrants further investigation.     

Microbiology of the tonsils and adenoids in a pediatric population

To investigate the microbial flora of the tonsils and adenoids, the core tissue from the tonsils and adenoids of 50 children undergoing tonsillectomy and adenoidectomy for either recurrent infection or airway obstruction was cultured aerobically and anaerobically, and the number of bacterial colonies was quantitated. The most common organisms isolated were alpha-hemolytic streptococci, nonpathogenic Neisseria species, Haemophilus species, Staphylococcus aureus, and Corynebacterium species. No anaerobes were identified. Bacterial isolates from the tonsils and adenoids were similar in number and frequency of occurrence. Potential pathogenic bacteria (Haemophilus species, S aureus, beta-hemolytic streptococci, and Streptococcus pneumoniae) were identified in 40 patients. Seventy-three percent of these patients shared a common pathogen in tonsil and adenoid tissue. Haemophilus species were recovered in 54% of patients and S aureus in 46%. No significant difference exists between the type and number of pathogens in patients undergoing adenotonsillectomy for recurrent infection or obstruction.     

Cine magnetic resonance imaging: evaluation of persistent airway obstruction after tonsil and adenoidectomy in children with Down syndrome

OBJECTIVE/HYPOTHESIS: Although usually successful, not all obstructive sleep apnea is cured by removal of the tonsils and adenoids (T&A). This is particularly true in children with Down syndrome and craniofacial anomalies. This is because of the multiple levels of obstruction in their airways, with obstruction present not only at the level of the tonsils and adenoids but also from base of tongue obstruction, soft palate collapse, and hypopharyngeal collapse. The cine magnetic resonance image (MRI) is useful in evaluating the upper airway in those patients who have not achieved a normal polysomnogram after T&A surgery. STUDY DESIGN: Prospective case series. METHODS: Fifteen children with Down syndrome who had previously undergone a T&A but continued to have abnormal postoperative polysomnograms underwent a cine MRI with fast gradient cine MRI images. RESULTS: The cine MRI identified different areas and levels of obstruction that ultimately affected the children's treatment courses. Recurrent adenoid tissue, glossoptosis, soft palate collapse, hypopharyngeal collapse, and enlarged lingual tonsils were identified. The results as well as several illustrative cases are presented. CONCLUSION: Cine MRI evaluates upper airway obstruction in children who may have multiple sources of obstruction causing their obstructive sleep apnea. This is particularly helpful in children with Down syndrome and craniofacial anomalies. This technology is useful in all children with complex upper airway obstruction.     

Coinfection by Multiple Strains of Epstein-Barr Virus in Infectious Mononucleosis in Immunocompetent Patients

Objective--A molecular study of Epstein-Barr virus (EBV)-induced infectious mononucleosis (IM) was performed. The presence of a 30-bp deletion on the latent membrane protein-1 (LMP-1) oncogene from EBV in Caucasian IM patients was evaluated. Material and Methods--Peripheral blood mononuclear cells were obtained from 27 IM patients and 18 adenoids, 28 tonsils and 16 EBV-related reactive lymphadenitis specimens were used as controls. DNA isolation, EBV polymerase chain reaction (PCR) and LMP-1 oncogene PCR analysis were performed. Results--The 30-bp deletion on LMP-1 was identified in 29.6% of IM patients, but was always seen in conjunction with full-length LMP-1. Although the LMP-1-deleted strain seemed to be more prevalent in IM (29.6%) and EBV-related reactive lymphadenitis (37.5%) than in adenoid (0%) or tonsil specimens (21.4%), these differences were not significant (p&gt;0.05;χ²). Thus, a 30-bp deletion on LMP-1 was present in almost a third of Caucasian IM patients. Conclusion--The finding of coinfections in IM patients confirms that primary infection by more than one EBV strain is possible.     

Relation between adenoid size and otitis media with effusion

AimsThis study compares the efficacy of adenoidectomy on otitis media with effusion (OME) in patients with different size of adenoids and the connection between differently sized adenoids and middle ear effusion.Material and methodsChildren with a history of at least 3 months’ OME underwent adenoidectomy and myringotomy without the insertion of a tympanostomy tube. Treatment assignment was stratified by adenoids’ size causing choanal obstruction (grade I-III) and according to Eustachian tube ostium obstruction (grade A–C). The subjects were followed for 12 months.ResultsAdenoidectomy was significantly more effective in children with adenoids in contact with torus tubarius (grade B, C) compared to those with small adenoids without contact (P < 0.001). The volume of the adenoids was irrelevant (P = 0.146). The size of adenoids did not affect the viscosity of the middle ear secretion. The distribution of mucous and serous secretion was not dependent on the size of adenoids; the efficacy of adenoidectomy was 82% in mucous as well as serous secretion.ConclusionThe relation between adenoids and torus tubarius is more important than the volume of the adenoids. The viscosity of middle ear fluids (serous or mucous) did not influence the rate of treatment efficacy.     

Tonsil and adenoid surgery for upper airway obstruction in children.

We studied the outcomes of 76 children, aged 3 to 12 years, with large tonsils and/or large adenoids who underwent surgery to relieve upper airway obstruction over a 1-year period. Following surgery, nearly all patients experienced an alleviation of all symptoms, except for enuresis. We suggest that children who have large tonsils and/or adenoids will gain substantial benefit if they are removed, even children who do not have a history of severe sleep apnea or objective evidence from polysomnography.     

基于计算流体力学分析腺样体大小对儿童上气道气流的影响

目的 通过构建同一气道中腺样体大小依次递减的8种上气道有限元数值模型,分析腺样体大小对上气道流场特性的影响,帮助临床医生进一步认识腺样体在小儿鼾症中的发病机制及规范腺样体手术适应证。方法 基于上气道CT扫描图,通过三维重建软件Amira构造相同气道中腺样体大小依次递减的8种上气道三维模型;采用计算流体力学(CFD)模拟各上气道吸气气流;从气流流速、流动方式、气流压强和通气量等方面分析腺样体大小对上气道流场特性的影响。结果 当腺样体肥大阻塞后鼻孔55%以内时,平静吸气气流流速和压强变化趋势与正常气道基本一致,气流流线规则,通气量为77.812~74.854 mL/s。当阻塞度达64%以上时,鼻咽部的气流流速和压降急剧增加,流线紊乱,平静吸气时上气道通气量显著减少。结论 腺样体肥大阻塞后鼻孔达2/3以上时,可严重影响儿童正常吸气。腺样体越大,患儿夜眠憋气、打鼾、呼吸暂停等症状越明显。腺样体肥大是造成儿童阻塞性睡眠呼吸暂停低通气综合征(OSAHS)的重要因素。     

Obstructive hypertrophic adenoids and tonsils as a cause of infantile failure to thrive: reversed by tonsillectomy and adenoidectomy

Isolated failure to thrive in an infant caused by chronic hypoventilation due to hypertrophic adenoids and tonsils, has not been previously described. A 9 month-old infant presented with weight loss and mild clinical respiratory signs. Hypoxemia and CO2 retention, however, were documented by transcutaneous gas measurement, and ENT examination revealed enlarged tonsils and adenoids. Adenoidectomy and tonsillectomy at 9 1/2 months of age completely reversed the patient's hypoventilation and growth pattern. While the exact mechanism of failure to thrive secondary to upper airway obstruction in infancy is not clear, we conclude that routine ENT evaluation should be a regular part of the workup of infants under one year who suffer from failure to thrive.     

Assessment of common otolaryngological diseases among children in rural primary schools in south eastern Nigeria

ObjectivesDespite a global improvement in health care delivery, rural areas in developing countries still have poor access to specialist care. This study aims to assess the occurrences of ear, nose, and throat (ENT) disorders among rural primary school children in south-eastern Nigeria.MethodsTwo rural primary schools were selected randomly from one of the rural regions of South Eastern State of Nigeria. All the pupils of the schools who gave consent were recruited. A structured study proforma investigating the pupils' biodata, otolaryngological symptoms, ear, nose and throat examination findings, was used to evaluate each pupil in the presence of the teachers.ResultsA total of 246 children participated in the study. 145(58.9%) were males while 101(41.1%) were females with a mean age of 8.5 ± 2.4 years. The commonest symptoms reported were nasal discharge (20%) followed by nasal obstruction (11.1%), itching of the ears (11.1%) and sneezing bouts (10%), while 3.7% had subjective hearing impairment. The commonest ENT finding was cerumen auris (43%) and this was observed in 43.4% of males and 42.4% of females, 11% had abnormal tympanic membranes and 20% had grades 3/4 tonsils(Brodsky grading).ConclusionENT disorders are still common in children in the rural areas of developing countries. To avoid the morbidity associated with these preventable and easily manageable disorders, community health workers should be trained to manage common ENT disorders and mobile clinics with scheduled visits made available in areas where ENT services remain inaccessible.     

HHV-6 infection of tonsils and adenoids in children with hypertrophy and upper airway recurrent infections

Objective

Human herpes virus 6 (HHV-6), the agent of a self-limiting exanthematic disease in childhood, persists in a silent state in the secondary lymphoid organs and the reactivation is characterized by HHV-6-induced inflammatory cytokines. This study investigates the possible etiological role of HHV-6 in children affected by tonsil and adenoid hypertrophy.

Methods

55 tonsils, 80 adenoids fresh tissues and 74 blood samples were collected from 80 children (mean age 4.8 years, 43.5% female) undergoing elective tonsillectomy and/or adenoidectomy for tissue hypertrophy. Moreover, patients with <5 years old documented upper airway recurrent infections not related to relapsing of acute tonsillitis. Specific IgG antibodies and virus detection (by PCR, variant A/B enzymatic genotyping and real-time PCR) were performed.

Results

In our series, HHV-6 seroprevalence was tested at 50%. HHV-6 variant B was the unique strain finding in 25% of adenoids, in 12.7% of tonsils and in 4% of peripheral blood mononuclear cells (PBMCs). HHV-6-B was prevalent in tonsils of children affected by upper airway infections (17.8% vs 7.4%) while the adenoids represented the more frequent reservoir (30.7% vs 19.5%) in patients with hypertrophy. HHV-6 viral load was low, ranging from 80 to 600 copies/10⁶ cells suggesting a latent/persistent phase of infection.

Conclusion

These results reinforce the role of the secondary lymphoid organs as an important reservoir for HHV-6B. Nevertheless, infection of lymphoid cells, sustained by a low level of replication, could be sufficient to increase the local injury through an autologous mechanism of inflammation.     

Upper airway obstruction and the pharyngeal lymphoid tissue

Enlarged tonsils and adenoids can cause chronic upper airway obstruction that may result in a spectrum of clinical findings ranging from sleep apnea to cor pulmonale and right heart failure. The clinical findings associated with this entity are reversible if the condition is identified early and removal of the obstructing tissue is performed before life-threatening changes occur.     

睡眠呼吸障碍儿童扁桃体及腺样体组织细菌学分析

目的　探讨睡眠呼吸障碍（sleep disordered breathing,SDB）儿童扁桃体及腺样体组织的细菌学特点。方法　经多导睡眠图监测确诊的163例SDB患儿纳入研究,其中120例同时接受扁桃体及腺样体切除术,4例接受单纯扁桃体切除术,39例接受单纯腺样体切除术,124例接受扁桃体切除术的患儿按照有无扁桃体炎反复发作的病史分为两组,扁桃体炎组71例和无扁桃体炎组53例。术中取部分扁桃体和（或）腺样体组织进行细菌学检查。结果　120例患儿中的114例（95.00%）两个部位分离出的细菌种类相同,120例中有17例（14.17%）两个部位均感染了两种细菌,混合感染的细菌种类均相同。在各个季节两个部位中金黄色葡萄球菌和流感嗜血杆菌的检出率无显著性差异（扁桃体：χ2=8.538,P =0.201;腺样体：χ2=5.427,P =0.490）。有无慢性扁桃体炎病史的扁桃体组织内的各种细菌检出率无显著性差异（χ2=3.028,P =0.387）。结论　同一个SDB患儿的扁桃体和腺样体组织检出的细菌种类几乎相同,有无慢性扁桃体炎病史的扁桃体组织内的不同细菌检出率无显著性差异。     

The correlation between EBV viral load in the palatine tonsils of patients with recurrent tonsillitis and concurrent serum titers of VCA–IgG

Epstein–Barr virus (EBV) infection usually occurs in early childhood and can persist in palatine tonsil lymphocytes to induce tonsillitis at a later date. We have examined the presence of EBV in palatine tonsils and relationship between EBV-DNA quantity in tonsil tissues and VCA–IgG quantity in autologous sera. Tonsils were obtained from 36 patients, male 20 (55.6%), female 16 (44.4%) (mean age 7.96 ± 6.97 years), who underwent tonsils removal because of recurrent tonsillitis. Tissues were processed for real-time PCR and patient’s sera were assayed to determine VCA–IgG by VCA–IgG ELISA. In 27 out of 36 cases (75%), positive EBV-DNA reaction was found. However, statistical analysis showed no correlation between EBV-DNA quantity and VCA–IgG quantity. We conclude that tonsils of children can be colonized by EBV and that virus may have a direct and indirect role in recurrent tonsillitis and nasopharyngeal carcinoma.     

The association of residential mold exposure and adenotonsillar hypertrophy in children living in damp environments

BackgroundThere are many consequences of mold exposure related to respiratory system health of children This retrospective cohort study aims to find the association between adenoid hypertrophy and mold exposure in children living in damp environments.MethodsChildren with history of recurrent respiratory tract infections were enrolled in the study between June 2012 and June 2013 and were followed up for adenoid hypertrophy from June 2013 to June 2016. One hundred and forty two children were residents of moldy houses and 242 were living in normal houses. Skin prick test results for 60 common allergens, vitamin D levels, IgE levels, age, presence of comorbidities such as urticaria, atopic dermatitis, allergic conjunctivitis, allergic rhinitis, asthma, frequency of upper respiratory tract infections and lower respiratory tract infections, were evaluated in both groups.ResultsA total of 384 children (mean age ± standard deviation = 53.37 ± 36 months; 198 males and 186 females) were included. The children were classified into 2 groups (1)Children living normal houses (n = 242) (2); Children living in damp houses (n = 142) according to mold exposure. Children with adenoid hypertrophy (p < 0,001) and higher IgE levels (p < 0,001) were more common in mold exposed group. Lower respiratory tract infections were more common in children with mold exposure (p < 0,05). Bivariate correlation analysis showed no significant association between IgE levels and adenoid hypertrophy. Multiple linear regression analysis was performed to evaluate IgE levels, vitamin D levels, and presence of adenoid as independent variables; age as dependent variable among two groups and was found statistically significant (p < 0,001). Dermatophagoid sensitive group living in damp houses had a significant increase in adenoid hypertrophy (p = 0,01). Housedustmite sensitive children with recurrent lower respiratory tract infection and upper respiratory tract infection were mainly residents of damp houses (p < 0,001). Allergic comorbidities were significantly more in damp environment group (p < 0,001), but there was no significant increase in any of the subgroups.ConclusionsChildren with mold exposure had significantly increased adenoid hypertrophy regardless of their atopic nature, however, they may have become more sensitized due to other environmental triggers and genetic factors. In damp environments, sensitization to dermatophagoids, was significantly increased in children with adenoid hypertrophy. During the period of infancy, when children were mostly vitamin D supplemented, they were not sensitized and had normal adenoids. As children with recurrent respiratory tract infections grow, they tend to have lower vitamin D levels, become more atopic and tend to have adenoid hypertrophy.     

Sleep apnea in children

Sleep apnea in children develops when airway obstruction at night is severe; however, lesser degrees of obstruction may also cause problems. The most common cause of nighttime obstruction with or without apnea is hyperplasia of the tonsils and adenoids. Other conditions such as craniofacial anomalies and neuromuscular disorders may predispose children to obstruction of the airway during sleep. Although cor pulmonale, heart failure, and cardiorespiratory arrest are the most dramatic results of obstructive apnea, before these occur many other problems may develop that are detrimental to the child's health, including failure to thrive. A careful history and physical examination are usually sufficient to determine if obstruction and apnea are present at night. Additional studies such as sleep sonography and polysomnography are helpful for documentation of the disorder. The treatment of obstructive apnea, unless associated with central apnea, is surgical. The vast majority of children with obstruction have dramatic resolution of their obstruction following a tonsillectomy and adenoidectomy. Occasionally additional procedures including uvulopalatopharyngoplasty and tracheotomy are needed.     

Extra-esophageal acid reflux induced adenotonsillar hyperplasia: case report and literature review

The etiology of adenotonsillar hyperplasia is not well understood. A 3-year-old child presented with obstructive sleep apnea believed to be secondary to enlarged tonsils and adenoids. Subglottic stenosis was encountered during intubation; the adenotonsillectomy was cancelled. Severe extra-esophageal reflux was identified and treated. At follow-up endoscopy 3 weeks later, the tonsils and adenoids were no longer enlarged or obstructing the airway. The role of extra-esophageal reflux in the pathogenesis adenotonsillar hyperplasia is discussed.