Serum immunoglobulins in patients with chronic tonsillitis

Cancer risk following surgical removal of tonsils and adenoids - a population-based, sibling-controlled cohort study in Sweden

BACKGROUND

Removal of tonsils and adenoids is among the most common surgical procedures worldwide. Evidence of increased risk of cancer following such surgery is, however, inconclusive.

METHODS

We conducted a population-based, sibling-controlled cohort study of 4,953,583 individuals in Sweden with a follow-up during 1980-2016. History of tonsillectomy, adenotonsillectomy, and adenoidectomy was identified from the Swedish Patient Register whereas incident cases of cancer during follow-up were identified from the Swedish Cancer Register. We used Cox models to calculate hazard ratios (HR) with 95% confidence intervals (CI) of cancer in both a population and a sibling comparison. The sibling comparison was used to assess the potential impact of familial confounding, due to shared genetic or non-genetic factors within a family.

RESULTS

We found a modestly increased risk for any cancer following tonsillectomy, adenoidectomy, or adenotonsillectomy in both the population (HR 1.10; 95%CI 1.07-1.12) and sibling (HR 1.15; 95%CI 1.10-1.20) comparisons. The association did not differ greatly by type of surgery, age at surgery, or potential indication for surgery, and persisted more than two decades after surgery. An excess risk was consistently observed for cancer of the breast, prostate, thyroid, and for lymphoma in both population and sibling comparisons. A positive association was observed for pancreatic cancer, kidney cancer, and leukemia in the population comparison whereas a positive association was observed for esophageal cancer in the sibling comparison.

CONCLUSIONS

Surgical removal of tonsils and adenoids is associated with a modestly increased risk of cancer during the decades following the surgery. The association is unlikely attributed to confounding due to shared genetic or non-genetic factors with a family.

Prevalence of palatine tonsilloliths in Dominican patients of varying social classes treated in university clinics

The relevance of tonsils lies not only in local but also in systemic immunity. One of the most common ailments afflicting the tonsils are palatine tonsilloliths (PT), dystrophic calcifications found in the tonsillar crypts. PT prevalence reports have been conducted for Caucasian and Asian patients, but not for black patients. The aim of this cross-sectional study is to gauge the prevalence of PT in patients who sought treatment at two university clinics in the Dominican Republic, and to analyze any links with the race of patients. Two hundred and nine consecutive patients attending the dental services of two clinics located in different cities in the Dominican Republic, from March 1 to April 30, 2019, were selected. Computed tomography scans of patients were evaluated for a PT diagnosis. Determined prevalence of PT in this population sample was 5.85%. A non-significant relationship between occurrence of PT and race or kind of health service utilized was found. Nonetheless, more white patients used private health clinics while more black patients used the public health system. Previous tonsillitis was the only factor showing a significant correlation with the occurrence of PT. Also, PT prevalence was significantly higher in patients under 40 years of age. General prevalence of PT was significantly lower than reported in previous studies involving other countries/races. Considering the limitations of this study, when comparing it to a previous similar study and taking into account the Asian- and Caucasian-centric results obtained, a race influence on prevalence of calcifications may be suggested. Despite our results showing no racial differences within the Dominican Republic, black patients appear to present a lower prevalence of PT than Caucasian and Asian patients.

The effect of tonsillectomy on the immune system: A systematic review and meta-analysis

IMPORTANCE

The immunological sequelae of tonsillectomy in children have been a source of debate among physicians and a continuous concern for parents. Contradictory pertinent results exist in the literature.

OBJECTIVE

To understand the real effect of tonsillectomy on the immune system.

DATA SOURCES

MEDLINE, EMBASE and COCHRANE.

STUDY SELECTION

Articles addressing the effect of tonsillectomy on the immune system, up to Dec 2014. Related keywords and medical subject headings were used during the search. The abstracts were reviewed to determine suitability for inclusion based on a set of criteria. Manual crosscheck of references was performed.

DATA EXTRACTION

We checked the tests results and the conclusion of each study to classify it as supporting or refuting the hypothesis of a negative effect of tonsillectomy on the immune system.

RESULTS

We reviewed 35 articles, published between 1971 and 2014, including 1997 patients. Only Four studies (11.4%), including 406 patients (20.3%) found that tonsillectomy negatively affects the immune system. We performed a separate meta-analysis on various reviewed humoral and cellular immunological parameters (e.g. total and specific serum Ig's, SecIgA, cellular immunity, and Ag specific Ig). There is more evidence to suggest that tonsillectomy has no negative clinical or immunological sequalae on the immune system. Study limitations included heterogeneity in the diagnostic tools, timing of testing, indication for tonsillectomy and patients' age.

CONCLUSION

It is reasonable to say that there is enough evidence to conclude that tonsillectomy has no clinically significant negative effect on the immune system. It will be important for future studies to uniformly use both preoperative and control laboratory tests' levels to compare the postoperative levels with, to have short and long term follow-up levels, and to include both humoral and cellular immunity in their measurements.

RELEVANCE

The results should reassure both surgeons and parents that tonsillectomy has no proven clinical sequalae. If more research is to be done in the future, it should be performed in a standardized way to avoid the heterogeneity seen in the literature.

Short and long term impact of adenotonsillectomy on the immune system

Palatine and pharyngeal tonsils are immune reactive lymphoid organs that manifest specific antibodies and B/T-cell activity to respond to a variety of antigens. They perform humoral and cellular immune functions. The possible effects of adenotonsillectomy upon the immune system remain controversial.

Objective

To study the short and long-term impacts of tonsillectomy upon the cellular and humoral immunity of children.

Method

This longitudinal prospective study included 29 children referred to adenotonsillectomy for adenotonsillar hypertrophy. Serum IgA, IgM, and IgG and lymphocyte counts were analyzed at three points in time: before surgery, 1-2 months after surgery (short term), and 12-14 months after surgery (long term).

Results

TCD4+ cell counts were significantly increased shortly after surgery. IgA and IgG values were significantly reduced in the long run, but were within normal ranges for this age group.

Conclusion

This study indicated that adenotonsillectomy does not pose negative short or long term impacts upon the cellular and humoral immunity of children submitted to the procedure.

Tonsillectomy has beneficial effects on remission and progression of IgA nephropathy independent of steroid therapy

BACKGROUND

Indication of tonsillectomy in IgA nephropathy is controversial. The purpose of this study was to examine the efficacy of tonsillectomy on remission and progression of IgA nephropathy.

METHODS

We conducted a single-center 7-year historical cohort study in 200 patients with biopsy-proven IgA nephropathy. Study outcomes were clinical remission defined as disappearance of urine abnormalities at two consecutive visits, glomerular filtration rate (GFR) decline defined as 30% GFR decrease from baseline and GFR slope during the follow-up.

RESULTS

Seventy of the 200 patients received tonsillectomy. Tonsillectomy was associated with increased incidence of clinical remission (P+0.01, log-rank test) and decreased incidence of GFR decline (P=0.01, log-rank test). After adjustment for age and gender, hazard ratios in tonsillectomy were 3.90 (95% confidence interval 2.46-6.18) for clinical remission and 0.14 (0.02-1.03) for GFR decline. After further adjustment for laboratory (baseline mean arterial pressure, GFR, 24-h proteinuria and hematuria score), histological (mesangial score, segmental sclerosis or adhesion, endocapillary proliferation and interstitial fibrosis) or treatment variables (steroid and renin-angiotensin system inhibitors), similar results were obtained in each model. Even after exclusion of 69 steroid-treated patients, results did not change. GFR slopes in tonsillectomy and non-tonsillectomy groups were 0.60±3.65 and -1.64±2.59 mL/min/1.73 m2/year, respectively. In the multiple regression model, tonsillectomy prevented GFR decline during the follow-up period (regression coefficient 2.00, P=0.01).

CONCLUSION

Tonsillectomy was associated with a favorable renal outcome of IgA nephropathy in terms of clinical remission and delayed renal deterioration even in non-steroid-treated patients.

Concentration-dependent effect of fibrinogen on IgG-specific antigen binding and phagocytosis

In this paper, we aim to characterize fibrinogen-IgG interactions, and explore how fibrinogen alters IgG-mediated phagocytosis. Using enzyme-linked binding assays, we found that fibrinogen binding to IgG is optimized for surfaces coated with high levels of IgG. Using a similar method, we have shown that for an antigen unable to specifically bind fibrinogen, fibrinogen enhances binding of antibodies towards that antigen. For binding of IgG antibodies to cells expressing Fc receptors, we found a bimodal binding response, where low levels of fibrinogen enhance binding of antibody to Fc receptors and high levels reduce it. This corresponds to a bimodal effect on phagocytosis of IgG-coated particles, which is inhibited in the presence of excess IgG during coating of the particles with antibodies and fibrinogen. We conclude that fibrinogen can modulate phagocytosis of IgG-coated particles in vitro by changing IgG binding behavior, and that high fibrinogen levels could negatively affect phagocytosis.

Evaluation of long-term impacts of tonsillectomy on immune functions of children: a follow-up study

OBJECTIVE

The purpose of this follow-up study was to investigate the long-term effects of tonsillectomy in comparison with their short-term results.

PATIENTS AND METHODS

We successfully retrieved 20 out of our previously reported 37 patients who underwent tonsillectomy in our clinic 54 months ago. The blood levels of CD3+, CD4+, CD8+, CD19+, CD25+ and CD16++56+ (cellular immunity), and IgG, IgA, IgM, C3 and C4 (humoral immunity) were determined and compared with their previously reported short-term respective values.

RESULTS

There were no statistically significant differences between the short-term (1 month) and long-term (54 months) values of IgA, IgG, IgM and C4 levels of the patients (P>0.05). There was a slight but statistically significant decrease in complement factor C3 value compared to its the early-stage value (P<0.05) but this was not significantly different from age-matched healthy controls (P>0.05). The levels of CD4+ and CD19+ were higher and the levels of CD16++56+ and CD25+ were lower in the late-stage (54 months) compared to their early-stage values (P<0.05). When the long-term immune parameters of the tonsillectomized patients were compared with aged-match healthy controls, there were no significant differences between the levels of immunoglobulins, complements and lymphocytes (IgA, IgG, IgM, C3, C4, CD3+, CD4+, CD8+, CD19+, CD25+, CD16++56+) (P>0.05).

CONCLUSION

The results of this long-term follow-up study indicate that tonsillectomy do not compromise the immune functions of children as humoral and cellular immunity of patients recovered compared to their early-stage immune status (1 month), as they have similar immune capacity compared to their age-matched healthy controls at both early- and late-stages. Although a small sample of patients enrolled, our results are of importance with respect to the reassuring in settling the widely held urban myth that tonsillectomy compromises life long immunity.

Long-term effects of pediatric adenotonsillectomy on serum immunoglobulin levels: results of a randomized controlled trial

BACKGROUND

It remains controversial whether pediatric adenotonsillectomy ultimately results in decreased serum immunoglobulin levels and if so whether such a decrease is associated with increased susceptibility to upper respiratory tract infections (URIs).

OBJECTIVE

To evaluate changes in serum immunoglobulin levels in relation to occurrence of URIs in children participating in a randomized controlled trial on the effectiveness of adenotonsillectomy.

METHODS

A total of 300 children aged 2 to 8 years, with symptoms of recurrent throat infections or tonsillar hypertrophy, were randomly assigned to either adenotonsillectomy or watchful waiting (WW). Serum samples were collected at baseline and at 1-year follow-up. Occurrence of throat infections and other URIs during first-year follow-up was recorded in a diary by the child's parents.

RESULTS

Paired serum samples were available for 123 children (63 in the adenotonsillectomy group and 60 in the WW group). IgG1 and IgG2 levels decreased but remained within the reference range for age in both study arms. IgM and IgA levels decreased as well but remained elevated. The IgA level in the adenotonsillectomy group decreased in significantly greater degree compared with the WW group, but this difference disappeared in cases where children experienced frequent URIs. In general, no relation between immunoglobulin levels and the number of throat infections or URIs at 1-year follow-up was found.

CONCLUSIONS

Immunoglobulin levels of children undergoing adenotonsillectomy decreased from elevated to slightly elevated or reference values for age during 1-year follow-up irrespective of treatment (adenotonsillectomy or WW). IgA showed a greater decrease in the adenotonsillectomy group but rose to levels comparable with the WW group in cases of frequent URIs. This finding indicates that the remaining mucosa-associated lymphoid tissue can compensate for the loss of tonsil and adenoid tissue.

Early stage impacts of tonsillectomy on immune functions of children

OBJECTIVE

The purpose of this study was to investigate the changes in the humoral and cellular immunity of patients with chronic tonsillitis before and 1 month after tonsillectomy.

PATIENTS AND METHODS

37 patients scheduled for tonsillectomy were enrolled in this study. The levels of CD3+, CD4+, CD8+, CD19+, CD25+ and CD16+ + 56+ were measured for cellular immunity, and levels of IgG, IgA, IgM, C3 and C4 were measured for humoral immunity in blood samples taken from these patients before and 1 month after the operation.

RESULTS

The levels of CD3+, CD8+ and CD19+ were reduced in post-operative period as compared to pre-operative period but this was not statistically significant (P > 0.05). However it was found that the level of CD4+ was significantly increased while the level of CD25+ was reduced (P < 0.05) in the post-operative period. There were statistically significant differences between pre- and post-operative levels of immunoglobulins, C3 and C4, which were decreased after tonsillectomy (P < 0.05), but these levels were comparable with those of the control group.

CONCLUSION

The results from the present study indicate that humoral and cellular immunity of patients undergoing tonsillectomy were decreased in the early period and came to normal later. The cellular and humoral immune responses are stimulated in patients with tonsillitis, and tonsillectomy removes this stimulus without negatively affecting the patient's immune functions.

Decreased serum and pharyngeal antibody levels specific to streptococcal lipoteichoic acid in children with recurrent tonsillitis

OBJECTIVE

Streptococcus (S.) pyogenes is a common cause of primary as well as recurrent tonsillitis (RT). Lipoteichoic acid (LTA) has been proposed as a possible candidate for vaccine formulation against streptococcal infections, because LTA is a common constituent of streptococci and the antibody to LTA inhibits bacterial attachment to epithelial cells in vitro. Streptolysin-O and streptococcal whole cell body are highly immunogenic and the antibodies to these antigens are reported to be better parameters for streptococcal infections The objective of the present study is to investigate how systemic and local immune activities against S. pyogenes may be associated with RT.

METHODS

Sera from 178 children with or without RT aged 1-15 years with a median age of 5 years were investigated for the levels of total immunoglobulins and antibodies specific to streptococcal antigens such as whole cell body, LTA, and streptolysin-O. Pharyngeal secretions from 67 children with or without RT aged 2-14 years with a median age of 6 years were subjects to secretory IgA (SIgA) antibody levels to streptococcal LTA. The antibodies to whole cell body and LTA were measured by enzyme-linked immunosorbent assay. Total immunoglobins and the anti-streptolysin-O antibody were assayed by nephelometry.

RESULTS

An age-matched comparison revealed that either levels of serum IgG antibody or pharyngeal SIgA antibody to streptococcal LTA at 2-5 years of age were significantly lower in RT children than in non-RT children (1.39 vs. 5.14 microg/ml, P=0.001; 10.6 vs. 29.9 units/ng/ml total SIgA, P=0.015; respectively) and correlated inversely to episodes of tonsillitis (r=-0.242, P=0.024; r=-0.3, P=0.024; respectively). Either serum total immunoglobulin levels of IgG or IgA correlated positively to episodes of tonsillitis in children aged 2-5 years (r=0.293, P=0.011; r=0.361, P=0.002; respectively). No difference was found on either serum levels of IgG antibody to streptococcal whole cell body or antibody to streptolysin-O between RT and non-RT children in any age-matched comparisons. High serum antibody levels to whole cell body was associated with high antibody levels to streptococcal LTA in non-RT children (r=0.198, P<0.05), but no association was found between these antibody levels in RT children.

CONCLUSIONS

Selective immunologic failure in systemic and pharyngeal antibody response to streptococcal LTA may be a potential cause of RT in young children.

Neutrophils are hyperactive in recurrent tonsillitis

The pathogenesis of recurrent tonsillitis has not been fully explored. Most studies in this field have focused on pathogenic bacteria whereas less research has been done concerning the host defense. In earlier studies it was shown that there is an active cellular defense in the tonsillar surface secretion, consisting of phagocytes, and therefore in this study the possibility that this defense is altered in patients with recurrent tonsillitis was explored. Neutrophils were obtained from tonsillar surface secretions in eight patients with recurrent tonsillitis and eight healthy volunteers and the capacity of the neutrophils to respond to chemotactic stimuli was examined in an in vitro system. A significantly higher fraction of the neutrophils obtained from the patients with recurrent tonsillitis responded to chemotactic stimuli compared to those obtained from the healthy volunteers. It is concluded that there is a hyperactive cellular defense in the tonsillar surface secretion in patients with recurrent tonsillitis. This finding and its significance in the pathogenesis of recurrent tonsillitis are discussed.

Is a history of tonsillectomy associated with a decreased risk of Helicobacter pylori infection?

To determine the relation between a history of tonsillectomy and the prevalence of colonization by Helicobacter pylori (HP), we conducted an observational, cohort study at the University of Oklahoma Hospital over a 13-month period. Subjects under-going upper endoscopic evaluation and antral biopsies for HP at the University of Oklahoma Hospital formed the database. The indication of the endoscopy and biopsies was determined by the endoscopist. The antral biopsy specimens were tested for HP using a rapid urease test. We recorded the patient's name, age, gender, race, history of smoking, and history of appendectomy or tonsillectomy. One hundred nine subjects constituted our database. There was no difference in age, gender, or smoking between the HP+ (n = 37) and HP- (n = 72) groups. The ability to pay for healthcare through a third-payor party also was similar. The prevalence of prior tonsillectomy was 30.6% in HP- group versus 5.4% in HP+ group (p < 0.01). In contrast, the prevalence of prior appendectomy was 21.6% in HP+ group versus 23.6% in HP- group (p = not significant). Multiple regression was carried out to account for confounding variables. The model showed that only white race and tonsillectomy were significantly related to the presence of HP colonization. Both appendectomy and health insurance, which were the surrogate markers for access to healthcare and socioeconomic status, were insignificant. We conclude that a history of tonsillectomy is associated with decreased prevalence of HP colonization.

The effect of tonsillectomy on neutrophil chemotaxis in adults with chronic tonsillitis

Neutrophil random motility and chemotactic responsiveness were determined in 17 healthy adults and 19 adult patients with chronic tonsillitis before and 10 days after tonsillectomy, using a modified Boyden chamber method. The mean chemotactic index values of the healthy controls were significantly higher when compared with the chronic tonsillitis patients before tonsillectomy. The postoperative mean chemotactic values were increased, and there was a statistically significant difference between the mean chemotactic index of neutrophils in preoperative and postoperative patients. The authors conclude that this change in host defense mechanism may be the reason for frequent attacks of acute tonsillitis in these patients.

Acute upper respiratory tract infections and indications for tonsillectomy in children. I. Immunoglobulin synthesis in the palatine tonsil tissue

Current viewpoints and practice concerning indications for tonsillectomy are presented. The annual specific risk for upper respiratory infection in children aged up to 15 is 1.1. The risk is higher in the youngest age group, in whom it rises to 1.8, decreasing with age and being lowest among children aged 12-15 years (0.5). The proportion of tonsillitis among acute upper respiratory tract infections is highest in the age group up to 3 years (36.9%); at the age of 4-5 years it is 37.1%, and is lowest among children aged 12-15 years (21.9%). The risk of tonsillitis caused by streptococci is highest among children aged up to 5 years. Statistical significance of differences in the synthesis of immunoglobulins (G, M, A and sA) and lysozymes in the palatine tonsil tissue of tonsillectomized children and healthy volunteers was tested by non-parametric tests for independent samples. Significant differences of the above mentioned syntheses were found in all entities studied. Any contribution to the documentation on the nature and cause of each tonsillitis in childhood is of great clinical value, because it is the only basis for rational consideration of indications for tonsillectomy.

Changes in immunologic response in tonsillectomized children. I. Immunosuppression in recurrent tonsillitis

The possible immunoregulatory role of the tonsils was studied by determining immunoglobulins IgG, A, M, E and factors C'3, C'4 and PFB of the complement system before and after tonsillectomy. The synthesis in vitro of IgG and IgM by lymphocytes stimulated with pokeweed mitogen was also measured. There were statistically significant differences between pre and post-operative levels of serum IgG, IgA and IgM, which decreased after surgery. Practically no change in the mean values of IgE and no significant differences in the levels of serum C'3, C'4, and PFB, were found. The in-vitro synthesis of both immunoglobulins (IgG, IgM) by lymphocytes increased significantly after tonsillectomy. Our results suggest that not only does tonsillectomy have no counterproductive effect on the immune system, but that, on the contrary, it seems to improve the immune response, since it appears to unblock the suppression to which the immune system was subject.

Serum immunoglobulin E levels in children with chronic tonsillitis

Serum immunoglobulin E (IgE) levels were estimated by ELISA in 50 children with chronic tonsillitis before and after tonsillectomy. When compared with the control group, mean serum IgE concentration was found to be significantly higher in children with chronic tonsillitis (P less than 0.001). After tonsillectomy the levels returned to normal.

Modern assessment of tonsils and adenoids

Modern assessment of the tonsils and adenoids is based on an appreciation of new concepts pertaining to the pathogenesis of tonsil and adenoid disease. Recognition of the emergence of beta-lactamase-producing and encapsulated anaerobic bacteria in the tonsils and adenoids should lead to a reconsideration of present therapeutic recommendations for antibiotic therapy in infectious tonsil and adenoid disease. The performance of a precise history, use of a standardized physical examination, and judicious use of laboratory evaluation are all necessary for appropriate patient management and improved communication between the pediatrician and otolaryngologist. Thus, appropriate recommendation for tonsillectomy and adenoidectomy will enhance their benefits, and the result will be happier and healthier children.

Antibody response to pneumococcal vaccination as related to tonsillectomy

In each of twelve matched pairs of patients undergoing tonsillectomy one patient was vaccinated with Pneumovax, a pneumococcal polysaccharide antigen, prior to tonsillectomy, the other patient being vaccinated after tonsillectomy. Sera were tested for antibody response to three different pneumococcal types of IgG, IgA and IgM classes. The patients with intact tonsils at vaccination did not develop higher antibody response than did those tonsillectomised prior to vaccination. On the contrary, in the case of pneumococcus type 6A, the IgM antibody response in tonsillectomised patients was significantly higher than that in patients with intact tonsils at vaccination (p = 0.021). Thus, the present study did not support the notion that tonsillectomy affects antibody response against pneumococcal vaccination. The palatine tonsils' role as an immunologically reactive organ is also discussed.

Indication of tonsillectomy for recurrent tonsillitis

The indication of tonsillectomy for recurrent tonsillitis was discussed from the standpoint of clinical immunology. Elevated serum IgG was observed in 29.8% of the patients under 8 years of age preoperatively. In contrast, in 25% of patients between 9-15 years of age, serum IgG was low preoperatively. In the patients over 16 years of age no abnormal serum IgG was found, and the elevated serum IgG returned to normal after tonsillectomy. The patients with normal serum IgG preoperatively retained normal values postoperatively. The low preoperative IgG level group still remained low postoperatively. As to postoperative improving symptoms, high and low grade fever improved most (100%), followed by cervical lymphadenopathy (93%), frequent absence from school (93%), sore throat (88%) and recurrence of bronchitis (85%). The patients with recurrent tonsillitis for 8 years showing high serum IgG had indications for tonsillectomy.