Does tonsillectomy reduce medical care visits for pharyngitis/tonsillitis in children and adults? Retrospective cohort study from Sweden.

OBJECTIVE: To assess the effectiveness of tonsillectomy/adenotonsillectomy in reducing medical care visits for pharyngitis or tonsillitis in children and adults with chronic/recurrent tonsillitis. DESIGN: Retrospective cohort study. SETTING: Data were retrieved from the VEGA register, a comprehensive regional cohort in Sweden. PARTICIPANTS: 1044 children (<15 years) and 2244 adults. INTERVENTION: Tonsillectomy/adenotonsillectomy compared with no surgical treatment. MAIN OUTCOME MEASURES: Changes in yearly mean rates of medical care visits due to pharyngitis/tonsillitis. RESULTS: In children, there was a significant decrease in the yearly mean medical care visits rate from 1.93 (1.82 to 2.04) before surgery to 0.129 (0.099 to 0.165) after surgery, with a mean change of -1.80 (-1.90 to -1.69), p<0.0001. In patients who did not undergo surgery, the corresponding mean change was -1.51 (-1.61 to -1.41), resulting in a mean difference in the change in visit rates between the intervention and control groups of -0.283 (-0.436 to -0.135), p=0.0002. In adults, a significant decrease in the yearly mean medical care visit rate was observed from 1.45 (1.39 to 1.51) before surgery to 0.152 (0.132 to 0.173) after surgery, with a mean change of -1.30 (-1.36 to -1.24), p<0.0001, compared with -1.18 (-1.24 to -1.13) in the control group. The difference in the change in yearly mean visit rate between the surgical and non-surgical groups was -0.111 (-0.195 to -0.028), p=0.0097. The subgroup analysis showed a greater effect of surgery in children, in patients with a higher number of medical care visits before surgery and in the first year of follow-up. CONCLUSION: In this cohort of patients moderately or less affected with chronic/recurrent tonsillitis, the effectiveness of tonsillectomy/adenotonsillectomy in reducing medical care visits for pharyngitis and tonsillitis compared with no surgical treatment was low and of questionable clinical value.

Probiotics study with Streptococcus salivarius and its ability to produce bacteriocins and adherence to KB cells / Estudo de probióticos Streptococcus salivarius e sua habilidade de produzir bacteriocinas e aderência à células KB

Abstract Introduction Streptococcus salivarius is a dominant oral species and the best suitable candidate for probiotic of the oral cavity. Since Streptococcus salivarius is able to produce bacteriocins against Streptococcus pyogenes interest has been focused on the use of it as a probiotic to avoid sore throats by Streptococcus pyogenes. Objective This study is for selecting Streptococcus salivarius strains for potential use as probiotics for the oral mucosa, that is, production of bacteriocin against Streptococcus pyogenes and the ability to bind to KB cells. Material and method Tongue material from 45 students was collected and seeded on Mitis Salivarius Agar plaques. The strains were tested by the production of bacteriocin-like substances (BLIS) against S. pyogenes, biochemically and PCR for identification of S. salivarius. The best strains were tested for adherence to KB cells. Briefly, S. salivarius strains were cultured in broth, washed and suspended at 108cells/ml. KB cells were inoculated into plaques, washed and incubated with the bacteria, for adhesion. These were washed for lysis of the KB cells and release bacteria for determination of CFU. Result The bacteriocin test showed that 133 strains presented inhibition of S. pyogenes. The samples tested for adhesion to KB cells, presented different profiles and only three strains presenting high adhesion capacity. Conclusion The selection of strains of Streptococcus salivarius with high inhibitory activity against Streptococcus pyogenes, as well as adherence to KB cells leads us to the next future step, that is, to use the best strains for in vivo colonization tests

Resumo Introdução Streptococcus salivarius é uma espécie dominante na cavidade bucal e tem sido indicada como um ótimo candidato para uso como probiótico. Visto que a espécie Streptococcus salivarius é capaz de produzir bacteriocinas contra Streptococcus pyogenes, desenvolveu-se interesse no uso desse microrganismo como probiótico, para evitar amigdalites causadas por Streptococcus pyogenes. Objetivo A pesquisa em questão tem o objetivo de selecionar cepas de Streptococcus salivarius para seu uso potencial como probióticos na cavidade bucal, ou seja, produção de bacteriocinas contra Streptococcus pyogenes e habilidade de aderência à células KB. Material e método Coletou-se material de língua de 45 estudantes e semeou-se em placas de ágar Mitis Salivarius. As amostras foram testadas para verificar a produção de substâncias semelhantes à bacteriocina (BLIS) contra S. pyogenes, bioquimicamente e através de PCR para identificação de S. salivarius. As melhores cepas foram testadas quanto aderência à células KB. Resumidamente, as cepas de S. salivarius foram cultivadas em caldo, lavadas e suspensas à correspondência de 108 cels/ml. As células KB foram inoculadas em placas, lavadas e incubadas com as bactérias, para adesão. Estas foram lavadas para lise das células KB e liberação das bactérias para determinação de UFC. Resultado O teste de bacteriocina, mostrou que 133 cepas apresentaram atividade inibitória contra Streptococcus pyogenes. As cepas testadas para aderência à células KB, apresentaram diferentes perfis e somente três com alta capacidade de adesão. Conclusão: A seleção de cepas de Streptococcus salivarius com alta atividade inibitória contra Streptococcus pyogenes, bem como aderência a células KB, pode nos levar ao próximo passo, ou seja, o uso das melhores cepas para o estudo de colonização in vivo.

[Prophylaxis of chronic adenoiditis in the children].

This study was undertaken with the purpose of improving the effectiveness of the preventive treatment of chronic adenoiditis in the children. The open randomized comparative study included 219 children aged from 6 to 7 years presenting with clinical and anamnestic signs of chronic adenoiditis. The study group was comprised of 113 patients given the Streptococcus salivarius K12-based probiotic complex during 30 days in combination with the nasal-douche. The control group consisted of 106 patients treated with the nasal douche alone. The analysis of the results of the study has demonstrated that episodes of exacerbation of adenoiditis on day 30 after the onset of the treatment occurred in 56 (49.6%) children of the study group compared with 95 (88.7%) patients of the control group. Three months later, acute sinusitis was diagnosed in 4 (3.5%) children of the study group compared with 14 (13.2%) ones in the control group. Acute otitis media was documented in 2 (1.8%) and 5 (4.7%) children of the study and control groups respectively. It is concluded that the treatment with the use of the Streptococcus salivarius K12-based probiotic complex permits to decrease the frequency of exacerbations of chronic adenoiditis and its complications in the children and reduces the requirement for medication therapy.

[A novel view of prophylaxis and treatment of chronic adenoiditis in children].

The present clinical study had the objective to evaluate the role of a hypertonic solution of sterile water from the Adriatic Sea in the prevention and treatment of chronic adenoiditis in children. It included 30 children aged from 2.5 to 15 years. The control group was comprised of 30 children treated by intransal drop infusion of physiological saline followed by irrigation of the nasal cavity with framicetin as recommended by the manufacturer. The study failed to reveal a significant difference (P > 0.05) between dynamics of the symptoms of chronic adenoiditis in the patients of either group assessed based on the 10-point analog visual scale. However, the frequency of relapses of adenoiditis during the observation period (3 months) was significantly lower in the patients treated with the hypertonic solution of sterile seawater. Microbiological investigations of the material from the pharyngonasal cavity showed no difference between the occurrence of tansient bacterial microflora in the patients of the study and control groups.

Role of atypical bacteria in children undergoing tonsillectomy because of severely recurrent acute tonsillopharyngitis.

The aim of this study was to verify the frequency of atypical bacterial infections in children undergoing tonsillectomy because of severely recurrent acute tonsillopharyngitis (AT) and the possible benefit of surgery in cases in which Mycoplasma pneumoniae and Chlamydophila pneumoniae seem to play a role in causing the recurrences. A total of 118 patients (76 males; mean age +/- standard deviation, 6.67 +/- 3.31 years) were enrolled: 59 underwent tonsillectomy because of severely recurrent AT and 59 underwent adenotonsillectomy because of obstructive sleep apnea syndrome (OSAS). The results show, for the first time, that the great majority of children with a history of severely recurrent AT (and, therefore, considered to be eligible for elective tonsillectomy) are infected by atypical bacteria, mainly M. pneumoniae, and that tonsillectomy seems to be effective in reducing the recurrence of both AT and acute respiratory disease during 12 months follow-up postsurgery.

[Otologic sequels in velopalatine clefts. Analysis and management]. / Séquelles otologiques dans les fentes palatovélaires. Analyse et prise en charge.

As early as in 1878, medical teams managing children born with a velopalatine cleft had noted the prevalence of middle-ear pathologies largely related to anatomic and inflammatory Eustachian tube dysfunction. The aim of this study was to describe otologic sequels related to a velopalatine cleft and to suggest an adapted management. These sequels are evolving presentations of chronic serous otitis; they worsen the functional prognosis (hypoacousia) and more rarely the vital prognosis (cerebral or infectious complications of cholesteatoma). We must stress the importance of prevention: during the initial management, by Eustachian tube rehabilitation, and by ENT (Ear, Noseand Throat) follow-up allowing to prevent these sequels and to bring hearing to normal as soon as possible, so as to support cognitive development, language skills, and sociofamilial integration of the children.

[Clinical and therapeutic management of respiratory tract infections. Consensus document of the Andalusian Infectious Diseases Society and the Andalusian Family and Community Medicine Society]. / Aproximación clínica y terapéutica a las infecciones de las vías respiratorias. Documento de Consenso de la Sociedad Andaluza de Enfermedades Infecciosas y de la Sociedad Andaluza de Medicina Familiar y Comunitaria.

Respiratory tract infections are frequent and they are one of the commonest causes of antibiotic prescription. However, there are few clinical guidelines that consider this group of infections. This document has been written by the Andalusian Infectious Diseases Society and the Andalusian Family and Community Medicine Society. The primary objective has been to define the recommendations for the diagnosis and antibiotic treatment of respiratory tract infections apart from pneumonia. The clinical syndromes evaluated have been: a) pharyngitis; b) sinusitis; c) acute otitis media and otitis externa; d) acute bronchitis, laryngitis, epiglottitis; e) acute exacerbation of chronic bronchitis; and f) respiratory infectious in patients with bronchiectasis. This document has focused on immunocompetent patients.

Epidemiology and virulence gene expression of intracellular group A streptococci in tonsils of recurrently infected adults.

Intracellularly persistent group A streptococci (GAS, Streptococcus pyogenes) have been associated with recurrent tonsillopharyngitis and antibiotic treatment failure. As a supplementation of the published in vitro data, conventional bacteriology and molecular epidemiology was performed on material from 29 adult patients of a German army hospital with anamnestic signs of recurrent tonsillopharyngitis. Pre-surgery tonsil swabs and the surgically removed tonsils were examined with respect to growth of aerobic bacteria in absence and presence of antibiotics with exclusively extracellular activity. Under such antibiotic selection, Staphylococcus aureus and GAS were cultured from specimens of 13 and 3 patients, respectively. In every material GAS-positive by culture methods, the intracellular location of the penicillin-susceptible GAS isolates was confirmed by immunohistologic examination of tonsillar sections using a GAS-specific IgG antibody. The three intracellular GAS isolates were typed by emm gene sequencing and could be associated to types M6 and M49 (two isolates). The bacteria were serially passaged on sheep blood agar, and semiquantitative mRNA analysis from virulence genes was performed using bacteria of the 4th and 25th passage after isolation. An M-type-specific pattern of virulence gene expression and different gene expression levels in relation to the passage number were observed.

Estudo clínico-imunológico da eficácia de timomodulina (Leucogen©) na otite média aguda recorrente e na amigdalite de repetição / Assessment of efficacy and safety of thymomodulin (Leucogen©) in the prevention of recurrent otitis media and recurrent tonsillitis

Os autores realizaram estudo em 35 crianças portadoras de otite média aguda recorrente e amigdalite de repetiçäo em um estudo duplo-cego com timomodulina e placebo. As crianças tratadas com timomodulina© receberam 4mg/kg/dia do medicamento diariamente durante três meses. Foi realizado controle bioquímico antes do tratamento e com cinco meses e nove meses após o término do tratamento. Além da avaliaçäo clínica foram realizados os seguintes exames: hemograma, TGO, TGP dosagem de IgA, IgG, IgM e IgE antes do início do tratamento e nos controles. Os resultados evidenciaram tendência à diminuiçäo do número de infecçöes e o número de ciclos de antibióticos, em relaçäo a informaçäo do último ano (pré-tratamento), principalmente no grupo tratado com timomodulina, assim como tendência ao aumento do IgA e IgG após tratamento com timomodulina, o que näo ocorreu no grupo placebo. Os exames laboratoriais, contagem de eritrócitos, de hematócrito, hemoglobina, leucócitos e transaminases (TGO e TGP) näo mostraram diferenças entre os grupos, nem alteraçöes 12 meses após o início da medicaçäo, evidenciando a ausência total de toxicidade da timomodulina. Houve apenas um efeito colateral com o uso de timomodulina (náusea e vômito) numa criança com amigdalite purulenta que tomou cefalexina concomitantemente

[The tonsils and adenoids as a site of infection and the cause of obstruction]. / Tonsille e adenoidi come sede di infezione e causa di ostruzione.

The failure to eradicate group A beta-hemolytic streptococci from the pharynx is partly due to a low compliance, but above all, an alteration of the oropharyngeal microbiological flora: reduction of alpha-haemolytic streptococci which inhibit group A beta-hemolytic streptococci and increase of microorganisms such as Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis. These latter act indirectly destroying the beta-lactamic ring of penicillins. However, this obstacle is overcome by the use of antibiotics which do not contain beta-lactamic rings such as macrolides or associating amoxicillin with clavulanic acid or with new cephalosporins which are more resistant to beta lactamases. To restrict the diffusion of resistance to antibiotics, it is essential to limit their use diagnosing streptococcal tonsillopharyngitis more precisely, thanks to an improved use of micro-biological diagnostic tests and by a more extended use of tonsillectomy in recurrent tonsillitis (more than 6-7 in 1-2 years). Adenoiditis is closely related to the post nasal drip syndrome, to recurrent otitis media and to otitis media with effusion. All these situations could, therefore, represent an indication, although not well defined, for adenoidectomy. Nasopharyngeal obstruction due to adeno-tonsillar hypertrophy becomes critical during sleep when the hypotony of the upper airway muscles becomes additional to the anatomical obstruction. At this point the inspiratory effort required and the consequent decrease of intra airway pressure increase the pharyngeal obstruction suctioning the pharyngeal walls toward the median line. The resulting clinical picture is defined as sleep-disordered breathing (SDB) due to adenotonsillar hypertrophy (idiopathic), to be distinguished from SDB due to cranio-facial abnormalities or neuromuscular diseases. SDB includes both the more serious sleep apnea syndrome and the less severe upper airway respiratory resistance syndrome. A combination of symptoms and clinical data detectable both while awake or asleep, make the diagnosis simple. During sleep, both apnea and paradoxical inspiratory movements are highly specific while snoring is highly sensitive. To evaluate nasopharyngeal obstruction radiography and optic fibre endoscopy are both equally reliable. The gold standard test for non idiopathic SDB is the polysomnography, whereas for SDB, due to adenotonsillar hypertrophy, one is limited today to the recording during sleep of O2 saturation or of end tidal CO2. These investigations are, however, generally used up to 2 years of age, when the decision to carry out an adenoidectomy and especially a tonsillectomy is more difficult because of the greater risks which surgery involves at this age. The pharmacological therapy has a purely palliative function and is based on antibiotics, local vasoconstrictors, steroids and theophylline which acts more as an antiflogistic than as a breath stimulant. O2 therapy and nasal continuous positive airway pressure (CPAP) give better results, but are more difficult to carry out, in particular on a long term basis. Adenoidectomy especially if associated with tonsillectomy, leads to the resolution of the symptoms, but not always to a normalization of functional alterations (hypoxia and hypercapnia). For this reason, it is necessary to act on other factors which cause oedema of the nasopharyngeal mucosa contributing to the obstruction. In this area, the prevention of viral infections can be achieved by vaccination against influenza and by preventing the child from attending crowded day care centers. With regard to allergic inflammation, skin prick tests could be a first step in view of allergens avoidance measures. With regard to indoor air pollution, passive smoke must be stopped and the child kept out of the kitchen.

Faringoamigdalites episodicas e recorrentes / Episodic and recurrent sorethoat

Os autores analisam aspectos diagnosticos e terapeuticos relacionados as faringites agudas e recorrentes da crianca, a luz dos relatos da literatura e da experiencia dos medicos da Divisao de Pediatria do Hospital Universitario da Universidade de Sao Paulo

The impact of social and environmental changes on allergic rhinitis among Saudi children. A clinical and allergological study.

Eighty four children with allergic rhinitis out of 316 consecutive cases were investigated, treated and followed-up for 2 years. Diagnostic skin testing were done with identified common allergens found in Saudi environment (2). Cat fur, Bermuda grass and mesquite were the most common allergens found. Symptoms of recurrent rhinosinusitis, otitis media with effusion, tonsils and adenoids infection were commonly noticed among them. The rapid change of environment in Saudi Arabia in the form of agricultural and other factors seem to play part in the increasing incidence of allergic manifestation in paediatric population. With antiallergic treatment and control of infection, most of these children responded well and only four children required surgery. The treatment of allergic disease saves a lot of children from unnecessary surgical procedures usually carried out on them.

Prevençäo primária: o tratamento das faringoamigdalites estreptocócicas / Primary prevention: the treatment of tonsillo Pharyngitis spreptococcal

A dor de gargante, sintoma muito comum nas crianças, tem como principal etiologia vírus e bactérias. Constituti-se na maior imprortância o diagnóstico correto do agente etiológico, pois a faringoamigdalite causada pelo streptococco beta hemolítico do Grupo A é responsável pelo desencadeamento posterior da febre reumática. Os sintomas da amigdalite estreptocócica podem ser característicos ou apresentar variaçöes de acordo com a faixa etária. Para diagnóstico diferencial utiliza-se os testes rápidos, a cultura de orofaringe e a dosagem de anticorpos específicos tais como o antiestreptolisina O. Em suma, o tratamento visa a erradicaçäo do estreptococco beta hemolítico do Grupo A, sendo a droga de escolha a penicilina benzatina ou a eritrominica nos casos comprovados de alergia a penicilina.