Comparative Evaluation of the Effects of Adenotonsillar Hypertrophy on Oral Health in Children.

We aimed to investigate the oral health of children in terms of the presence of dental caries, periodontal health, halitosis, and dentofacial changes in patients who had adenotonsillar hypertrophy related to mouth breathing and compared these findings with nasal breathing healthy and adenotonsillectomy-operated children. The patient group comprised 40 mouth-breathing children who were diagnosed with adenotonsillar hypertrophy, while the control group consisted of 40 nasal breathing children who had no adenotonsillar hypertrophy. Forty children who had undergone an adenotonsillectomy operation at least 1 year prior to the study were included in the treatment group. Oral examinations of all children were conducted, and the parents were asked about medical and dental anamnesis, demographic parameters, toothbrushing and nutrition habits, oral health-related quality of life (OHRQoL), and symptoms of their children. Demographic parameters, toothbrushing and nutrition habits, and the presence of bad oral habits did not differ between groups (p > 0.05). Adenotonsillectomy is associated with a remarkable improvement in symptoms; however, some symptoms persist in a small number of children. The salivary flow rate, dmft/s, DMFT/S index, plaque, and gingival index scores did not differ between groups (p > 0.05). The patient group showed higher rates of halitosis when compared with the treatment and control groups (p < 0.001). Mouth breathing due to adenotonsillar hypertrophy caused various dentofacial changes and an increase in Class II division 1 malocclusion (p < 0.001). It was shown that adenotonsillar hypertrophy does not negatively affect OHRQoL, it could be a risk factor for dental caries, periodontal diseases, and halitosis, but by ensuring adequate oral health care, it is possible to maintain oral health in children with adenotonsillar hypertrophy. Also, it is recommended that orthodontic treatment should start as soon as possible if it is required. In this context, otorhinolaryngologists, pedodontists, and orthodontists should work as a team in the treatment of children with adenotonsillar hypertrophy.

Bilateral synchronous tonsillar metastasis from a mixed form of neuroendocrine tumor in the lung: Case report and literature review.

Here, we report the case of a 54-year-old man with a history of squamous cell carcinoma (SCC) of the lung, who developed bilateral neuroendocrine carcinoma (NEC) of the palatine tonsils. Faced with this atypical situation, another biopsy of the lung lesion was performed, revealing NEC histology patterns. This article describes the first case of metastasis to the bilateral palatine tonsils from the NEC component of a mixed NEC/SCC of the lung, highlighting the importance of reconsidering the diagnosis of the primary tumor histology, particularly in lung cancer with the possible presence of mixed tumor after phenotype transdifferentiation of the primary tumor. KEY POINTS: SIGNIFICANT FINDINGS OF THE STUDY: Mixed lung carcinoma can be revealed after the presence of neuroendocrine carcinoma metastasis. WHAT THIS STUDY ADDS: Bilateral neuroendocrine carcinoma of the palatine tonsils should be considered as metastases, particularly in the presence of lung cancer with a poor response to treatment.

Sleep endoscopy findings in children in supine versus left lateral position.

OBJECTIVE: To describe how drug-induced sleep endoscopy (DISE) findings in children with obstructive sleep apnea (OSA) change with lateral positioning. METHODS: Children undergoing DISE for OSA in 2018-19 at a tertiary care children's hospital were positioned first supine and then in left lateral (LL) and findings were compared. RESULTS: 63 children were included, 30 (47.6%) female and 33 (52.4%) male, mean age 4.64 years, and a mean Z-score 0.70. Mean pre-op Apnea Hypopnea Index (AHI) was 6.41 and REM AHI was 15.04. In supine position, 20 had obstruction at the palate (31.7%), 39 (61.9%) had obstruction at each of the base of tongue and the larynx, 17 (27.0%) had obstruction at the tonsils. In LL position, 11 (17.5%) were obstructed at the palate, 21 (33.3%) at the tonsils, 8 (12.7%) at the base of tongue and 7 (11.1%) at the larynx. Larynx and base of tongue were most likely to improve in LL position, as 54% of patients obstructed in supine position were open in LL position. Overall 38 (60.3%) patients improved on LL, 18 (28.6%) had no change, and 7 (11.1%) worsened. 30 (47.6%) patients improved in 1 site while 12 (19.0%) improved in more than 1 site. 16 (25.4%) patients worsened in 1 site and 9 (56.3%) of these had improvement in another site. CONCLUSION: A significant number of patients improved airway patency, particularly at the base of tongue/larynx, during DISE when placed in LL position as compared to standard supine positioning.

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.

Classical versus controlled rapid sequence induction and intubation in children with bleeding tonsils (a retrospective audit).

PURPOSE: To determine whether bag-mask ventilation between induction of anaesthesia and tracheal intubation in children with post-tonsillectomy bleeding reduces the incidence of hypoxaemia and difficult direct laryngoscopy without increasing perioperative respiratory complications. METHODS: Medical records, anaesthesia protocols and vital sign data were analysed from February 2005 to March 2017 for patients undergoing anaesthesia for surgical revision of bleeding tonsils. Type of rapid sequence induction and intubation (RSII; classical, ie, apnoeic, vs controlled, ie, with gentle bag-mask ventilation) was noted. Primary outcomes were incidence of moderate and severe hypoxaemia, grade of direct laryngoscopic views as well as occurrence of noted tracheal intubation difficulties. Haemodynamic alterations during RSII and perioperative adverse events such as noted gastric regurgitation, pulmonary aspiration and perioperative pulmonary morbidity were also recorded. RESULTS: A classical RSII was performed for 22 surgical revisions in 22 children and a controlled RSII was used for 88 surgical revisions in 81 children. Patients undergoing controlled RSII had less incidence of severe hypoxaemia (1 vs 3; P = .025), better direct laryngoscopic views (P = .048) and less hypertension (5 vs 9; P < .001) than those patients managed by classical RSII. No tracheal intubation difficulties occurred. There was no significant perioperative pulmonary morbidity reported in either group. CONCLUSIONS: Controlled RSII had advantages over classical RSII in children with post-tonsillectomy bleeding and may become a strategic option in these patients to avoid hypoxaemia, difficult laryngoscopy and hypertension during induction of anaesthesia and tracheal intubation. Bag-mask ventilation in patients with bleeding tonsils did not lead to pulmonary morbidity.

[Palatine tonsils: physiology and pathology]. / Nebnye mindaliny: fiziologiia i patologiia.

The article presents modern ideas about the etiology, pathogenesis, and features of the clinical picture of chronic tonsillar pathology. Specific attention is paid to the classification of chronic tonsillitis, in particular the classification of B.S. Preobrazhensky - V.T. Palchun. Data on modern methods for assessing the morphofunctional state of palatine tonsils, including immunohistochemical studies, are presented. Modern approaches to therapy are considered.

Oxidative stress, apoptosis and abnormal expression of apoptotic protein and gene and cell cycle arrest in the cecal tonsil of broilers induces by dietary methionine deficiency.

Methionine (Met) is often called the first limiting amino acid in birds. Broilers have high requirement for Met, so they are at high risk of Met deficiency. The aims of the present research is to study the effects of Met deficiency on the histomorphological changes, antioxidant functions, apoptosis and cell cycle in the cecum tonsil of broilers. A batch of 120 one-day-old Cobb broilers in total are divided into two groups and fed on a Met deficiency diet or a control diet for six weeks, followed by analysis using the methods of experimental pathology, biochemical method, immunohistochemical method, ELISA, FCM, Tunel assay, and qRT-PCR. Results showed that the cecal tonsils were impaired, and the SOD, CAT and GSH-Px activity, the ability to suppression on the hydroxy radicals, and the content of GSH reduced in Met deficiency group comparing to the control group. In contrast, the MDA content is higher in Met deficiency group. As measured by immunohistochemical method, ELISA, Tunel, FCM and qRT-PCR, increased proportion of apoptotic cells, abnormal content or expression of apoptotic proteins, as well as cell cycle arrest were observed. In conclusion, dietary Met deficiency imposes a severe impact on the cecal tonsils, mainly in the forms of histological injury, cell cycle arrest, oxidative stress, and increased cellular apoptosis. The oxidative stress leads to cellular apoptosis and then induces the injury of the cecum tonsils. The local intestinal mucosal immune system would finally be injured by the oxidative stress and apoptosis in the intestine.

[The specific pathogenetic features of the development of chronic tonsillar pathology]. / Patogeneticheskie osobennosti formirovaniia khronicheskoi tonzilliarnoi patologii.

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 prevalence of human papillomavirus in pediatric tonsils: a systematic review of the literature.

BACKGROUND: HPV-related head and neck cancer rates have been increasing in recent years, with the tonsils being the most commonly affected site. However, the current rate of HPV infection in the pediatric population remains poorly defined. The objective of this study was to systematically review and evaluate the prevalence and distribution of HPV in the tonsils of pediatric patients undergoing routine tonsillectomy. METHODS AND RESULTS: The literature was searched using PubMed, EMBASE, Scopus, CINAHL, Cochrane Library, and ProQuest Dissertations & Theses Global databases (inception to December 2017) by two independent review authors. Inclusion criteria included articles which evaluated the prevalence of HPV in a pediatric cohort without known warts or recurrent respiratory papillomatosis, those which used tonsil biopsy specimens for analysis, and those with six or more subjects and clear outcomes reported. Eleven studies met the inclusion criteria. Using the Oxford Clinical Evidence-based Medicine (OCEBM) guidelines, two reviewers appraised the level of evidence of each study, extracted data, and resolved discrepancies by consensus. The systematic review identified 11 articles (n = 2520). Seven studies detected HPV in the subject population, with prevalence values ranging from 0 to 21%. The level of evidence for all included studies was OCEBM Level 3. CONCLUSIONS: HPV may be present in pediatric tonsillectomy specimens; however, the largest included study demonstrated a prevalence of 0%. Future testing should be performed using methods with high sensitivities and specificities, such as reverse transcript real-time PCR or digital droplet PCR.

Formula for the prediction of apnea / hypopnea index in children with obstructive sleep apnea without polysomnography according to the clinical parameters: Is it reliable?

PURPOSE OF THE STUDY: The aim of the study was to propose "the risk formula" for obstructive sleep apnea in children according to the general and local clinical parameters and findings relevant for obstructive sleep apnea (OSA) severity. The unmet need for this formula arises from the economic burden of polysomnography (device, staff, training, special sleep centers, etc) as the golden standard for the diagnostics. MATERIALS AND METHODS USED: The study was performed from January 2013 until January 2016 in the Sleep Center, Department for Neuroscience, School of Medicine of the University of Split, Department of Pediatrics, University Hospital Split, Croatia and ENT Dept. University Hospital in Split, Croatia. Inclusion criteria were: age > two years, AHI >1 diagnosed by polysomnography. Exclusion criteria were: chronic lung disease, active tonsillitis/pharyngitis at the time of the physical exam and syndromes that affect breathing. All polysomnograms were scored by a qualified sleep technologist and interpreted by two board certified sleep physicians independently. Age, sex, BMI, Mallampati score, tonsillar size and adenoids size were recorded. All statistical calculations were performed using SPSS 20. RESULTS: In total 60 children were included in the study. The median of age was 5 years (range 2-9). There were 19 (32%) girls and 41 (68%) boys. Of all evaluated predictors, there were statistically significant differences in the values of AHI among children with different modified Mallampati score (χ2 = 28.2; p < 0.001), different size of tonsils (χ2 = 25.3; p < 0.001) and different size of adenoids (z = 2.7; p = 0,006) in univariate regression analysis. Strong positive association of AHI with modified Mallampati score (standardized B = 0.51; partial correlation = 0.542, r = 0.631) was found, as well as positive correlation of AHI with tonsillar size (standardized B = 0.246; partial correlation = 0.295,R = 0.489) in the multivariate forward stepwise regression analysis. CONCLUSION: Even though we are aware that PSG is the gold standard for diagnostics of SDB there is a significant financial burden for this diagnostic procedure. That is why there is a necessity for establishing good clinical standards and possible formula for OSA severity evaluation. We propose formula which includes Mallampati score and tonsillar size for OSA -risk calculation in order to perform early therapeutic intervention thereby reducing the risk of long-term negative consequences. We recommend this formula as the screening formula in circumstances where PSG is not available, in cases when the "waiting list" is too long or when a child can not cooperate to perform it. In developing countries like Croatia on time intervention with reduced procedure-associated costs is of the utmost importance.

Influencing factors on CPAP adherence and anatomic characteristics of upper airway in OSA subjects.

Although continuous positive airway pressure (CPAP) is the most effective treatment modality, poor adherence still remains a problem for obstructive sleep apnea (OSA) treatment and there is little evidence regarding how this might be improved. This study aims to analyze the anatomic and clinical factors of OSA subjects who failed to comply with CPAP therapy.The medical records of 47 OSA subjects who received CPAP therapy as a first-line treatment modality were retrospectively reviewed. The medical records were reviewed for demographic and polysomnographic data and anatomic findings of the nasal cavity and oropharynx.24 patients who adhered to CPAP therapy and 23 patients who were nonadherent were enrolled in the study. There were no statistically significant differences in sleep parameters between CPAP-adherent patients and CPAP nonadherent subjects. Mean body mass index of CPAP nonadherent group was significantly higher than CPAP adherent group. Higher grades of septal deviation and hypertrophic change of the inferior turbinate were observed more in the CPAP nonadherent group. In addition, CPAP nonadherent subjects showed considerably bigger tonsils and higher grade palatal position comparing with the CPAP adherent subjects. Subjective discomfort including inconvenience, mouth dryness, and chest discomfort were the main problems for OSA subjects who did not comply with CPAP therapy.Excessive upper airway blockage in the nasal cavity and oropharynx was predominant in CPAP nonadherent subjects, which might cause the reported subjective discomfort that reduces CPAP compliance. Therefore, resolution of these issues is needed to enhance CPAP compliance for control of OSA.

Montelukast for Children with Obstructive Sleep Apnea: Results of a Double-Blind, Randomized, Placebo-Controlled Trial.

RATIONALE: Obstructive sleep apnea (OSA) is highly prevalent in children and is usually treated by adenotonsillectomy. Nonsurgical therapies for OSA consist primarily of antiinflammatory approaches and have gained popularity, but their efficacy remains to be critically examined. OBJECTIVES: To determine the effect of montelukast on pediatric OSA. METHODS: A prospective randomized double-blind controlled trial of polysomnographically diagnosed OSA in children ages 2-10 years who were treated with either oral montelukast (4 or 5 mg daily) or placebo for 16 weeks. Adherence to the medication was ascertained using automated timed pill dispensers along with weekly telephonic reminders. MEASUREMENTS AND MAIN RESULTS: Ninety-two children diagnosed with OSA were approached, and 64 (69.6%) agreed to participate. Of these, 57 (89.0%) completed the 16-week trial, 28 in the montelukast group and 29 in the placebo group. Age, sex, and percentage of obesity were similar in the two groups, as were initial apnea-hypopnea index (AHI) scores. Overall, intention-to-treat analyses revealed that beneficial effects occurred in 20 children receiving montelukast (71.4%), whereas only 2 (6.9%) of the children receiving placebo showed reductions in AHI score (P < 0.001). Indeed, AHI decreased from 9.2 ± 4.1/hour total sleep time (TST) to 4.2 ± 2.8/hour TST (P < 0.0001) in montelukast-treated children, whereas in children receiving placebo, the AHI did not change (from 8.2 ± 5.0/h TST before to 8.7 ± 4.9/h TST at completion of the trial). CONCLUSIONS: When compared with placebo, montelukast for 16 weeks effectively reduced the severity of obstructive sleep apnea in children 2-10 years of age. These results support a therapeutic role for leukotriene modifiers in pediatric OSA provided that long-term trials confirm current findings. Clinical trial registered with www.clinicaltrials.gov (NCT 00599534).

The relevance of tissue thiol histochemistry to diagnostic hematopathology.

Expression analyses suggest that alterations of the antioxidant state of some diffuse large B-cell lymphomas can assist prognosis; reversibly oxidized thiols may serve as a surrogate marker for identifying such cases. Little is known about the distribution of free thiols and reversibly oxidized thiols in human tissues. We developed a staining technique that enables visualization of tissue thiols in situ using bright field microscopy and validated it using gastrointestinal tissue specimens. We used our thiol staining technique to assess benign tonsillectomy and diffuse large B-cell lymphoma specimens. The gastrointestinal series revealed the presence of free thiols within epithelial cells and cells of the lamina propria. Staining for reversibly oxidized thiols was robust in gastric foveolar cells, intestinal goblet cells and the mucus they produce. Tonsillectomy specimens exhibited diffuse presence of free thiols. Staining for reversibly oxidized thiols was confined to germinal center macrophages and sinus histiocytes. Among the diffuse large B-cell lymphoma specimens, we observed strong staining for free thiols within malignant cells. By contrast to benign B-cells, the malignant cells demonstrated pronounced and diffuse staining for reversibly oxidized thiols. We demonstrated intrinsic differences between benign and malignant cells.

[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.

Pathophysiology of T follicular helper cells in humans and mice.

Follicular helper T cells (TFH cells) compose a heterogeneous subset of CD4(+) T cells that induce the differentiation of B cells into plasma cells and memory cells. They are found within and in proximity to germinal centers in secondary lymphoid organs, and their memory compartment also circulates in the blood. Our knowledge on the biology of TFH cells has increased significantly during the past decade, largely as a result of mouse studies. However, recent studies on human TFH cells isolated from lymphoid organ and blood samples and recent observations on the developmental mechanism of human TFH cells have revealed both similarities and differences between human and mouse TFH cells. Here we present the similarities and differences between mouse and human lymphoid organ-resident TFH cells and discuss the role of TFH cells in response to vaccines and in disease pathogenesis.

Evaluation of acoustic characteristics of snoring sounds obtained during drug-induced sleep endoscopy.

INTRODUCTION: Snoring sounds are discussed to contain acoustic information about their geneses. Nocturnal snoring can easily be recorded acoustically but it is difficult to visually verify its genesis. Contrary, snoring patterns induced by drug-induced sleep endoscopy (DISE) can be visually differentiated. The aim of the study was to classify patterns of obstructions and vibration during DISE and to evaluate acoustic characteristics between these different patterns of snoring. METHODS: DISE was performed in 41 male patients with sleep-disordered breathing. The recorded video sequences (n = 108) were classified visually at a mute mode in different patterns of snoring (velar, velar obstructive, tonsillar, post-apnoeic). The sound tracks of these subgroups were analysed and compared with regard to the parameters sound pressure level, loudness, sharpness, roughness, fluctuations strength and centre frequency. RESULTS: Obstructive snoring patterns revealed a higher loudness than non-obstructive patterns (>25 sone). Velar snoring showed more roughness (>150 cAsper) than tonsillar and post-apnoeic snoring and revealed the lowest centre frequency (<3000 Hz) of all patterns. Tonsillar snoring presented the highest sharpness (>1.6 acum) whereas post-apnoeic snoring revealed the largest fluctuation strength (>50 cVacil). CONCLUSION: Different snoring patterns induced by DISE can be classified visually, and an approach to differentiate them acoustically by means of psychoacoustic analyses is demonstrated. On the basis of these results, nocturnal snoring might also be differentiated by psychoacoustic algorithms which could be implemented in acoustic polygraphic screening devices in the future.

Feasibility of rapid discharge after transoral robotic surgery of the oropharynx.

OBJECTIVES/HYPOTHESIS: To investigate the use of an algorithm for rapid discharge after transoral robotic surgery (TORS) and its effect on postoperative complications. STUDY DESIGN: Retrospective cohort study. METHODS: A retrospective analysis of TORS cases from September 2009 to February 2013 was conducted. The effect of patient and tumor characteristics on postoperative length of stay (LOS) and complications were analyzed. RESULTS: A total of 91 patients were included; 79 underwent TORS for malignancy and 12 for a benign process. The mean LOS was 1.51 days (range, 1-5 days) with a median of 1 day. The mean time to initiation of oral diet was 1.26 days (range, 1-7 days) with a median of 1 day. Eleven (12%) patients experienced one or more complications during their postoperative course. Multivariate analysis demonstrated a significant association between patient and procedure variables and postoperative complications. TORS base of tongue reduction for obstructive sleep apnea (OSA) was associated with a significantly greater mean incremental time to initiation of oral diet (1.0 days, 95% confidence interval [CI]: 0.4 to 1.7, P < .001). A significantly greater mean incremental LOS was observed for patients with advanced comorbidity and a delay in initiation of oral diet beyond 24 hours. CONCLUSIONS: Rapid initiation of oral diet and rapid discharge home is feasible and not associated with postoperative complications. Similarly, the performance of a concurrent neck dissection does not contribute to LOS or the development of postoperative complications. Patients undergoing TORS for OSA are at greater risk of delay in initiation of oral diet and increased LOS. LEVEL OF EVIDENCE: 4