Tonsillar Crypts Research Articles

A Case Report of Giant Tonsillolith

ABSTRACT Tonsilloliths, also known as tonsil stones or tonsillar calculi, are clusters of calcified material that form in the crypts of palatine tonsils. They are usually of small size. Large or giant tonsilloliths are rare. We report a case of giant tonsillolith in the right palatine tonsil and literature is reviewed. How to cite this article Gangaraj SS, Maruthi N. A Case Report of Giant Tonsillolith. Int J Otorhinolaryngol Clin 2013;5(2):100-101.

A Case Report of Giant Tonsillolith

ABSTRACT Tonsilloliths, also known as tonsil stones or tonsillar calculi, are clusters of calcified material that form in the crypts of palatine tonsils. They are usually of small size. Large or giant tonsilloliths are rare. We report a case of giant tonsillolith in the right palatine tonsil and literature is reviewed.

Tonsillolith: A polymicrobial biofilm

Tonsilloliths are rare concretions found in the tonsillar crypt.1 Tonsillolith occurs rarely in children compared to the adults.2 The size of tonsillolith ranges from visible size to pea size.3 Patients with tonsillolith had increased halitosis and also feel foreign body sensation.1,4 Tonsillolith is not just a stone but a living biofilm. Mechanism of tonsillolith formation is due to the bacteria forms a three-dimensional structure dormant bacteria being in the center to serve as a constant nidus of biofilm.5 However, the exact cause and the pathogenesis of tonsillolith are not yet completely defined. Hence, the present case with tonsillolith was studied and tonsillolith was analyzed by physical, chemical and microbiological methods.

PD-1:PD-L1(B7-H1) pathway in adaptive resistance: A novel mechanism for tumor immune escape in human papillomavirus-related head and neck cancers.

5506 Background: Human papillomavirus-associated head and neck squamous cell carcinomas (HPV-HNSCC) are associated with a strong host immune response. Despite ample tumor infiltrating lymphocytes (TILs), the cancer is able to persist and grow. Here, we provide evidence for an adaptive immune resistance mechanism mediated through the PD-1:PD-L1 pathway. Methods: We evaluated the peripheral blood and tumor infiltrating lymphocytes for PD-1 expression using flow cytometry in HPV-HNSCC patients. We evaluted PD-L1 expression within the tumors using immunohistochemistry. We performed functional assays evaluating IFN-gamma secretion of PD-1+ and PD-1(-) CD8+ T cells isolated from the tumor microenvironment of PD-L1+ and PD-L1(-) HPV-related head and neck cancers. Results: We found the majority of CD8+ TILs in HPV-HNSCC express the PD-1 co-inhibitory receptor. We report a striking association between expression of its ligand PD-L1 on tumor cells and tumor associated macrophages, and the presence of TILs. Interestingly, membranous PD-L1 staining on tumor cells and CD68+ antigen presenting cells was geographically localized to the periphery of tumor nests and juxtaposed to fronts of infiltrating T cells. Functional assays demonstrated that PD-1-dependent T cell inhibition required expression of PD-L1 in the tumor microenvironment. Finally, we report localized expression of PD-L1 in the deep crypts of normal tonsils, the site of HPV infection and origin of HPV-HNSCC. Conclusions: Our findings support the role of the PD-1:PD-L1 interaction in creating an immune-privileged site for initial viral infection and subsequently adaptive immune resistance once tumors are established and suggest a rationale for therapeutic blockade of this pathway in patients with HPV-HNSCC.

Giant tonsillolith - a rare cause of dysphagia.

Tonsilloliths are calcified concretions that originate within the palatal tonsil crypts. Moreover, development of these concretions into giant tonsilloliths is exceptionally uncommon. We present a 17-year-old female with a two-year history of increasing dysphagia, persistent oral cavity swelling and speech alteration. Clinical examination of the oral cavity revealed a large solid left tonsil with no obvious neck masses. Computer tomography demonstrated a well-defined, large calcified left tonsillar fossa mass of uncertain underlying cause. This patient subsequently underwent surgical excision for histology.

Tonsillolith- Presentation of Two Cases on Routine Clinical Examination

Tonsillolith is an uncommon dystrophic calcification as a result of chronic inflammation of the tonsils. Etiology for the formation of tonsillolith are multifactorial. Varying degrees of presentation of tonsilloliths are documented in the literature. Here we present two cases of clinically identified tonsilloliths which were asymptomatic and detected upon routine clinical examination. The aim of this paper is to enumerate the importance of examination of the tonsillar crypts and to make the general dentist aware of the presence of accumulations of such concretions in those crypts.

An Unusual Case of a Tonsillolith

Tonsilloliths are rare calcified concretions that develop in tonsillar crypts within the substance of the tonsil or around it. Large tonsilloliths can mimic many conditions including abscesses or neoplasms. Given the wide range of differentials, it is difficult to diagnose tonsilloliths unless there is a considered emphasis on thorough history taking, careful inspection and a detailed characterisation of the lesion through digital palpation. This may be further supplemented with investigations such as plain radiography and computer tomography. Here, we illustrate a case with risk factors of oropharyngeal cancer and a history of fish bone impaction in the throat that was initially diagnosed as a “tonsillar foreign body” which turned out eventually to be a large tonsillolith.

Evidence of a true pharyngeal tonsil in birds: a novel lymphoid organ in Dromaius novaehollandiae and Struthio camelus (Palaeognathae)

BackgroundTonsils are secondary lymphoid organs located in the naso- and oropharynx of most mammalian species. Most tonsils are characterised by crypts surrounded by dense lymphoid tissue. However, tonsils without crypts have also been recognised. Gut-associated lymphoid tissue (GALT), although not well-organised and lacking tonsillar crypts, is abundant in the avian oropharynx and has been referred to as the “pharyngeal tonsil”. In this context the pharyngeal folds present in the oropharynx of ratites have erroneously been named the pharyngeal tonsils. This study distinguishes between the different types and arrangements of lymphoid tissue in the pharyngeal region of D. novaehollandiae and S. camelus and demonstrates that both species possess a true pharyngeal tonsil which fits the classical definition of tonsils in mammals.ResultsThe pharyngeal tonsil (Tonsilla pharyngea) of D. novaehollandiae was located on the dorsal free surface of the pharyngeal folds and covered by a small caudo-lateral extension of the folds whereas in S. camelus the tonsil was similarly located on the dorsal surface of the pharyngeal folds but was positioned retropharyngeally and encapsulated by loose connective tissue. The pharyngeal tonsil in both species was composed of lymph nodules, inter-nodular lymphoid tissue, mucus glands, crypts and intervening connective tissue septa. In S. camelus a shallow tonsillar sinus was present. Aggregated lymph nodules and inter-nodular lymphoid tissue was associated with the mucus glands on the ventral surface of the pharyngeal folds in both species and represented the Lymphonoduli pharyngeales. Similar lymphoid tissue, but more densely packed and situated directly below the epithelium, was present on the dorsal, free surface of the pharyngeal folds and represented a small, non-follicular tonsil.ConclusionsThe follicular pharyngeal tonsils in D. novaehollandiae and S. camelus are distinct from the pharyngeal folds in these species and perfectly fit the classical mammalian definition of pharyngeal tonsils. The presence of a true pharyngeal tonsil differentiates these two ratite species from other known avian species where similar structures have not been described. The pharyngeal tonsils in these ratites may pose a suitable and easily accessible site for immune response surveillance as indicated by swelling and inflammation of the tonsillar tissue and pharyngeal folds. This would be facilitated by the fact that the heads of these commercially slaughtered ratites are discarded, thus sampling at these sites would not result in financial losses.

Actinomycotic Brain Abscess and Subdural Empyema of Odontogenic Origin: Case Report and Review of the Literature

Actinomyces are gram-positive, nonacid-fast, branching filamentous prokaryotic microorganisms with anaerobic or microaerophilic requirements.1-5 Actinomyces species are part of the normal flora of the oropharyngeal cavity, specifically concentrated in the tonsillar crypts, the surface of carious teeth, and the gingival pocket.4,6 Actinomycosis is rarely a pathologic concern because of the organism's low virulence and does not appear to be an opportunistic disease because there is no specific predisposition toward immunocompromised individuals.

Associations between Oral HPV16 Infection and Cytopathology: Evaluation of an Oropharyngeal “Pap-Test Equivalent” in High-Risk Populations

Human papillomavirus (HPV) is responsible for the rising incidence of oropharyngeal squamous cell cancers (OSCC) in the United States, and yet, no screening strategies have been evaluated. Secondary prevention by means of HPV detection and cervical cytology has led to a decline in cervical cancer incidence in the United States. Here, we explored an analogous strategy by evaluating associations between HPV16 infection, cytopathology, and histopathology in two populations at elevated risk for OSCCs. In the first, a cross-sectional study population (PAP1), cytology specimens were collected by means of brush biopsy from patients presenting with oropharyngeal abnormalities. In the second (PAP2), a nested case-control study, bilateral tonsillar cytology samples were collected at 12-month intervals from HIV-infected individuals. The presence of cytopathologic abnormality in HPV16-positive tonsil brush biopsies (cases) was compared with HPV16-negative samples (controls) matched on age and gender. HPV16 was detected in samples by consensus primer PCR and/or type-specific PCR. Univariate logistic regression was used to evaluate associations. In PAP1, HPV16 alone (OR: 6.1, 95% CI: 1.6-22.7) or in combination with abnormal cytology (OR: 20, 95% CI: 4.2-95.4) was associated with OSCC. In PAP2, 4.7% (72 of 1,524) of tonsillar cytology specimens from HIV-infected individuals without oropharyngeal abnormalities were HPV16 positive. Tonsillar HPV16 infection was not associated with atypical squamous cells of unknown significance (ASCUS), the only cytologic abnormality identified. Therefore, HPV16 was associated with OSCCs among individuals with accessible oropharyngeal lesions but not with cytologic evidence of dysplasia among high-risk individuals without such lesions. An oropharyngeal Pap-test equivalent may not be feasible, likely due to limitations in sampling the relevant tonsillar crypt epithelium.

Small Lymphocytic Lymphoma Obscuring Microscopic Tonsillar Squamous Cell Carcinoma: an Unknown Occurrence with a Known Primary

Head and neck squamous cell carcinoma (HNSCC) often presents with cervical lymph node metastases and at times the primary tumor cannot be identified despite extensive workup. Lymphoma is the second most common neoplasm in the head and neck region but is seldom synchronous with HNSCC and rarely involves regional mucosal sites. We report herein a rare occurrence of tonsillar involvement by small lymphocytic lymphoma (SLL) incidentally detected during the workup for a cervical lymph node SCC metastasis of a 52-year-old non-smoker male. The microscopic human papillomavirus-positive SCC involving the tonsillar surface and crypts was obscured by SLL leading to the initial designation of 'unknown primary'. The occult HNSCC are likely explained by small tumor size, quality and quantity of sampling, thoroughness of endoscopic, radiological and pathological assessment or a combination of the above. The coexistence of another tumor such as lymphoma has not yet been reported as a confounding factor in the workup for cervical SCC metastasis. Since oropharyngeal SCC can be very small and Waldeyer's ring is a common site for lymphoma involvement, identification of such rare collision tumors requires pathologists' awareness, extensive sampling and occasionally ancillary studies for the accurate diagnosis and staging essential for the correct management.

Tonsillar Crypts and Bacterial Invasion of Tonsils: A Pilot Study

Objective: To investigate histologically if a lack of protection of the deep lymphoid tissue in tonsillar crypts by an intact epithelial covering is an aetiological factor for tonsillitis. Method: A prospective histological study of the tonsillar crypt epithelium by immunostaining for cytokeratin in 34 consecutive patients undergoing tonsillectomy either for tonsillitis or tonsillar hypertrophy without infection (17 patients in each group). Results: Discontinuity in the epithelium was found in 70.6% of the groups of patients with tonsillitis and in 35.3% of the groups of patients with tonsillar hypertrophy. This is of borderline significance. Conclusion: We found no clear correlation between tonsillitis and a defect in the tonsillar crypt epithelium. Tonsillitis might be due to immunological differences of subjects rather than a lack of integrity of the crypt epithelium. Further study with larger sample size and normal control is suggested.

Coccoid Helicobacter pylori exists in the palatine tonsils of patients with IgA nephropathy

Helicobacter pylori infection is acquired by oral ingestion. H. pylori has been reported to be present in the palatine tonsils. To clarify the route and mode of infection, the prevalence of tonsillar H. pylori was evaluated, and an attempt was made to culture tonsillar H. pylori. In a prospective study, 55 patients with recurrent pharyngotonsillitis or IgA nephropathy underwent a tonsillectomy. The carbon 13-urea breath test and enzyme-linked immunosorbent assay for the detection of H. pylori IgG antibodies in the serum were performed. Tonsillar H. pylori was cultured under conventional culture conditions for gastric H. pylori with or without the following shock methods; heat shock, hydrogen-peroxide-degrading compounds, or parasitizing amoebae. Immunofluorescence and immunoelectron microscopy using antibodies against H. pylori and cytotoxin-associated antigen A were used to identify tonsillar H. pylori. H. pylori in the coccoid form was present in tonsillar crypts. Of 55 patients, 43 (78.2%) had tonsillar H. pylori, and 15 (27.3%) were infected with gastric H. pylori. All patients with gastric H. pylori also had tonsillar H. pylori (p < 0.01). Cytotoxin-associated antigen A was observed in 38 (88.4%) of 43 tonsillar H. pylori. Tonsillar H. pylori could not be cultured in any culture conditions. All patients with IgA nephropathy had tonsillar H. pylori (p < 0.01). The present research might provide some insight into clarifying the route and mode of H. pylori infection. Our findings may indicate that tonsillar H. pylori is one of the antigens causative of IgAN.

Prevalence, Morphology, and Prognosis of Human Papillomavirus in Tonsillar Cancer

We sought to identify the prevalence of human papillomavirus (HPV) in tonsillar squamous cell carcinoma, and to examine the relationship of HPV to prognosis and tumor morphology. We performed in situ hybridization for HPV and retrospective clinical outcome analysis. Of the 48 patients with tonsillar carcinoma, in situ hybridization identified 35% as HPV-positive tumors. Age-matched controls had no evidence of HPV. There was no significant difference between HPV-positive and HPV-negative patients regarding age (p = 0.34), tobacco consumption (p = 0.59), alcohol consumption (p = 0.91), or treatment method (p = 0.39). Forty-four patients were eligible for outcome analysis. The overall rate of recurrence in this population was 25%, and the disease-specific survival rate was 84%. There was no significant difference between the two groups either in the incidence of recurrence (p = 0.14) or in the disease-specific survival rate (p = 0.19). HPV-associated tumors developed from the tonsillar crypts significantly more frequently than did HPV-negative tumors (p = 0.01). As previously described, HPV is significantly associated with squamous cell carcinoma of the tonsil; however, HPV status in our series did not correlate with clinical outcome. Morphologically, we found that HPV-positive tumors had their origin in the tonsillar crypts, whereas HPV-negative tumors arose from the surface epithelium.

The Microanatomy of the Palatine Tonsils of the One‐Humped Camel (Camelus dromedarius)

Tonsils form a first line of defense against foreign antigens and are also a route of entry and a replication site for some pathogens. The palatine tonsils are the largest of all the tonsils. Despite their general importance, little is known about the microanatomy of the palatine tonsils of the one-humped camel. Palatine tonsils of 10 clinically healthy male camels were obtained directly after slaughtering for human consumption. The tonsils were examined macroscopically and by light, scanning, and transmission electron microscopy. Palatine tonsils had the unique form of several spherical macroscopic nodules protruding into the pharyngeal lumen. These spherical masses were numerous and close together in the lateral oropharyngeal wall, with a few solitary nodules in the dorsal wall. Each nodule had one or two apical openings to crypts, and was enclosed by an incomplete connective tissue capsule and covered apically with stratified squamous keratinized epithelium. The tonsillar crypt was lined with stratified squamous non keratinized epithelium. Several lymphocytes infiltrated the epithelial layer, forming patches of reticular epithelium. Lymphoid follicles with obvious germinal centers extended under the epithelial surface. Diffusely localized lymphocytes were seen in the interfollicular region. High endothelial venules, dendritic cells, macrophages, and plasma cells were observed among these lymphocytes. The unique arrangement of palatine tonsils in separate units with individual crypts results in a very large surface exposed to antigen and indicates a significant immunological role of palatine tonsils in the camel.

Detecção do vírus Epstein-Barr em tonsilites recorrentes

As tonsilites recorrentes têm sido objeto de muitos estudos. Eventos considerados na predisposição e causa incluem a utilização errônea de antibióticos em crises agudas, alterações da microflora, mudanças estruturais nas criptas epiteliais tonsilares e infecções virais. A infecção pelo vírus Epstein-Barr (EBV) ocorre freqüentemente na infância persistindo em linfócitos de tonsilas, podendo causar tonsilites recorrentes. Pouco se conhece sobre a persistência e reativação do EBV em pacientes imunocompetentes. Alguns métodos como a hibridização in situ, a reação em cadeia da polimerase (PCR) e a imuno-histoquímica têm sido utilizados no estudo da patogenia do vírus. OBJETIVO: Para caracterizar a associação do vírus Epstein-Barr com tonsilites recorrentes examinamos a presença do EBV pela PCR e por imuno-histoquímica usando como alvo a proteína viral LMP-1. FORMA DE ESTUDO: Estudo transversal com análise de prevalência amostral. MATERIAL E MÉTODOS: Foram selecionados 24 blocos parafinados de tonsilas, provenientes do Serviço de Anatomia Patológica, removidas de crianças de 2 a 12 anos com diagnóstico de tonsilite recorrente. Resultados: O genoma do EBV foi detectado em 13 (54,1%) e a LMP-1 em 9 (37,5%) dos casos. CONCLUSÃO: As tonsilas das crianças podem ser colonizadas pelo EBV e este pode estar associado à patogenia das tonsilites recorrentes.

Recurrent tonsillitis and tonsillectomy in juvenile idiopathic arthritis

Objectives: To compare the clinical and bacteriological features of recurrent tonsillitis between patients with and without juvenile idiopathic arthritis (JIA).Methods: A total of 122 participants, aged 2-18 years, were consecutively recruited into four groups: (i) JIA and recurrent tonsillitis; (ii) JIA; (iii) recurrent tonsillitis; and (iv) healthy. All the patients with recurrent tonsillitis underwent tonsillectomy. Swabs from tonsillar surface crypts of all children and samples from tonsillar core tissue in case of tonsillectomy were processed for culturing. Mycoplasma pneumoniae was determined by polymerase chain reaction (PCR).Results: Significantly lower rates of recurrences but more frequent tonsillar detritus, paratonsillar scars, and more intensive bleeding during tonsillectomy were found in patients with JIA and recurrent tonsillitis, versus patients with recurrent tonsillitis without arthritis. In JIA patients with recurrent tonsillitis, Staphylococcus aureus was cultured from the tonsillar surface in 36%, and from the core tissue in 92% of cases (p = 0.0000). In patients suffering from recurrent tonsillitis alone, this pathogen was cultured from the core in 55.9% of cases (p = 0.0066 compared to JIA patients with recurrent tonsillitis). No M. pneumoniae was revealed by PCR in samples from the tonsillar surface and the core tissue.Conclusions: The increased rate of S. aureus in the core tissue of tonsils, the higher frequency of tonsillar detritus, the more pronounced paratonsillar scarring, and more intensive bleeding during tonsillectomy, associated with the lower frequency of tonsillitis recurrences, are characteristic for recurrent tonsillitis in JIA as compared to recurrent tonsillitis without arthritis.

Detection of Epstein-Barr virus in recurrent tonsillitis

SummaryRecurrent tonsillitis has been the subject of frequent investigation. Misuse of antibiotic therapy in acute tonsillitis, changes to the tonsillar microflora, structural changes to the tonsillar crypts, and viral infections have been listed as predisposing or causal factors for recurrent tonsillitis. Epstein-Barr virus (EBV) infection usually occurs in early childhood and may persist in tonsillar lymphocytes, thus leading to the onset of recurrent tonsillitis. Little is known about the persistence and reactivation of EBV strains in immunocompetent patients. Methods such as in situ hybridization, polymerase chain reaction (PCR), and immunochemistry have been used to study the pathogenesis of the EBV. Aim: this study aims to characterize the association between EBV and recurrent tonsillitis by investigating the presence of EBV through PCR and immunohistochemistry, using viral protein LMP-1 as a target. Study design: this is a cross-sectional study with analysis of sample prevalence. Materials and method: twenty-four paraffin-embedded tonsil specimens from the Pathology Service were selected. The specimens were removed from children aged between 2 and 12 years diagnosed with recurrent tonsillitis. Results: EBV genome was detected in 13 (54.1%) specimens, whereas viral protein LMP-1 was found in 9 (37.5%) specimens. Conclusion: children’s tonsils can be colonized by EBV and such colonies may be associated with the pathogenesis of recurrent tonsillitis.

Tonsillar crypts and bacterial invasion of tonsils, a pilot study

Objective: To investigate histologically if a lack of protection of the deep lymphoid tissue in tonsillar crypts by an intact epithelial covering is an aetiological factor for tonsillitis. Method: A prospective histological study of the tonsillar crypt epithelium by immunostaining for cytokeratin in 34 consecutive patients undergoing tonsillectomy either for tonsillitis or tonsillar hypertrophy without infection (17 patients in each group). Results: Discontinuity in the epithelium was found in 70.6% of the groups of patients with tonsillitis and in 35.3% of the groups of patients with tonsillar hypertrophy. This is of borderline significance. Conclusion: We found no clear correlation between tonsillitis and a defect in the tonsillar crypt epithelium. Tonsillitis might be due to immunological differences of subjects rather than a lack of integrity of the crypt epithelium. Further study with larger sample size and normal control is suggested.

Early pathogenesis of equineStreptococcus equiinfection (strangles)

Little is known about entry and subsequent multiplication of Streptococcus equi following exposure of a susceptible horse. This information would have value in design of intranasal vaccines and understanding of shedding and protective immune responses. To determine entry points and sites of subsequent replication and dispersion of S. equi at different times after intranasal infection or commingling exposure. Previously unexposed horses and ponies were subjected to euthanasia 1, 3, 20 or 48 h following intranasal inoculation with biotin labelled or unlabelled S. equi CF32. Some ponies were inoculated with suspensions of equal numbers of CF32 and its mutants lacking capsule, S. equi M-like protein or streptolysin S. Others were infected by commingling exposure and subjected to euthanasia after onset of fever. Tonsils and lymph nodes were cultured for S. equi and tissues sectioned for histopathological examination and fluorescent microscopy. Tonsillar tissues of both the oro- and nasopharynx served as portals of entry. Entry was unexpectedly rapid but involved few bacteria. Small numbers of organisms were detected in tonsillar crypts, in adjacent subepithelial follicular tissue and draining lymph nodes 3 h after inoculation. By 48 h, clumps of S. equi were visible in the lamina propria. At onset of fever, tonsillar tissues and one or more mandibular and retropharyngeal lymph nodes were heavily infiltrated by neutrophils and long chains of extracellular S. equi. Mutant S. equi lacking virulence factors were not seen in draining lymph nodes. Although very small numbers of S. equi entered the lingual and nasopharyngeal tonsils, carriage to regional lymph nodes occurred within hours of inoculation. This observation, together with visual evidence of intracellular and extracellular multiplication of S. equi in tonsillar lymphoid tissue and lymph nodes over the following days, indicates involvement of potent antiphagocytic activity and failure of innate immune defences. Future research should logically address the tonsillar immune mechanisms involved including identification of effector cell(s) and antigens.