Tonsil Hyperplasia Research Articles

Long-term effect observation after 10 years of tonsillotomy （Histological analysis of one case of secondary operation）

Objective:To investigate the long-term effect of partial tonsillectomy in children with tonsil hypertrophy. Methods:A total of 146 children with obstructive sleep apnea（OSA） who received surgical treatment for tonsil hyperplasia from January 2010 to January 2013 were selected and divided into the observation group（n=69） and the control group（n=77）. The observation group was received tonsillotomy（TT）, and the control group was received total tonsillectomy（TE）. Parental satisfaction and OSA quality of life questionnaire for children（OSA-18） were surveyed. Residual tonsil size was measured, and polysomnography（PSG） was monitored after 10 years. HE and immunohistochemical analysis were performed on tonsil tissues of one patient who performed a second operation after TT in 2017 year. Results:The results of questionnaire survey showed that the symptoms of respiratory obstruction were significantly improved in both groups, and the satisfaction of TT group was higher than that in the TE group. No increase in the number of respiratory tract infections was observed in all patients. In the TT group, nine cases（13.04%） had tonsil hyperplasia toⅡ°, and the remaining patients had tonsil hyperplasia to Ⅰ°. In addition, one case hadtonsil suppurative infection at the 14th month after surgery, and no recurrence or reoperation was found after treatment. There were seven cases in the TT group and eight cases in the TE group with occasional snoring and mouth breathing after surgery, but the PSG examination of the patients did not meet the diagnosis of OSA. The main causes were obesity and allergic rhinitis. Compared with the first operation, the cicatricial obstruction and infection of tonsil tissue in the second operation were not significantly changed, and the immunohistochemical results also demonstrated that the expression of CD20 was not changed, and the expression of CD3 was decreased. Conclusion:Both TT and TE can effectively improve the symptoms of OSA obstruction in children. TT has less trauma, less postoperative pain, faster recovery and lower rate of hyperplasia, which can be used as one of the main methods for the treatment of tonsil hypertrophy in children.

A rare case of unilateral lymphoid papillary hyperplasia of tonsil in a nine-year-old girl

We report a rare case of lymphoid papillary hyperplasia of palatine tonsil in a 9-year-old girl. It is a rare benign pathology characterised by papillomatous appearance of palatine tonsil with reactive lymphoid hyperplasia. Early recognition of this lesion is important because in spite of clinical feature being suggestive of malignant tumour, it is a benign tumour-like proliferation, that can easily be cured by tonsillectomy.

Modern approaches to rational combination pharmacotherapy of allergic rhinitis

Allergic rhinitis (AR) can significantly reduce the quality of life of patients leading to increased fatigue, mood changes, cognitive impairment, and depression. In clinical practice, insufficient effectiveness of initial AR monotherapy is often noted, and a significant proportion of patients referring for medical care have moderate-severe AR. In this regard, the issues of optimization of combined pharmacological treatment of AR are becoming more and more urgent. This paper provides analysis of the opportunities of combined pharmacotherapy within the framework of current management strategy of AR. Based on the results of some studies and known pharmacological properties of medications it is being discussed the advantages of combined use of intranasal corticosteroids and leukotriene receptor antagonists, in particular mometasone furoate and montelukast, in the therapy of AR, including such comorbidities as bronchial asthma, chronic polyposis rhinosinusitis and pharyngeal tonsil hyperplasia. Some aspects of combination therapy with montelukast and second-generation systemic antihistamines as an alternative approach in case of inability to take intranasal corticosteroids, including the reasonability of using a fixed combination of montelukast and levocetirizine, are analyzed from the perspective of rational pharmacotherapy. The problem of interchangeability of brand-name and generic drugs for the treatment of AR is discussed, considering the almost complete absence of studies of their therapeutic equivalence.

Anatomic Features of the Nasal and Pharyngeal Region Do Not Influence PAP Therapy Response.

The objective of this study was to investigate to which extent anatomic features of the nasal and pharyngeal region contribute to the severity of obstructive sleep apnea (OSA) and positive airway pressure (PAP) therapy response. Therefore, 93 patients (mean age 57.5 ± 13.0 years, mean body mass index 32.2 ± 5.80 kg/m2, 75 males, 18 females) diagnosed with OSA who subsequently started PAP therapy were randomly selected from the databank of a sleep laboratory of a tertiary university medical center. Patients were subdivided based on nasal anatomy (septal deviation, turbinate hyperplasia, their combination, or none of the above), pharyngeal anatomy (webbing, tonsillar hyperplasia, their combination, or none of the above), and (as a separate group) tongue base anatomy (no tongue base hyperplasia or tongue base hyperplasia). Then, polysomnographic data (e.g., arousal index, ARI; respiratory disturbance index, RDI; apnea index, AI; hypopnea index, HI; and oxygen desaturation index, ODI) of diagnostic polysomnography (PSG) and PAP therapy control PSG were collected, grouped, and evaluated. Septal deviation, turbinate hyperplasia, or their combination did not significantly affect the assessed PSG parameters or the response to PAP therapy compared with patients without nasal obstruction (p > 0.05 for all parameters). Accordingly, most PSG parameters and the response to PAP therapy were not significantly affected by webbing, tonsil hyperplasia, or their combination compared with patients without pharyngeal obstruction (p > 0.05 for RDI, AI, HI, and ODI, respectively). However, in the pharyngeal anatomy group, ARI was significantly higher in patients with tonsil hyperplasia (p = 0.018). Further, patients with tongue base hyperplasia showed a significantly higher HI in the diagnostic PSG (p = 0.025) compared with patients with normal tongue base anatomy, but tongue base anatomy did not significantly affect the response to PAP therapy (p > 0.05 for all parameters). The influence of anatomic features of the nasal and pharyngeal region on PAP therapy response appears to be small, and generalizability of these results requires further studies.

Post-COVID syndrome in children and adolescents of a large industrial city

Background. About 30 to 80% of children who have had a new coronavirus infection, suffer from post-COVID syndrome, the manifestations of which are diverse and persist for 12 weeks or more. Post-COVID syndrome remains an urgent problem in pediatrics, the clinical variants of which are diverse. There is no statistically significant relationship between the severity of coronavirus infection and the development of post-COVID syndrome. According to current data, the risk group for post-COVID syndrome includes children under 1 year of age, children with comorbid pathology.
 Aim. To evaluate the frequency of development, clinical variants and course of post-COVID syndrome in children and teenager of a large industrial city in order to optimize recommendations for their rehabilitation after a new coronavirus infection.
 Materials and methods. The were analyzed developmental histories of 6252 children and adolescents in Kemerovo (form 112/y) who had a new coronavirus infection.
 Results. Data on post-COVID syndrome were recorded in the developmental histories of 3066 (49.04%) children and adolescents, analyzed by medical documents. At the age of 13–15 years, the incidence of post-COVID syndrome is 55%, which is statistically significantly higher than in other age groups (p=0.005–0.0001). The following clinical variants of post-COVID syndrome were identified: asthenic, respiratory, cardiac, recurrent ears, nose, and throat, functional gastrointestinal disorders and mixed, the frequency of which varies depending on age and gender. Children with comorbid pathology (iron deficiency anemia and grade I–II pharyngeal tonsil hypertrophy) are statistically significantly more likely to suffer from post-COVID syndrome (p=0.000000001; 0.00000009; 0.00000009) than children without a history of comorbid pathology.
 Conclusion. Post-COVID syndrome occurs in half of children and adolescents who have had a new coronavirus infection. The frequency of post-COVID syndrome variants in children and adolescents differs. The presence comorbid pathology (iron deficiency anemia, pharyngeal tonsil hyperplasia of the 2 degree) increases the risk of developing post-COVID syndrome. It is necessary to examine patients in a timely manner for the purpose of differential diagnosis and drawing up an individual rehabilitation plan. Special attention should be paid to children with comorbid pathology.

Correlation between Malocclusions, Tonsillar Grading and Mallampati Modified Scale: A Retrospective Observational Study.

to investigate the correlation between growth tendency and different patient malocclusion, tonsillar grading, and tongue size (Mallampati index). The sample is composed of 64 males and 40 females; patients aged between 6 and 16 years (median age 11 years, IQR 9-13) were included. The final sample is therefore 104 patients. After the first orthodontic visit, all the children underwent a collection of documentation (photographs, digital arch models, and X-rays). Patients were classified according to their malocclusion, palatal conformation, tonsillar grading, and Mallampati index. Group comparisons were performed using Fisher's test. A p-value less than 0.05 was considered statistically significant. The narrow palate was more frequent in those with Angle class III (p = 0.04), while the other variables considered (tonsillar grading, Mallampati, and lingual frenulum) were not significantly associated with dental class (p > 0.05). Furthermore, a different distribution of tonsillar grading was observed between subjects with normal palate and subjects with narrow palate, while no statistically significant association was found between the palatal shape and Mallampati index (p = 0.88). This study found that children with higher tonsillar grading had a higher prevalence of crossbite or narrow palate compared to other children at the same developmental stage. However, we did not observe any association between tonsil hyperplasia and the prevalence of class II malocclusion, anterior open bite, or patient divergence in this sample. Furthermore, no correlation was found between the Mallampati index and patients' dental class, narrow palate, or divergence in this study.

Effect of palatine tonsil hypertrophy on tongue posture and maxillofacial dentition: A pharyngeal airway computational fluid dynamics study

This study aimed to clarify the effect of palatine tonsil hypertrophy-induced ventilation obstruction on maxillofacial dentition morphology using computational fluid dynamics (CFD) to represent tongue posture and maxillofacial dentition three dimensionally. We analyzed data of 20 patients with tonsil hypertrophy (tonsil hypertrophy group (TG); 9.0 years old, seven boys) and a comparison group (CG) of 20 patients without tonsil hyperplasia (comparison group; 9.4 years old, 10 boys). Cone-beam computed tomography and CFD data were used to assess the effects of palatine tonsil hypertrophy on pharyngeal airway ventilation, tongue posture, and morphology of the maxillofacial dentition. The TG exhibited significantly greater depth, narrower width, smaller cross-sectional area of the pharyngeal airway, and narrower maxillary dental arch with Class II than the CG. Additionally, the tongue was positioned significantly more anteriorly and inferiorly in the TG than that in the CG. Our data suggest that hypertrophy of the palatine tonsils narrows the pharyngeal airway, resulting in a smaller cross-sectional area. Widening of the pharyngeal airway may occur due to compensatory anterior displacement of the tongue to prevent ventilation obstruction. This may decrease palatal support, disturbing the pressure balance of the maxillary molar region between the buccal and palatal sides and resulting in lateral undergrowth of the maxillary bone and narrowing of the maxillary dental arch.

Epidemiological Aspects and Antibiotics Susceptibility Patterns of Streptococcus pyogenes Isolated from Subjects with Tonsillitis, Sudan

Background: Globally, Streptococcus pharyngitis is a major public health challenge. The current study investigates the prevalence of Streptococcal pyogenes among children under 17 years old in ENT Kosti Teaching Hospital and examines the susceptibility of isolated S. pyogenes strains to commonly used antibiotics.Methods: A total of 384 throat swabs were obtained from children under the age of 17 who attended the Kosti Teaching Hospital between 2019 and 2021. Streptococcus pyogenes was isolated by conventional microbiology procedures. Each S. pyogenes strain was subjected to antibiotic susceptibility testing according to the CLSI guidelines.Results: Most participants of this study were females 219 (57%) and aged between 5 and 10 years 259 (67.4%). Out of the 384 participants, 134 (34.9%) and 255 (66.4%) suffered from lymphadenopathy and tonsil hyperplasia, respectively. Interestingly, lymphadenopathy and tonsil hyperplasia were more (P 0.05) in the 5–10 age group than those aged 11–16 years. Moreover, 41.4% of the participants were infected by a GAS sore throat. GAS sore throat is significantly associated with lymphadenopathy (AOR: 2.375, 95% CI: 1.479–3.815, P 0.000) and tonsil hyperplasia (AOR: 3.374, 95% CI: 1.939–5.874, P 0.000). Notably, males (AOR: 0.853, 95% CI: 0.549–1.325, P 0.479) and individuals aged 5–10 years (AOR: 0.867, 95% CI: 0.464–1.618, P 0.654) were less likely to have a GAS sore throat. In our study, all isolated strains were sensitive to penicillin. Clindamycin, azithromycin, and erythromycin resistance were observed in 7 (4.4%), 44 (27.7%), and 47 (29.6%) isolates, respectively.Conclusion: The study displayed the current situation of GAS sore throat in the White Nile state. Penicillin was found to be the effective drug to cure S. tonsillitis but a high rate of resistance to macrolides was noticed which is an alarming sign.

Hypertrophy of lingual tonsil following tonsillectomy and correlation with BMI

The hyperplasia of the lingual tonsil is a rare and at the same time potentially dangerous change in the area of the upper respiratory tract. The pathogenesis of the lingual tonsillar hyperplasia is still largely unknown. In this study, we investigated if there is a compensatory lingual tonsil hyperplasia after tonsillectomy. 300 patients were examined consecutively in the ENT clinic of the Hannover Medical School. In the context of indirect laryngoscopy, the lingual tonsil, the visibility of the larynx and its subregions were assessed according to a scheme. The data were then evaluated depending on the status of the palatal tonsils. In addition, the body mass index (BMI) was determined and compared with the results of laryngoscopy. Out of 300 patients, 89 (29.6%) were in condition after bilateral tonsillectomy. In the total population, a greatly enlarged lingual tonsil was only detectable in 14 cases (4.6%). Of these 14 patients, 4 had a history of tonsillectomy. In patients with severe lingual tonsil hyperplasia the mean BMI was 27.3 compared to 24.4 in patients with a normal lingual tonsil. In our population the incidence of severe lingual tonsil hyperplasia is 4.7%. We couldn't prove s a connection between a condition after tonsillectomy and compensatory lingual hyperplasia statistically. However, there was a significant relationship between BMI and lingual tonsil hyperplasia.

The Tonsil Lymphocyte Landscape in Pediatric Tonsil Hyperplasia and Obstructive Sleep Apnea.

Tonsil hyperplasia is the most common cause of pediatric obstructive sleep apnea (OSA). Despite the growing knowledge in tissue immunology of tonsils, the immunopathology driving tonsil hyperplasia and OSA remains unknown. Here we used multi-parametric flow cytometry to analyze the composition and phenotype of tonsillar innate lymphoid cells (ILCs), T cells, and B cells from pediatric patients with OSA, who had previous polysomnography. Unbiased clustering analysis was used to delineate and compare lymphocyte heterogeneity between two patient groups: children with small tonsils and moderate OSA (n = 6) or large tonsils and very severe OSA (n = 13). We detected disturbed ILC and B cell proportions in patients with large tonsils, characterized by an increase in the frequency of naïve CD27-CD21hi B cells and a relative reduction of ILCs. The enrichment of naïve B cells was not commensurate with elevated Ki67 expression, suggesting defective differentiation and/or migration rather than cellular proliferation to be the causative mechanism. Finally, yet importantly, we provide the flow cytometry data to be used as a resource for additional translational studies aimed at investigating the immunological mechanisms of pediatric tonsil hyperplasia and OSA.

Роль ендогенних антимікробних пептидів у бактеріальній колонізації носоглотки в дітей із гіперплазією ретроназальної мигдалини

Досліджено рівень антимікробних пептидів у сироватці крові 35 дітей з аденоїдитом, асоційованим із гіперплазією ретроназальної мигдалини. Установлено, що в дітей із гіперплазією ретроназальної мигдалини відбувається зниження вмісту в сироватці крові кателіцидину LL-37, сурфактантного білка SP-D, бактерицидного білка, що посилює проникність клітин, та підвищення рівня лактоферину. Доведено, що порушення продукції антимікробних пептидів є одним із патогенетичних факторів розвитку хронічного запалення в носоглотці при гіперплазії ретроназальної мигдалини в дітей. При цьому вираженість даних змін залежить від ступеня гіперплазії ретроназальної мигдалини та максимально проявляється при аденоїдних вегетаціях 3-го ступеня. Фактором компенсації, спрямованим на відновлення адекватної імунної реактивності в дітей із гіперплазією ретроназальної мигдалини, є розвиток гіперплазії піднебінних мигдалин, що необхідно враховувати при плануванні обсягу лікувальних заходів.

PALATİN TONSİL'İN EPİDERMOİD KİSTİ: RASTLANTISAL NADİR BİR DURUM VE LİTERATÜRÜN GÖZDEN GEÇİRİLMESİ

Epidermoid cysts are developmental lesions and may be seen in the head and neck area with an incidence rate of 2% as well as in different organs of the body. Epidermoid cysts are located in sublingual, submental, submandibular and buccal mucosa and rarely at tonsils in the head and neck area. They congenitally occur in fetal period or occur as an acquired lesion due to a trauma or implant after surgery. 
 In this case report, we will discuss the epidermoid cyst, a rare incidental finding developing at tonsils, in a 6-year-old boy with chronic tonsillitis with literature review. 
 In conclusion, tonsil hyperplasia may also be caused by cystic developments at the tonsils. It should clinically be kept in mind especially in differential diagnosis of malignancy in the asymmetry of tonsils. Tonsillectomy materials commonly used in routine medical practice should be histopathologically and carefully examined and other accompanying pathologies of chronic tonsillitis should also be considered

Association between the microbiomes of tonsil and saliva samples isolated from pediatric patients subjected to tonsillectomy for the treatment of tonsillar hyperplasia

Oral microbes have the capacity to spread throughout the gastrointestinal system and are strongly associated with multiple diseases. Given that tonsils are located between the oral cavity and the laryngopharynx at the gateway of the alimentary and respiratory tracts, tonsillar tissue may also be affected by microbiota from both the oral cavity (saliva) and the alimentary tract. Here, we analyzed the distribution and association of the microbial communities in the saliva and tonsils of Korean children subjected to tonsillectomy because of tonsil hyperplasia (n = 29). The microbiome profiles of saliva and tonsils were established via 16S rRNA gene sequencing. Based on the alpha diversity indices, the microbial communities of the two groups showed high similarities. According to Spearman’s ranking correlation analysis, the distribution of Treponema, the causative bacterium of periodontitis, in saliva and tonsils was found to have a significant positive correlation. Two representative microbes, Prevotella in saliva and Alloprevotella in tonsils, were negatively correlated, while Treponema 2 showed a strong positive correlation between saliva and tonsils. Taken together, strong similarities in the microbial communities of the tonsils and saliva are evident in terms of diversity and composition. The saliva microbiome is expected to significantly affect the tonsil microbiome. Furthermore, we suggest that our study creates an opportunity for tonsillar microbiome research to facilitate the development of novel microbiome-based therapeutic strategies.

Symptoms and parental expectation in adenoidectomy and adenotonsillotomy in preschool children

In this study, symptoms associated with adenoids and hyperplasic palatine tonsils and parental expectation of surgical outcome were recorded, to provide realistic parental information prior to adenoidectomy (AT) ± tonsillotomy (ATT). In total n = 111 children (3-6 years, ♂ 65 % ♀ 35 %) were recruited, who received AT (66 %) or ATT (34 %) at ENT University Hospital Ulm. By questionnaire-based survey, the most common symptoms and the main reason for the operation were reported from parent's perspective (operation day, follow-up: 3.5 months). Results were visualized in bar charts for total collective and AT and ATT surgical groups (significance level α = 5 %). Most commonly, parents observed signs of respiratory problems (mouth breathing 87 %, nasal obstruction 86 %, snoring 78 %), hearing loss (68 %) and infection of upper airways (66 %). Nasal obstruction (77.5 %) and hearing loss (53.2 %) were the main reasons for operation. In children with pharyngeal tonsil hyperplasia only, hearing problems dominated, while in additional tonsillotomy, nocturnal apneas were the most frequently reported reason for surgery. For all symptoms, a significant postoperatively improvement was achieved. With a differentiated indication for surgery, it is possible to inform the parents about a very good and realistic and effective reduction of symptom after AT and ATT.

Are computed tomography 3D measurements of the upper airways in mouth-breathing children in agreement with the ENT clinical diagnosis of obstruction?

IntroductionImaging studies have hystorically been used to support the clinical otorhinolaryngological evaluation of the upper respiratory tract for the diagnosis of obstructive causes of oral breathing. ObjectiveThe objective of this study was to compare 3D volumetric measurements of nasal cavity, nasopharynx and oropharynx of obstructed mouth-breathing children with measurements of non-obstructed mouth-breathing children. MethodsThis retrospective study included 25 mouth-breathing children aged 5–9 years evaluated by otorhinolaryngological clinical examination, flexible nasoendoscopy and full-head multi-slice computed tomography. Tomographic volumetric measurements and dichotomic otorhinolaryngological diagnosis (obstructed vs. non-obstructed) in three anatomical regions (the nasal cavity, nasopharynx and oropharynx) were compared and correlated. An independent sample t-test was used to assess the association between the 3D measurements of the upper airways and the otorhinolaryngological diagnosis of obstruction in the three anatomical regions. Inter- and intra-observer intraclass correlation coefficients were used to evaluate the reliability of the 3D measurements. ResultsThe intra-class correlation coefficients ranged from 0.97 to 0.99. An association was found between turbinate hypertrophy and nasal cavity volume reduction (p<0.05) and between adenoid hyperplasia and nasopharynx volume reduction (p<0.001). No association was found between palatine tonsil hyperplasia and oropharynx volume reduction. Conclusions(1) The nasal cavity volume was reduced when hypertrophic turbinates were diagnosed; (2) the nasopharynx was reduced when adenoid hyperplasia was diagnosed; and (3) the oropharynx volume of mouth-breathing children with tonsil hyperplasia was similar to that of non-obstructed mouth-breathing children. The adoption of the actual anatomy of the various compartments of the upper airway is an improvement to the evaluation method.

Comparison of three different adenoidectomy techniques in children - has the conventional technique been surpassed?

IntroductionPharyngeal tonsil hyperplasia is the most frequent cause of nasal obstruction and chronic mouth breathing during childhood. Adenoidectomy is the procedure of choice for the resolution of these symptoms. It is not yet known, however, whether the conventional technique (“blind curettage”) has been surpassed by more modern adenoidectomy techniques (video-assisted, with the aid of instruments). This study aimed to compare the conventional adenoidectomy technique with two other emerging techniques, performed in a reference otorhinolaryngology center. MethodsThis is a prospective and observational study of 33 children submitted to adenoidectomy using 3 different techniques that were followed up for a period of 3 months after surgery. The patients were divided into 3 different groups, according to the adenoidectomy technique: Group A (conventional technique - "blind curettage”); Group B (video-assisted adenoidectomy with microdebrider); Group C (video-assisted adenoidectomy with radiofrequency – Coblation®). The surgical time of each procedure was measured, being considered from the moment of insertion of the mouth gag until complete hemostasis was achieved. The questionnaire for quality of life OSA-18 was applied to all caregivers on the day of the surgery and 30–90 days after the procedure. Postoperative complications were also analyzed. ResultsFor the entire patient sample, there was an improvement in quality of life after the surgery (p < 0.05). When analyzing the evolution of OSA-18 index, all groups showed statistically significant improvement, for all assessed domains. There were no statistically significant differences between the 3 techniques assessed for quality of life improvement after the surgery (p > 0.05). Regarding the duration of the procedure, the conventional technique showed the shortest surgical time when compared to the others (p < 0.05). No postoperative complications were noted, for any patient. ConclusionsThe adenoidectomy resulted in improvement of quality of life, and there were no major postoperative complications, for all operated children, regardless of the technique used. The conventional technique was faster when compared to the more modern adenoidectomy techniques.

Prevalence of M75 Streptococcus pyogenes Strains Harboring slaA Gene in Patients Affected by Pediatric Obstructive Sleep Apnea Syndrome in Central Italy.

Recently we reported an association between pediatric obstructive sleep apnea syndrome (OSAS) and Group A streptococcus (GAS) sub-acute chronic tonsil colonization. We showed that GAS may contribute to tonsil hyperplasia via a streptolysin O (SLO)-dependent cysteinyl leukotrienes (CysLTs) production, which can trigger T and B cell proliferation. In the present study, we characterized the GAS strains isolated from pediatric OSAS patients in comparison with a panel of age and sex matched GAS strains unrelated to OSAS, but isolated in the same area and during the same period ranging from 2009 to 2013. We found that slaA gene, previously reported to be associated to CysLTs production pathway, was significantly associated to GAS OSAS strains. Moreover, the most numerous group (32%) of the GAS OSAS strains belonged to M75 type, and 6 out of 7 of these strains harbored the slaA gene. Multilocus Sequence Typing (MLST) experiments demonstrated that the clone emm75/ST49/ smeZ, slaA was associated to OSAS cases. In conclusion, we found an association between slaA gene and the GAS OSAS strains, and we showed that the clone emm75/ST49 harboring genes smeZ and slaA was exclusively isolated from patients affected by OSAS, thus suggesting that this genotype might be associated to the pathogenesis of OSAS, although further studies are needed to elucidate the possible role of SlaA in tonsil hypertrophy development.

Expression of CysLTR1 and 2 in Maturating Lymphocytes of Hyperplasic Tonsils Compared to Peripheral Cells in Children

Cysteinyl-leukotriene receptors 1 and 2 (CysLTR1 and 2) are related to allergic inflammatory responses. Recent studies demonstrated their role in lymphocyte division and maturation in the bone marrow. Few data are available about CysLTRs function in lymphocyte maturation in tonsils. The objectives of this study are to compare CysLTRs expression in peripheral blood lymphocytes with expression in maturating lymphocytes of hyperplasic tonsil and to check the influence of respiratory allergies in this process. Leukocytes of peripheral blood (PL) and hyperplasic tonsils of children were immunostained for CysLTR1, CysLTR2, CD3 (T cells), and CD19 (B cells) and read in flow cytometer. Lymphocyte of tonsils were divided in differentiating small cells (SC) and mitotic large cells (LC); percentage of B and T cells expressing CysLTRs was determined, and comparison was done using ANOVA and Tukey's tests. Data were analyzed as a whole and categorizing patients according the presence of allergies. Sixty children were enrolled in this study. There was a large expression of CysLTR1 and 2 in CD3+ LC, and such expression decreased progressively in SC and PL. In B cells, the highest expression of CysLTR1 and 2 was found in PL while SC showed the lowest and LC showed the intermediate expression. This pattern kept unchanged in groups of allergic and non-allergic individuals. CysLTRs seem to be involved in lymphocyte maturation that occurs in tonsils, without influence of allergies. New studies aiming the clinic treatment of tonsil hyperplasia must be targeted to the development of drugs capable of blocking both CysLTR1 and 2.

Combination of children’s pharyngeal tonsil hyperplasia and allergic rhinitis

The prevalence of adenoid hypertrophy and allergic rhinitis data based on the study of the overall medical examination of children in 2002 and the further monitoring of children in Russia in 2005-2009 (population study) are presented. The main principles of therapy are specified. Special attention has been paid to the use of Vibrocil combination drug among children, which contains antihistamine component Dimethindene, and decongestant Phenylephrine.

Difficult Laryngeal Mask Airway Placement.

To the Editor; Laryngeal mask airway (LMA), which consists of a silicone tube connected to a miniature silicone mask appropriate for the shape of hypopharynx and covers the larynx as a gasket, was developed in 1980s in the United Kingdom. It is frequently used both to avoid negative effects of endotracheal intubation by establishing direct connection with the airway of patient and to easily provide a more reliable airway as compared to the facial mask. It has particular importance in difficult airway management and cardiopulmonary resuscitation since it can be successfully placed even by inexperienced users. Gel is applied to the posterior surface of the mask and it is placed blindly into the airway by pushing towards hypopharynx while the head of the patient is in extension position. Herein, we present a case, in which LMA could not be placed despite several attempts and a mass tissue was detected in the hypopharynx during laryngoscopy performed subsequently. An 81-year-old, 70 kg male patient was scheduled for cystoscopy in the urology clinic. Preanaesthetic evaluation revealed no pathology or concomitant disease except for advanced age. He had previously undergone prostate surgery under spinal anaesthesia. His Mallampati score was 3 and he had a large tongue (Figure 1). As the procedure was anticipated to take a short time and the patient, who had a high Mallampati score, did not want to be awake during the procedure, LMA was preferred for airway management. Figure 1 Examination image for Mallampati score Induction of anaesthesia was made with propofol, fentanyl and rocuronium, the patient was easily ventilated with a face mask, and an attempt was made to place a size 5 standard LMA; but as the mask, which was pushed forward, came back, it was thought that the mask was large for the patient and the attempt was repeated using a size 4 mask. However, as this attempt was also unsuccessful, it was thought that silicone tip of the balloon was folded; thus, I-Gel (size 4), which is a supraglottic airway device without a cuff and stands more stable, was tried to be placed. However as size 4 I-Gel LMA was pushed forward and ventilation was initiated, a significant air leakage occurred, and considering that size 4 was small, we again tried using size 5. However, observing substantial amount of air leak at the end of all these attempts, LMA was planned to be placed under laryngoscopic guidance. Airway examination, which was performed by a Macintosh laryngoscope, revealed a 2×2 cm mass located at the base of the hypopharynx, covered by normal mucosa, and appeared to be neither cystic nor ulcerated (Figure 2). It was thought that the mass, which was located at the same place where LMA device was placed, caused the tip of standard LMAs to be folded or remain between the mass and pharyngeal tissue, and hindered I-Gel LMA to closely fit after being placed and caused leakage from the back of the device, and consequently the attempts were unsuccessful. The patient, of whom Cormack-Lehane score was 2, was then intubated by size 8 endotracheal tube. We encountered no problem during intraoperative period and the patient was extubated without problem at the end of the procedure that lasted for 45 minutes; he was recommended to refer to the ENT outpatient clinic. Meanwhile, consent of the patient was obtained for presenting his case as a case report. Figure 2 The appearance of the mass through the laryngoscope Unforeseen dangers might have been in question because of blindly placed LMA, in this patient who had a deeply localized asymptomatic lesion that could not be detected by routine airway examination. If this mass located in the hypopharynx, had been cystic, it would have been perforated during the attempts to place the LMA and would have led to serious consequences by the spread of cyst content into the lungs. Again, if it had been a vascular mass like a haemangioma, it would have been difficult to control the unexpected bleeding. Lingual tonsil hyperplasia, which is more common in paediatric cases, may lead to similar problems (1, 2). Although blind placement of LMA without using a laryngoscope is an advantage, it may turn into a disadvantage in complicated cases and may lead to various problems. In case of recurrent failure while placing a supraglottic device, an airway disorder, as well as common problems such as incompatibility between device and patient anatomy and folded balloon, should be considered and attempts should aim at performing non-traumatic interventions as much as possible without insisting on blind replacement.