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Medicine Science
ORIGINAL RESEARCH International
Medical Journal

Medicine Science 2019;8(3):732-5

Prevalence of atopy in children with hypertrophic tonsil and recurrent/chronic tonsillitis

Mustafa Altintas

Serik State Hospital, Clinic of Otolaryngology Head and Neck Surgery Antalya Turkey

Received 10 May 2019; Accepted 06 July 2019

Available online 12.2019 with doi:10.5455/medscience.2019.08.9078

Copyright © 2019 by authors and Medicine Science Publishing Inc.

Abstract
The incidence of allergic diseases is increasing every day. Many studies have been conducted to investigate the relationship between many diseases and the presence of
atopy. However, there is not enough publication about the presence of atopy and a similar relationship between tonsil diseases. The aim of this study was to determine
how hypertrophic, recurrent / chronic tonsils are affected by the presence of atopy. Study was conducted by produced from the thesis of Atopy Prevalence in Hypertrophic
Tonsil and Recurrent / Chronic Tonsillitis Children. This study was carried out in Azerbaijan, Neriman Nerimanov Medical University, Department of Ear-Nose-Throat, on
the children under the age of 15 years (minimum 2, largest 15 years, mean age 6.3). Tonsillectomy was diagnosed as recurrent / chronic tonsillitis or tonsillar hypertrophy
and the first 50 patients were included in the study group and discussed with the literature. In our study, the presence of atopy in 50 children between the ages of 2-15 with
tonsillar hypertrophy and recurrent / chronic tonsillitis was investigated. In 27 patients with advanced hypertrophic tendencies 7 (25.9%), in 23 patients with recurrent /
chronic tonsillitis, atopy was detected in 1 (4.3%) and the difference was statistically significant. Serum total IgE levels were higher in patients with hypertrophic tonsil
than patients with recurrent / chronic tonsillitis. This difference seems to be related to the high atopy rate seen in the hypertrophic tonsil group. As a result of these
evaluations, it can be predicted that atopic patients may have hypertrophy in tonsils and atopy may be present in patients with tonsillar hypertrophy. Thus, tonsils may be
one of the allergic organs such as lower respiratory tract, nose, skin, eye.

Keywords: Hypertrophic tonsil, recurrent-chronic tonsillitis, atopy

Introduction prevalence of atopy in children with tonsillar hypertrophy with the

prevalence of atopy in children with recurrent / chronic tonsillitis,
The first line of defence against microorganisms in the respiratory to evaluate the results clinically and to draw attention to allergy
tract is adenoid and tonsils. They originated from lymphoid tissues. and allergic diseases that are one of the most important problems
Tonsils and adenoids, together with mucosal lymphoid tissues, are of today [7]. The fact that medical treatment was not successful
important in the production of secretory immunoglobulins [1,2]. enough in patients with hypertrophic tonsil or chronic tonsillitis,
Most of the antigenic substances enter the body via this route, different treatment results in each patient, frequent recurrences and
therefore, the role of this region in the immune system is crucial. lack of aetiology was thought to be related to atopy and led us to
Severe hypertrophic tonsils cause disorders such as chronic conduct this research..
persistent otitis media with effusion, upper airway obstruction,
and chronic sinusitis. IgE-mediated type I hypersensitivity Material and Methods
reactions have been implicated in both sinusitis and otitis media
with effusion [3, 4]. However, there is not enough data about the This study was produced from the thesis of Mustafa Altıntaş
role and frequency of allergic reactions in tonsil disorders. In titled “Prevalence of Atopy in Children with Hypertrophic Tonsil
the few publications we have found in the literature, conflicting and Recurrent / Chronic Tonsillitis” at Neriman Nerimanov
results have been reported about the relationship between tonsil Medical University, Ear-Nose-Throat Department, Azerbaijan.
diseases and allergy [5, 6]. The aim of this study is to compare the Tonsillectomy was performed on a total of 50 patients (22 girls,
28 men) under the age of 15 years (minimum 2 and maximum
15 years old, mean = 6.3 years). Tonsillectomy was diagnosed as
recurrent / chronic tonsillitis or tonsillar hypertrophy and the first
*Coresponding Author: Mustafa Altintas, Serik State Hospital, Clinic of 50 patients were included in the study group and discussed with
Otolaryngology Head and Neck Surgery Antalya Turkey
E-mail: dr_altintas@yahoo.com
the literature. Ear, nose and throat examinations of the children

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were performed before the operation in the Ear-Nose-Throat Results

Clinic and the children who had recurrent / chronic tonsillitis
and tonsillar hypertrophy were included in the study. Distinction The number of patients included in the study with diagnoses of
between recurrent / chronic tonsillitis and tonsillar hypertrophy in hypertrophic tonsil and recurrent / chronic tonsillitis was 50.
all children was made by the same team physicians. Twenty-seven of these patients had hypertrophic tonsil (54%) and
23 had recurrent / chronic tonsillitis (46%). Skin tests revealed
The inclusion criteria in patients with hypertrophic tonsil: atopy in 8 of 50 children (16%).). Atopy was detected in 7
(25.9%) of 27 children with hypertrophic tonsil and in 1 (23%)
1. Tonsils to be +3 and +4 in size of 23 children with recurrent / chronic tonsillitis (Table 1). The
2. Difficulty swallowing tonsils difference between the two groups was statistically significant in
terms of the presence of atopy (Table 2). Fisher’s Exact Chi-square
Inclusion criteria in patients with recurrent / chronic tonsillitis: test was used for statistical evaluation and p value was found as
0.035 (p<0.05).
1. Despite repeated medical treatment, there are recurrent attacks
of tonsillitis. As a result of the study, there was a correlation between the degree
2. Had more than 7 tonsillitis attacks in the last one year or 5 of hypertrophy and the presence of atopy. Atopy was detected in 3
tonsillitis attacks every year in the last two years, or 3 attacks of 5 children with hypertrophic tonsils with the size of +4 (60%)
every year in the last three years. and in 4 of 22 children with hypertrophy of +3 size (18.1%). When
3. Having systemic disease due to streptococcal tonsillitis children whose tonsils were between +3 and +4 were compared
4. Chronic - intermittent sore throat that cannot be attributed to with the presence of atopy, the difference was statistically
another cause. significant (p <0.05). As the degree of hypertrophy increased,
5. Tonsillitis-induced febrile seizure. incidence of atopy tended to increase.
6. Tonsillitis-associated abscessed cervical adenopathy.
7. Halitosis due to debris in the tonsils.
Table 1. Comparison of the presence of atopy and tonsil size
8. The history of peritonsillar abscess.
9. Presence of peritonsillar hyperaemia-congestion, presence of Atopy
Total
tonsillolith. Present Absent
+3 4 (18.1 %) 18 (81.8 %) 22 (44 %)
Children with both hypertrophic and recurrent / chronic tonsillitis
were included in the hypertrophic tonsil group. Medical treatment Degree of hypertrophy +4 3 (60 %) 2 (40 %) 5 (10 %)
was given to children with acute tonsillitis and their surgery was
0 1 (4.3 %) 22 (95.6 %) 23 (46 %)
postponed. During their evaluation in the ENT department, the
history of the presence of atopy or atopic family history from Total 8 (16 %) 42 (84 %) 50 (100.0 %)
children and their families were not obtained and therefore, ENT
physician was blinded to the presence of atopy. Routine tests
Table 2. Allergy test results of hypertrophic tonsil and recurrent / chronic
(haemoglobin, white blood cell, platelet counts, prothrombin tonsillitis groups
time, thromboplastin time, lung radiography, complete urinalysis)
and total IgE measurements were obtained for preoperative Allergy test
preparation during the preoperative period. Paediatric consultation Total
Atopy Atopy
was requested for evaluation from the Paediatrics Department absent present
and a consultation was requested from the Anaesthesiology Hypertrophic Number 20 7 27
and Reanimation Department for local anaesthesia. While the Tonsil % 74.0% 25.9 % 100.0 %
consultation was requested, the patient was informed about Diagnosis
Recurrent / Number 22 1 23
that they will undergo tonsillectomy, but no information was chronic
given about the tonsillar morphology. Fifteen minutes after the Tonsillitis % 95.6 % 4.3% 100.0 %
epidermal and intradermal application of allergens to the skin, Number 42 8 50
induration and redness bigger than 3 mm of the negative control Total
% 84 % 16 % 100.0 %
group were considered to be a positive. Both the prick test and
the intradermal test were positive in the patients whom we
Discussion
considered as positive. This shows a high degree of sensitivity.
Allergen groups used were various meadows species, tree pollen, The first defence against the antigen is conducted by the mucus
house dust, mites, fungi, various types of foods and animal hairs. layer covering the mucosal surfaces in the upper respiratory tract.
Skin tests were performed at least 10 days washout period after Secretory immunoglobulins in the mucus form the basis of this
discontinuation of antihistaminic drugs. As an exception, patients defence. The production of secretory immunoglobulins takes
receiving astemizole were not included in the study. Because place in mucosal lymphoid tissues, periglandular lymphoid tissue,
this antihistamine is excreted from the body after 3-6 weeks. All tonsils and adenoids [8,9]. The second defence barrier against the
operations were performed under local anaesthesia. Dissection antigen is the mucosa. Mucosal lymphoid tissue and its drained
/ snare technique was used during tonsillectomy operations. All lymph nodes are the areas responsible for immune response. In the
tonsillectomy specimens were sent to the pathology department in upper respiratory tract, the tonsils and adenoids act as a mucosal
physiologic saline solution. lymphoid tissue. Tonsils and adenoids are located at the entrance of

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the respiratory tract and gastrointestinal tract and are the lymphoid There was a difference in serum total lgE levels between the
organs responsible for local immunity. For this reason, the first two groups. Serum IgE levels were found to be high in children
contact of the immune system with various antigenic substances with hypertrophic tonsils and while lower values were found in
in the microorganisms, foods and inhaled air occurs in this region the other group. The presence of atopy between the two groups
[10,11]. and the difference in serum total IgE levels suggest that there
is a relationship between the presence of atopy and tonsillar
In 1982, Ostergaard et al. [12] found plasma cells bearing IgE hypertrophy [19,20]. Allergens abundantly present in nature do
in 9 of 30 (30%) tonsillectomy specimens of 28 children with antigenic stimulation in allergic individuals. As a result, other
chronic tonsillitis. 27 of these children were followed for 8 years. B lymphocytes, together with the increasing number of IgE-
While three of the children were Alteman et al. [13] conducted producing plasma cells, cause growth in tonsil size with mechanical
tonsillectomy and adenoidectomy due to various reasons on 153 effect. Tissue edema in tonsil hypertrophy is also present in atopic
children with previously known allergies- In the pathological children Edema and paleness in the mucous membranes are one
examination of the tonsil and adenoid specimens, tissue edema was of the allergic manifestations [21,22]. Eosinophils can be seen in
detected in the submucosal corium layer, and edema in the adenoid nasal smears, in serum, allergic rhinitis and nonallergic seasonal
tissue was found to be higher than the edema in the tonsils. It has rhinitis, but are not primarily responsible for allergy. The serum
been suggested that this edema can be reduced by antihistamine total eosinophil count increases after 4-11 hours after exposure
treatment in their study, Ramadan et al. [14] investigated the to the allergen. Eosinophils are thought to migrate to the allergy
relationship between adenotonsillar disease and allergy in 108 region by responding the eosinophil chemotactic factor secreted
children and 59 control cases who underwent tonsillectomy. The by mast cells and basophils, phagocyte the damaged tissue, and
frequency of allergy (21%) in the adenotonsillectomy group due inactivate the heparin and histamine released from basophil and
to hypertrophy or chronic / recurrent infection was not different mast cells [23].
from the frequency of allergy in the control group (20%). Vinke
et al. [15], in their study, have found that adenoid tissue plays an Conclusions
active role in the pathogenesis of allergic reactions. In comparison
of the adenoidectomy specimens of 16 allergic and 16 nonallergic In conclusion, children with hypertrophic tonsil should be
adenoidectomy children, helper T lymphocytes, cytotoxic T evaluated for the presence of atopy, in other words, it should be
lymphocytes, macrophages, chymase, tryptase, IgE, major basic kept in mind that atopy-dependent tonsil hypertrophy can be found
proteins and IL-4-bearing cells did not differ between the two in a child having an atopic physiology. It may be appropriate to
groups, whereas CD1a-expressing cells were found to be increased follow the children who have hypertrophic tonsils and who do not
in the children in the allergic group. This finding supports the have atopy detected by skin prick test at least once a year in the
active role of adenoid tissue in allergic reactions. Gorfien et al. allergy department. Serum IgE measurements in late spring and
[16] compared the tonsillectomy specimens of 90 children aged early summer, when the pollens are abundant, may be effective
between 2 and 13 years who were operated after the diagnosis of in the early detection of such patients. **** Children with
hypertrophic tonsils and recurrent tonsillitis and found that the hypertrophic tonsils and are not diagnosed with atopy should be
area of germinal centres in hypertrophic tonsil cases increased monitored for atopy in the future.
significantly compared to recurrent tonsillitis cases. Financial Disclosure
All authors declare no financial support.
This study was conducted on 50 children (28 male and 22 female) Ethical approval
The study protocol has approved from local ethic committee
aged between 2-15 years (mean age 6.3 years). Tonsillectomy
patients were diagnosed with severe hypertrophic (+3 and +4) Mustafa Altıntas ORCID: 0000-0001-7436-2862
tonsils and had a tonsil size was between the anterior and posterior
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