TONSILLAR HYPERPLASIA

AND RECURRENT
TONSILLITIS: CLINICALHISTOLOGICAL CORRELATION
By :
Willdania Yolanda
Fendia Riska

JOURNAL IDENTITY
Title :
Tonsillar Hyperplasia and Recurrent Tonsillitis :
Clinical-histological Correlation

Author :
Luciana Guedes Vilela Reis, lia Cludia de Souza
Almeida, Juliano Carvalho da Silva, Gilberto de
Arajo Pereira, Valdirene de Ftima Barbosa,
Renata Margarida Etchebehere.

Publisher :
Brazilian Journal of Otorhinolaringology 79 (5)
September/October 2013

ABSTRACT
Hypertrophy and recurrent tonsillitis are
common indications of tonsillectomy.
Pathological reports are similar, regardless
of clinical aspects.
Search for histopathological changes that
differentiate palatine tonsils operated
because of hypertrophy vis--vis those
operated because of recurrent tonsillitis.

MATERIAL & METHODS

A prospective cross-sectional descriptive study.

Group I

22 with
hypertrophy

Group II

24 with
recurrent
tonsillitis

46 children

In the period between 2010 and 2012 in a public

hospital

MATERIAL & METHODS

Infiltration by
plasma cells and
neutrophils

Lymph
follicles
Germinal
centers
Clinical and
histopathologi
cal features

Reticulatio
n

Necrosi
s

Fibrosis

RESULTS
Group I
Patients age 2-11
years (5.172.28)

Group II

Latest infection 7
months
obstruction degree
>3 (50%)
Latest infection <7
months
obstruction degree
below 4 (75%)

Obstruction degree and number of germinal

center was higher in Group I

CONCLUSION
The number of germinal
centers is the only
histopathological criterion
that can be used to
differentiate the two groups.

BACKGROUND
Palatine tonsils Waldeyers lymphatic
ring first line of defense against
pathogens entranced of the air and
digestive tracts.
The lymphatic tissue is not usually apparent
in early childhood, but it gradually evolves
hypertrophy and hyperplasia and reaches its
largest size between 2 and 5 years of ages.
Tonsillectomy is one of the most performed
surgery in ENT practice, particulary in
children, due to the intense activity & large
amounts of lymphatic tissue existing in this
period of their lives

BACKGROUND
In many
children,
Adenotonsillar
hypertrophy is
associated
with :

Sleep
breathing
disorders,
ranging from
obstructionleading
snoring

Obstructive
Sleep
Hypopnea
Apnea
Syndrome

BACKGROUND
Clinical practice histopathological
diagnosis in most tonsillectomies
lymphoid tissue hyperplastic-reactive
state or nonspecific lymphatic
hyperplasia, regardless of the clnical
and surgical indication of the patient be
socciated with hypertrophy or recurrent
tonsillitis

BACKGROUND
To asses histopathological findings to
morphologically differentiate hypertrophy
with consequent obstruction from recurrent
tonsillitis and correlate them with clinical
signs.

THE AIM
Comparing tonsil
histopathology in
children with recurrent
tonsillitis and tonsillar
hyperplasia submitted
to tonsillectomy.

METHODS
Design :
Prospective
crosssectional
descriptive

Samples : 46
children in the
period
between 2010
and 2012 in a
public hospital

METHODS
- Age, Gender,

46 patients
Tonsillecto
my
2010-2012

The
guardian
consented
on
participatin
g and
signed the
consent
form

- Age, Gender,
Race
- Indication for
surgery
- Frequency of
tonsillitis
occurance
- The date of the
last tonsillitis
episodes
- The degree of
oropharingeal
obstruction by
the tonsils

22 children
with
hypertropy
24 children
with
recurrent
tonsillitis

METHODS
Tonsil removed were identified as left and right
and fixed in 10% formaldehyde

Macroscopic
description

-Weight
Measurements
-Features

Material cleavage
- Lymph Follicles
- Germinal Centers
- Fibrosis
- Necrosis
-Reticulation
- Infliltration by
plasmocytes

METHODS
Lymph
follicles

Hematoxylin-Eosin
(HE) at 40x
magnification

Follicles

Counted in five
fields at 40x
magnification

0 predominance of
primary follicle
1 predominance of
secondary follicles
2 similar proportions
between primary and
secondary follicles
1. <25 follicles/fields
2. 2 25 follicles/fields

METHODS
Germinal
Centers

Hematoxylin-Eosin
(HE) at 100x
magnification

Necrosis
& Fibrosis

100x
mafnifications

1. <6 germinal
centers/fields
2. >6 germinal
centers/fields
0 absent
1 mild
2
moderate
3 intense

METHODS
Neutrophil
permeation in
crypt epithelium
Reticulation &
infiltration
plasmocytes around
the crypt

400x
magnification
s

400x
mafnification
s

0 absent
1 mild
2
moderate
3 intense
0 absent
1 mild
2
moderate
3 intense

RESULTS
Hypertrophy group I most subjects
(81.8%) were white, with a slight
predominance of females (54.5%).
In Group II most were white (91.7%) and
there was a slight predominance of males
(58.3%).
The Groups were homogenous for age (p =
0.8), which ranged between 2 and 11 years
(5.172.28).

RESULTS
Half of the children had
had the last infection
last 7 months in the
past.
All had >50%
obstruction of the
oropharynx by the
palatine tonsils.

Group I

Group II
All children had the last
infection occurred < 7
months
41.7% had infections
per year
The vast majority had
obstruction degree 75%

RESULTS
A statistically significant higher degree of
oropharingeal obstruction by the palatine
tonsils (70.5%11.9%) and longer duration (in
months) since the last infection (6.4%4.1%)
in the hypertrophy Group (I), as expected.
Histopathological
characteristics

homogenous
for
the
tonsil
weight
(p=0.2942).
The number of germinal centers was
statistically significant (p=0.0002) between
the two groups higher in the Hypertrophy
Group (I)

RESULTS
The type and
number of lymph
follicles
Permeation
by
neutrophils in
the
epithelium of
the crypts

Necrosis

No
statistically
significant
differences
between the
two groups

Infiltration by
plasmocytes around
crypts

Fibrosis

Two patients (4.3%) from the total,

both belonging to group I (9.09%)
exhibited non-invasive colonies of
bacteria, morphologically consistent
with Actinomyces Sp.

RESULTS

RESULTS

DISCUSSION
According to Alcantara et al, Tonsillectomy is the most
commonly performed surgical procedure in pediatric
patients.
The ages of the patient in this study coincide
with the age group where hypertrophy and
tonsillitis are more intense & frequent

Hypertrophy with consequent respiratory obstruction, is

among the absolute indications for tonsillectomy.

DISCUSSION
The presence of the germinal center indicates that the lymphoid
follicle is very active in producing lymphocytes.

The highest degree of obstruction by

palatine tonsil hypertrophy in the
Hypertrophy grop was statistically
significant, as expected

DISCUSSION
There may be differences between the antigens
involved in the two entities, and in the Hypertrophy
Group there is a higher stimulus for greater B cell
differentiation.
The two groups could represent different poles of the
same disease, which still display the intermediate
cases in which the two manifestations associated with
hypertrophy and recurrent tonsillitis.

DISCUSSION
There is still controversy in in the literature
regarding the association between
Actinomyces sp. And palatine tonsil
hypertrophy.
A low insidence of this association was
describe by Dell Aringa, suggesting that
Actinomyces sp. May not be related to the
palatine tonsil hypertrophy.
Different results were published by Bhagarva
high incidence in children undergoing
tonsillectomy for obstructive reasons compared
with other ones operated because of recurrent
infections.

CONCLUSION
The number of germinal centers was
found to be the sole criterion able to
differentiate the palatine tonsils of
children operated by hypertrophy from
recurrent tonsillitis.

When there are > 6 germinal centers

per field at 100x magnification, it is a
case of tonsillar hypertrophy.

CRITICAL APPRAISAL

34

Analisis PICO
Population
Interventi
on

46 children submitted to tonsillectomy in

the period between 2010 and 2012 in a
public hospital.

Tonsillectomy

Comparis
on

Comparing
tonsil
histopathology
in
children with recurrent tonsillitis and
tonsillar
hyperplasia
submitted
to
tonsillectomy.

Outcome

To asses the simple histopathological

findings to morphologically differentiate
hypertrophy with consequent obstruction
from recurrent tonsillitis and correlate
them with clinical sign

Judul dan Pengarang

No.

Kriteria

Ya (+) atau Tidak (-)

Jumlah kata dalam judul < 12 kata

Deskripsi judul

Daftar penulis sesuai aturan jurnal

Korespondensi penulis

Tempat & waktu penelitian dalam

judul

+
(8 kata)
Menggambarkan isi
utama penelitian,
menarik dan tanpa
singkatan

Abstrak
No.

Kriteria

Ya (+) atau Tidak (-)

Abstrak satu paragraf

Mencakup komponen IMRC

Secara keseluruhan informatif

Tanpa singkatan selain yang baku

Kurang dari 250 kata

+
(199 kata)

Pendahuluan
No.

Kriteria

Ya (+) atau Tidak (-)

Terdiri dari dua bagian atau dua

paragraf

Paragraf pertama mengemukakan

alasan dilakukan penelitian

Paragraf kedua menyatakan

hipotesis atau tujuan penelitian

Didukung oleh pustaka yang relevan

Kurang dari satu halaman

+
( 5 paragraf )

Bahan dan Metode

Ya (+) atau Tidak (-)
Penelitian

No.

Kriteria

Jenis dan rancangan

penelitian

Waktu & tempat penelitian

Populasi sumber

Teknik sampling

Kriteria inklusi

Kriteria ekslusi

Perkiraan dan perhitungan

besar sampel

Perincian Cara penelitian

Blind

10

Uji statistik

11

Program komputer

12

Persetujuan subjek (IC)

Hasil
No.

Kriteria

Ya (+) atau Tidak (-)

Jumlah subjek

Tabel karakteristik subjek

Tabel hasil penelitian

Komentar & pendapat penulis ttg

hasil

Tabel analisis data dengan uji

Pembahasan, Kesimpulan,
Daftar Pustaka
No.

Kriteria

Ya (+) atau Tidak (-)

Pembahasan & kesimpulan dipaparkan

terpisah

Pembahasan & kesimpulan dipaparkan

dengan jelas

Pembahasan mengacu dari penelitian

sebelumnya

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Keterbatasan penelitian

Simpulan utama

Simpulan berdasarkan hasil penelitian

Saran penelitian

Penulisan daftar pustaka sesuai aturan

KESIMPULAN
Hasil penelitian VALID
Hasil penelitian PENTING
Hasil penelitian DAPAT
DITERAPKAN