IMMUNOLOGICAL ASPECT OF THE TONSILS

Dr. Dony Hartanto. SpTHT -KL, MKes. ENT-HNS, RSUD Sukoharjo/ UMS School of Medicine

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MANAGEMENT? EFFECT OF TONSILLECTOMY ON IMMUNE SYSTEM?

OUTLINE
1.

Weldeyers ring

2.
3. 4.

Lymphoid compartments of palatine tonsil

Immunology process in palatine tonsil Immunopathological aspect of palatine tonsil

Tonsilitis and tonsilectomy

WELDEYERS RING

1. Nasopharyngeal tonsil (NT) OR adenoid 2. Tubal tonsils (TT) 3. Palatine tonsils (PT) 4. Lingual tonsils (LT)

PALATINE TONSILS

entrance to the digestive & respiratory tracts

Immunological role: early recognition of antigen initiation of an immune response.

LYMPHOID COMPARTMENTS OF PALATINE TONSIL

Play a role in the immune function

1. 2. 3. 4.

Reticular crypt of epithelium The extrafolicular area The mantle zone of lymphoid follicles The follicular germinal centres

Lymphoid compartments of palatine tonsil

Reticulated crypt epithelium

Surface epithelium
Mantle zone Secondary lymphoid follicle Extrafollicular region B cell HEV T cell Germinal centre capsule Lymphoid follicle

Lymph vessel

CELLS IN TONSIL
Reticulated crypt epithelium M cells B cells T cells (CD8 > CD4), T cells Plasma cells Macrophages Interdigitating dendritic cells Mast cells Extrafollicular region T cells (CD4 > CD8) Lymphoid follicle

Germinal center Memory & nave CD4 B cells Interdigitating Nave B cells dendritic cells Centrocytes Centroblasts B cells Plasma cells Plasma cells Follicular dendritic Macrophages cells HEV T cells (memory CD4)

RETICULAR CRYPT OF EPITHELIUM

Each tonsil contains 10 30 branched crypts Enlarge the surface up to 300 cm2 increase the surface for Ag contact

SSE: stratified squamous epithel, CT: connective tissue, LN: lymphatic nodule

THE FUNCTION OF INTRAEPITHELIAL LYMPHOCYTES

IMMUNOLOGY PROCESS IN THE TONSIL

1.

Transportation of antigen by M cells or dendritic cells (DC) to the extrafollicular areas Activation of T cells in the extrafollicular area APC: Interdigitating DC (IDC)

2.

LYMPHOCYTE MIGRATION/TRAFFICKING
circulation TONSIL
H E V

lymphatic

Only few immunocompetent cells are available in normal tonsil Lymphocytes migrate continuously from the blood to tonsils

3. Stimulation of nave B cells in the extrafollicular zones by activated T cells Colonize the primary lymphoid follicles Act as founder cells for Germinal centres (GC)

4. Clonal expansion of B cells 5. Somatic hypermutaion in B cell Ig V region genes

6. Positive selection of B cells that are able to receive Ag specific signals by high affinity 7. Differentiation to B memory cells and plasma cells of various immunoglobulins

6. INDUCTION OF THE J CHAIN GENE IN B CELLS

J chain is needed for the formation of sIgA and sIgM Termination of effector B cells: Regional secretory effector sites (upper aerodigestive tract) As extrafollicular plasma cells

J-CHAIN AS LIGAND OF POLY-IG RECEPTOR

J-CHAIN AS LIGAND OF POLY IG-RECEPTOR

EFFECT OF REPEATED TONSILLAR INFLAMMATION AND ADENOID HYPERPLASIA DOGMA: Decreased J-chain expression by tonsilar B cells reduce sIg A levels in saliva

HOWEVER, IMMUNOLOGICAL ACTIVITY PERSISTS EVEN IN DISEASED TONSILS AND ADENOIDS IN CHILDREN

Ig producing cells/mm2

Age (years)

EFFECT OF ADENOTONSILECTOMY ON HUMORAL IMMUNITY

In children

Reduce the level of IgA antibody to poliovirus 3-4 times in the nasopharyngeal secretions Delay the local immune response to subsequent live oral polio vaccine Decrease serum Ig and salivary IgA for up to 3-4 yrs
Ogra, NEJM 1971; 284: 59-64 Jeschke, Klin Padiat 1980; 192: 51-60 Cantani et al., Ann. Allergy 1986; 57: 413-16 Lenander-Lumikari et al., Pediatr Dent 1992; 14: 86-91

EFFECT OF ADENOTONSILECTOMY ON HUMORAL IMMUNITY

Children 3 14 years old with tonsil & adenoid hypertrophy, measure of local and blod Ig A, Ig G, Ig M Before tonsilectomy > control group One month after tonsilectomy < control group Six month after tonsilectomy = control goup

Zielnik-Jurkiewicz, jurkiewic. Int. J. Pediatr. Otolaryngol 2002; 64: 127-132 Kaygusuz ,el al. Int. J. Pediatr. Otolaryngol 2003; 67: 1311-1315

EFFECT OF TONSILECTOMY ON CELLULER IMMUNITY AND HUMORAL IMMUNITY

Case : chronic tonsilitis, healthy children as control Measured count of blood B and T lymphocytes, Ig G, Ig A, Ig M. Before tonsilectomy : B cells, Ig G, Ig A, Ig M. > control After tonsilectony :

B cells : normal T cells : increase Ig G, Ig A and Ig M < before tonsilectomy Ig G, Ig A and Ig M = control

EFFECT OF ADENOTONSILECTOMY ON IMMUNITY

In young adults
A slight reduction of total IgM and salivary IgG antibodies to Streptococcus mutans and EBV
Kritila et al., Clin Immunol 1996: 80: 110-5

TONSILLECTOMY VERSUS NON-SURGICAL TREATMENT FOR CHRONIC/RECURRENT ACUTE TONSILLITIS (COCHRANE REVIEW 2009)

In severe case in children: Reduce the number of episodes of sore throat Reduce the days with sore throat
In less severely affected children: The impact is minimal some children get better without any surgery

Burton, Glasziou. 2009