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PubMed2006

Variations of the position of the cerebellar tonsil in adolescent idiopathic scoliosis with severe curves: a MRI study.

This study is an investigation into the position of the cerebellar tonsils in AIS with severe curves and any relationship it has with age, sex, curve severity and curve pattern. Sagittal magnetic resonance imaging (MRI) of hindbrain was performed on both of 205 AIS patients with a Cobb angle greater than 40 degrees and 86 healthy controls. The position of the cerebellar tonsil relative to the line connecting the basion and opisthion (BO line) was measured. In AIS and controls, the mean position of the cerebellar tonsil was 0.9 and 2.9 mm above the BO line, respectively. The incidence of tonsillar ectopia in AIS was found to be significantly higher than controls (34.5% versus 5.8%, p<0.001). No significant correlations were found between the position of the cerebellar tonsil with age or sex in AIS and controls. It was shown the position of the cerebellar tonsil was not significantly different among AIS patients with deferent curve severity. However, a significant lower incidence of tonsillar ectopia (p=0.049) was found in patients with lumbar curves when compared to those with thoracic or thoracolumbar curves. In conclusion, there was a relatively lower position of the cerebellar tonsil together with a significant higher incidence of tonsil ectopia in AIS patients. There was a trend that tonsillar ectopia was more often in thoracic or thoraco-lumbar curves, suggesting that a lower position of the cerebellar tonsil may play an important role in the etiopathogenesis of AIS.

Adolescent↗
PubMed1991

Fine-needle aspiration in recurrent tonsillitis.

The incidence of tonsillitis that is unresponsive to penicillin therapy is leading to concern. This phenomenon has been linked to a change in the core tonsil bacteria, in particular beta-lactamase production. To date, the only way to identify the presence of these resistant microbes is at tonsillectomy. In this prospective study, we performed fine-needle tonsil aspiration in 34 patients (mean age, 7.6 years) before tonsillectomy. The bacteriologic nature of the aspirate was compared with that obtained from culturing the tonsillar surface (in situ) and core of the resected tonsils. The bacteriologic findings of the aspirate corresponded closely with those of the tonsil core (qualitative and quantitative comparison), while the superficial swab was of limited value in predicting the core bacteria. Based on this study, tonsil fine-needle aspiration may have a place in the treatment of recurrent tonsillitis.

Adolescent↗
PubMed2006

Isolation of methicillin resistant Staphylococcus aureus from the surface and core of tonsils in children.

BACKGROUND: The rate of recovery methicillin resistant Staphylococcus aureus (MRSA) in tonsils that were removed because of recurrent Group A-beta-hemolytic streptococci (GABHS) tonsillitis was not previously reported. MRSA may serve as a potential source for the spread of these organisms to other body sites as well to other individuals. This study investigated the rate of recovery of MRSA as well as other aerobic organisms from tonsils that were removed because of recurrent GABHS infection. PATIENTS AND METHODS: Core and surface tonsillar cultures for aerobic bacteria were obtained from 44 children who had tonsillectomy because of recurrent GABHS tonsillitis. RESULTS: A total of 167 aerobic isolates were recovered from the core of the tonsils (3.8/specimen) and 151 (3.4/specimen) were isolated from the surface. The predominant isolates were alpha-hemolytic streptococci, GABHS, S. aureus, gamma-hemolytic streptococci, Haemophilus influenzae and Moraxella catarrhalis. Concordance in the recovery of all organisms was noted in 117 instances. Certain organisms (i.e. GABHS, S. aureus) were recovered more often from the tonsillar cores, where other (i.e. alpha-hemolytic streptococci, gamma-hemolytic streptococci) were recovered more often from the tonsillar surface. Forty-four beta-lactamase-producing bacteria (BLPB) were recovered from 32 (75%) of the tonsillar cores, and 28 were isolated from 23 (52%) of the tonsillar surfaces. The predominant BLPB were S. aureus, H. influenzae and M. catarrhalis. Seven isolates of MRSA were recovered from the cores and two were isolated from the surface. Five of the core isolates and the two surface isolates were also BLPB. All of the MRSA isolates were resistant to oxacillin, penicillin and erythromycin and were susceptible to clindamycin, trimethoprim-sulfamethoxazole and vancomycin. CONCLUSIONS: These data demonstrated that in recurrently GABHS infected tonsils, BLPB was recovered from over 75% of the tonsillar cores, core tonsillar cultures yielded more GABHS and S. aureus, and MRSA was isolated from 16% of the tonsils.

Adolescent↗
PubMedDate not supplied

Superoxide dismutase in pediatric palatine tonsils and adenoids and its related clinical parameters.

PURPOSE: The objective of this study was to investigate a protective system of pediatric palatine tonsils and adenoids against superoxide radicals (O(2)(-)) and to evaluate the clinical factors including otitis media with effusion that are related to both the expression and activities of copper zinc superoxide dismutases (CuZnSODs). DESIGN: CuZnSODs in the palatine tonsils and adenoids were studied using immunohistochemistry and reverse-transcription polymerase chain reaction. RESULTS: Immunohistochemistry showed that CuZnSODs distribute in the crypt epithelium, mucous membrane, mantle zone, and extrafollicular area of the pediatric adenoids as well as in the palatine tonsils. Otitis media with effusion and paranasal sinusitis were related to CuZnSODs expression in the pediatric adenoids. In addition, the frequency of tonsillitis and presence of recent tonsillitis were significantly related to CuZnSODs expression in the pediatric tonsils (P <.05). CONCLUSIONS: In both the pediatric palatine tonsils and adenoids, the mechanism of tissue protection against infection and frequent inflammatory reactions may be closely related to CuZnSODs expression. There may be close relationship between the increased level of O(2)(-) that leads to an increase in CuZnSODs in the pediatric adenoid tissue and the development of otitis media.

Adenoids↗
PubMed1993

The incidence and role of actinomyces in recurrent acute tonsillitis.

Although actinomyces has been identified in between 1.77% and 37% of resected tonsils its possible role in recurrent acute tonsillitis has received little attention. A histological and bacteriological study of 129 pairs of tonsils from patients with recurrent acute tonsillitis showed actinomyces to be present in 29.5%. The organism, however, was also present in 40% of tonsils from 10 patients with no history of tonsillar disease. In neither of these groups was there any specific evidence of tissue reaction to actinomyces nor was there a male preponderance as in clinical actinomycosis. The presence of actinomyces in the tonsil was not favoured by the concurrence of beta-lactamase producing bacteria. These data indicate that actinomyces does not have a causal role in recurrent acute tonsillitis.

Actinomyces↗
PubMedDate not supplied

Tonsillar suppressors of killer cells in tonsillitis.

The authors studied the effect of tonsil cells obtained from intact and inflamed tonsils on spontaneous cytotoxicity of autologous blood leucocytes. It has been shown that addition of tonsil cells of patients with chronic tonsillitis and those of animals with experimental tonsillitis to blood cells with a high cytotoxic potential did not augment cytolysis of heteroerythrocytes but inhibited it. Meanwhile in the joint cultivation of tonsil cells of intact animals and children with tonsillar hypertrophy with autologous blood leucocytes the killer effect exceeded that seen in a separate use of these cells. The data presented in this article indicate that non-specific suppressors capable of inhibiting spontaneous killing may appear in tonsils in the course of inflammation.

Adult↗
PubMed1984

Viral infections associated with recurrent tonsillitis.

To elucidate mechanisms responsible for susceptibility of the palatine tonsil to infections in patients with recurrent tonsillitis, we studied 46 patients with recurrent tonsillitis (RT), simple hypertrophic tonsil (SHT) or focal tonsillitis (FT) in regard to the participation of viral infections, especially Epstein-Barr virus (EBV) infection by using ELISA and immunostaining methods. Culture supernatants of tonsillar lymphocytes in RT group had antibodies to respiratory syncytial (RS) virus at greater positive rate (26.3%) than that of SHT group (16.7%). About 70% of patients with RT had serum antibodies to viral capsid antigen (VCA) of EBV in high titre over 160X, but only 30% in SHT group. Furthermore, in RT group 2 patients possessed IgM antibody to VCA and IgG antibody to early antigen (EA). In RT group, IgG, IgM and IgA antibodies to VCA and IgG antibody to EA presented in the supernatant in 58%, 17.6%, 11.7% and 17.6% respectively. In the 35 tonsillar lymphocyte suspensions tested 20% contained EBNA-positive lymphocytes. In RT group, 5 of 21 patients (23.8%) had EBNA-positive lymphocytes, but only one of 9 (14.3%) in SHT group. These results suggest that EBV infection and its reactivation in the palatine tonsil may be one of major mechanisms in recurrent episodes of tonsillitis.

Adolescent↗
PubMed1996

Immunological role of human palatine tonsil in Epstein-Barr virus persistence.

To determine whether EBV-specific cellular immunity persists and controls EBV in the palatine tonsil, we compared EBV-specific cellular immune responses in the palatine tonsil and peripheral blood. In 32 EBV-seropositive donors, we performed in vitro growth inhibition assays of EBV-induced B-lymphocyte transformation (regression assay). The results showed that EBV-specific cytotoxic T lymphocytes (CTL) precursor frequency was higher in the palatine tonsil than in the peripheral blood. After a first stimulation with autologous lymphoblastoid cell line (LCL), the EBV-specific cytotoxicity of reactivated CTL was higher in the palatine tonsil than in the peripheral blood. Furthermore EBV-specific CTL lines established from the palatine tonsil had significantly higher EBV-specific cytotoxicity in comparison with those from the peripheral blood. Both the EBV-specific CTLs from tonsils and peripheral blood were restricted by HLA class-I determinants. These data indicate that the palatine tonsil, which is frequently exposed to EBV, plays an important role in controlling EBV infection in the oropharynx.

Adult↗
PubMed2000

Quality of life and health status in pediatric tonsil and adenoid disease.

OBJECTIVE: To assess the baseline global health status and quality of life (QOL) in children with tonsil and adenoid disease. DESIGN: Cross-sectional multicenter survey series. SETTINGS: A tertiary academic pediatric specialty hospital and a tertiary academic hospital in 2 different cities. PATIENTS AND OTHER PARTICIPANTS: Consecutive series of 55 parents of children who were seen for tonsil and adenoid disease. INTERVENTION AND METHOD: Cross-sectional survey of the health status of affected children to assess their QOL and its relationship to tonsil and adenoid disease. MAIN OUTCOME MEASURES: Quality-of-life subscale scores of affected children on the Child Health Questionnaire version PF28 (CHQ-PF28); comparisons of population data from healthy normal children and children with asthma and juvenile rheumatoid arthritis. RESULTS: The overall health status and QOL of children with tonsil and adenoid disease is significantly worse than those of healthy normal children, as demonstrated by lower mean scores on several CHQ-PF28 subscales, including general health, physical functioning, behavior, bodily pain, and parental impact (emotional). In addition, the general health perception of children with tonsil and adenoid disease is similar to the perceptions of children with asthma and juvenile rheumatoid arthritis, but several aspects of health status, as measured by CHQ-PF28 subscale scores, were significantly worse in children with tonsil and adenoid disease. CONCLUSION: The health status impact of tonsil and adenoid disease appears to be quite significant, particularly in aspects related to the parental impact of the child's disease.

Child↗
PubMed2001

Validation of an outcomes instrument for tonsil and adenoid disease.

OBJECTIVE: To design and validate a disease-specific health status instrument-the Tonsil and Adenoid Health Status Instrument-for use in children with tonsil and adenoid disease. DESIGN: Prospective psychometric and clinimetric instrument validation in 3 stages. SETTINGS: A tertiary academic pediatric specialty hospital and a tertiary academic hospital, in 2 different cities. PATIENTS/OTHER PARTICIPANTS: Children with tonsil and adenoid disease presenting for evaluation and treatment (n = 224). INTERVENTION/METHOD: Prospective instrument validation. Stage 1 consisted of initial item testing, reduction, and subscale construction; stage 2, reliability and validity testing, factor analysis, and final item reduction; and stage 3, responsiveness analysis. MAIN OUTCOME MEASURES: Test-retest and internal consistency reliability; content, construct, and criterion validity; orthogonal principal components factor analysis; and response sensitivity analysis. RESULTS: Factor analysis and item analysis confirmed 6 distinct subscales measuring different constructs (aspects) of disease-specific health status that are affected by tonsil and adenoid disease: eating and swallowing, airway and breathing, infections, health care utilization, cost of care, and behavior. For each subscale, the Tonsil and Adenoid Health Status Instrument demonstrated excellent test-retest reliability (r = 0.72-0.88) and internal consistency reliability (Cronbach alpha = .73-.87). Content validity was ensured during the design process. Construct validity was demonstrated by means of convergent and divergent validity with a global quality-of-life instrument (the Child Health Questionnaire, version PF28). Criterion validity was also satisfactory. Finally, the instrument was appropriately sensitive, with high standardized response means and effect sizes. CONCLUSIONS: The Tonsil and Adenoid Health Status Instrument is a valid, reliable, and sensitive instrument with 6 distinct subscales. This instrument has significant utility for outcomes research in children with tonsil and adenoid disease.

Adenoids↗
PubMed2003

Temperature-controlled radiofrequency tonsil reduction in children.

OBJECTIVE: To evaluate the safety and efficacy of temperature-controlled radiofrequency tonsil reduction in the treatment of children with a sleep-related breathing disorder associated with tonsillar obstructive hypertrophy. DESIGN: Prospective, nonrandomized, case series feasibility study of children meeting the criteria for tonsillectomy or adenotonsillectomy for the treatment of an obstructive sleep-related breathing disorder. SETTING: Community-based hospital. Patients Ten children, aged 4 to 13 years, presenting consecutively to a community-based otolaryngology practice with tonsillar or adenotonsillar obstructive hypertrophy implicated clinically in causing a sleep-related breathing disorder; their parents consenting to temperature-controlled radiofrequency tonsil reduction instead of surgical tonsillectomy. Intervention Temperature-controlled radiofrequency tonsil reduction, along with surgical adenoidectomy, if adenoids were present, under general anesthesia. MAIN OUTCOME MEASURES: Tonsil size reduction, treatment morbidity, and symptom improvement with follow-up to 1 year. Baseline and 3-month posttreatment polysomnographic data were used. RESULTS: There was a reduction in tonsil size at 1 year of 75.0% on average, without evidence of regrowth during the 1-year follow-up. All children were drinking liquids in the recovery room, and most were eating soft diets within 6 hours; 8 of the 10 children were eating a normal diet by day 5. On average, the return to normal activity was 3.9 days, with 2.9 days of parental loss of work time. Quality-of-life variables all improved. Snore indexes decreased by 88.6%. Polysomnography at 3 months revealed an 84.2% reduction in the apnea index and a 52.3% reduction in the apnea/hypopnea index. There were no complications. CONCLUSION: Temperature-controlled radiofrequency tonsil reduction seems to be a safe, effective, and minimally morbid treatment for tonsil hypertrophy in children with obstructive sleep-related breathing disorders.

Adolescent↗
PubMed1993

Essential role of tumor necrosis factor-alpha in the differentiation of human tonsil in vivo induced B cells capable of spontaneous and high-rate immunoglobulin secretion.

Human tonsils contain B cells capable of spontaneous and high-rate immunoglobulin (Ig) secretion in vitro. These cells are in vivo induced mature B cells, and, as such, they provide and adequate model for studying tonsil B cell differentiation. The present report analyzes the effect of a variety of factors on purified tonsil B cells capable of spontaneous IgG secretion in fetal calf serum (FCS)-containing and serum-free supplemented cultures. Tumor necrosis factor-(TNF) alpha was found to be important for these B cells to reach the high-rate IgG-secreting stage, as is indicated by the following findings: (a) none of the factors used modified tonsil B cell IgG secretion in FCS-containing cultures; (b) TNF-alpha (5-20 ng/ml), but not other cytokines or factors including interleukin (IL)-6, was capable of restoring missing IgG production in serum-free supplemented cultures of tonsil B cells; and (c) IgG secretion in FCS-containing cultures was inhibited by the addition of blocking anti-TNF-alpha antibodies, but not anti-IL-6 antibodies, and this inhibition could be specifically reversed by exogenous TNF-alpha. TNF-alpha was actively produced by tonsil B cells (range 120-750 pg/ml) in the presence, but not in the absence, of FCS. The TNF-alpha inductive effect occurred during the first 12 h of culture and did not require DNA synthesis. These results indicate that the early and endogenous generation of TNF-alpha seems to be essential for tonsil in vivo induced B cells to differentiate into the high-rate Ig-secreting stage.

B-Lymphocytes↗
PubMed2006

Histological studies on the ontogeny of bovine palatine and pharyngeal tonsil: germinal center formation, IgG, and IgA mRNA expression.

The development and distribution of lymphocyte subsets in calf palatine and pharyngeal tonsil were examined. During prenatal development, B cells were distributed in the subepithelial area, and T cells and MHC class II(+) cells were found in the deep layer of B-cell area, respectively, in both tonsils. At neonatal stage, lymphoid follicle containing a few CD4(+) cells have been formed in both tonsils. IgG(+) and IgA(+) cells were found in the parafollicular and epithelial area. At 3 months old, many germinal centers were recognized in both tonsils. CD4(+) cells and IgG mRNA expression were detected in light zone of germinal centers. Many IgG, and IgA mRNA expressions also could be detected in the parafollicular and subepithelial area of both tonsils. The data suggest that both tonsils have an important role of local immune defense against invading antigen after birth. The comparison of the histological characteristics of tonsil and Peyer's patch during ontogeny is also discussed.

Adenoids↗
PubMed2005

Cytokines locally produced by lymphocytes removed from the hypertrophic nasopharyngeal and palatine tonsils.

OBJECTIVE: Human palatine tonsils and the nasopharyngheal tonsil are the largest components of the Waldeyer's ring. Subepithelial and intraepithelial lymphocytes of human adenoids and tonsils are responsible for the local and the systemic immune response. We studied the cytokine production by lymphoid cells isolated from 16 nasopharyngeal tonsils (adenoid) and 9 palatine tonsils surgically removed by from 25 children (aged from 4 to 15 years) suffering from tonsil hypertrophy. METHODS: We evaluated (by the cytometry method, using BD Bioscience kits, San Diego, CA) the concentration of IL-2, IL-4, IL-5, IL-10, TNF(alpha) and IFN(gamma) released from human peripheral blood mononuclear cells (MC) (activated or not activated by phytohaemagglutinin (PHA)) cultured in vitro during 72 h. The fluorescence-activated cell sorter (FACS) analysis was also performed and the percentage of mononuclear cells (unstimulated or activated by phorbol acetate during 24 h) stained with the monoclonal antibodies anti-CD3 containing the intracellular cytokines was calculated. RESULTS: The increased secretion of IL-2, IL-4, IL-5, TNF(alpha) and IFN(gamma) from PHA activated palatine origin immune cell cultures, as compared to adenoids, was revealed. The higher mobilization (Delta%) of CD3+ T-lymphocytes containing IL-12 in palatine cell cultures (798.5+/-276.29%), in comparison with to the adenoids (298.5+/-49.16%; p< or =0.05), was also noted. CONCLUSION: In palatine tonsils, as compared to adenoids, the cellular immune (Th1) response dominates over humoral immune (Th2) reaction.

Adenoidectomy↗
PubMed2003

The natural history of recurrent acute tonsillitis and a clinical trial of azithromycin for antibiotic prophylaxis.

The pharmacokinetics of azithromycin (Zitromax), Pfizer Inc., USA) in tonsil tissue warranted the present trial. In 110 patients eligible for tonsillectomy because of recurrent acute tonsillitis, surgery was replaced by randomized medication with azithromycin 500 mg or placebo once per week for 6 months. Subsequently, their clinical condition and microbiology was monitored for 12 months. Acute tonsillitis developed in 40% of the patients who received azithromycin and in 49% of the patients in the placebo group (P > 0.05). Accordingly, 45% of all patients developed acute tonsillitis. Resistance to azithromycin was not detected. In this trial long-term medication with azithromycin was not efficacious in recurrent acute tonsillitis. As all patients were eligible for tonsillectomy according to current criteria, it is surprising that only 45% developed acute tonsillitis during the trial period. Therefore, the criteria for tonsillectomy in recurrent acute tonsillitis must be revised.

Acute Disease↗
PubMed2003

The adequacy of gross pathological examination of routine tonsils and adenoids in patients 21 years old and younger.

Most hospitals microscopically examine all routine tonsil and adenoid specimens from healthy pediatric patients with recurrent infections or obstructive sleep apnea. Concern over missing the rare unsuspected, significant diagnosis propagates this practice. Careful gross examination for asymmetry and clinical findings should obviate the need for routine microscopic examination of tonsil and adenoid specimens in patients age 21 years and younger. A retrospective study was conducted using the SNOMED database of 4070 patients age 21 years or younger who underwent tonsillectomy and/or adenoidectomy between 1970 and July 2001 at the University of Florida. The age distribution of the study group was 0 to 5 years (52%), 6 to 12 years (37%), and 13 to 21 years (11%). Specimens consisted of tonsils only (15%), tonsils and adenoids (40%), and adenoids only (45%). Clinically significant diagnoses were diagnoses that impacted the care of patients and included malignancies and some infections. Non-clinically significant diagnoses included normal, acute or chronic tonsillitis, and tonsillar hyperplasia. Clinically significant pathological processes were seen in the tonsil or adenoid specimens of 3 of the 4070 patients. These 3 cases included a 2-year-old male with Burkitt's lymphoma, a 19-year-old male with non-Hodgkin's lymphoma (small noncleaved cell, non-Burkitt's type), and an 11-year-old male with a probable viral process but in whom a lymphoma could not be absolutely excluded. All 3 of these patients had signs and symptoms, including significant cervical lymphadenopathy, meriting microscopic analysis of the specimens. In conclusion, microscopic examination of all routine tonsils and adenoids for individuals 21 years or younger is not indicated. Gross examination is still recommended. Clinical suspicion and specimen asymmetry should be used to determine when thorough histological examination is merited.

Adenoidectomy↗
PubMed2005

Histology, immunohistochemistry and ultrastructure of the equine palatine tonsil.

The palatine tonsils of five young horses formed 10-12 cm elongated follicular structures extending from the root of the tongue on either side to the base of the epiglottis and lateral to the glossoepiglottic fold. The stratified squamous non-keratinized epithelium of the outer surface was modified into crypts as reticular epithelium by heavy infiltration of lymphoid cells from underlying lymphoid follicles. In places, lymphoid tissue reaching almost to the surface and with only one to two cell layers intact was identified as the lymphoepithelium. Langerhans cells with Birbeck granules were interspersed between epithelial cells. Lymphoid tissue organized in lymphoid follicles constituted the parenchyma of the palatine tonsil. CD4-positive cells were more numerous and CD8-positive lymphocytes less numerous compared with their distribution in the lingual tonsil. B cells and macrophages were also more numerous than in the lingual tonsil and lectins showed a different pattern of attachment. M cells were not observed. High endothelial venules with well-developed vesiculo-vacuolar organelle had structural evidence of transendothelial and interendothelial migration of lymphocytes. Striated muscles as seen in the deeper lamina propria mucosae of the lingual tonsil were absent. The immunohistological and ultrastructural characteristics of the equine palatine tonsil are similar to those of humans but differ from those of the lingual tonsil and are consistent with a role as an effector and inductor immunological organ.

Animals↗
PubMed1995

Induction of compartmentalized B-cell responses in human tonsils.

The capacity of tonsillar and nasal mucosal lymphoid tissues to serve as induction sites of local and/or distant B-cell responses in humans has been examined. The frequencies of vaccine-specific antibody-secreting cells (ASC) in cell suspensions from palatine tonsils (PT) and adenoids were determined after local (intra-tonsillar [i.t.]) and regional (intranasal [i.n.]) immunizations as well as peroral and parenteral immunizations with cholera and tetanus toxoids. While peroral and parenteral immunizations evoked negligible ASC responses in PT, i.t. vaccination induced a substantial ASC response which consisted of immunoglobulin G (IgG) and IgA ASC. Responses were highly restricted to immunized tonsils. Primary immunization in one PT followed by a second immunization of both PT evoked a larger ASC response in the primed tonsil. The latter ASC response was associated with higher frequencies of ASC precursors in primed tonsils. Furthermore, two i.n. immunizations induced only modest ASC responses in PT, although such immunizations evoked high ASC responses in adenoids. However, both i.t. and i.n. routes of immunization induced specific peripheral blood ASC responses, suggesting that a fraction of B cells activated in tonsils or in nasal mucosa may enter the circulation and disseminate to distant organs. These blood ASC responses preceded increases in both IgA and IgG antibody titers in nasal washes and serum samples. However, vaccine-specific ASC were not detected in duodenal cell suspensions from volunteers who had received i.t. or i.n. immunizations. Collectively, these results indicate that tonsils can serve as expression sites of locally induced antibody responses and support the development of immunological memory. Furthermore, tonsils may serve as powerful inductive sites for immune responses expressed in the upper aerodigestive tract.

Adenoids↗