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

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1. Weldeyer’s ring

2. Lymphoid compartments of palatine tonsil

3. Immunology process in palatine tonsil

4. Immunopathological aspect of palatine tonsil

• Tonsilitis and tonsilectomy

1. Nasopharyngeal tonsil (NT) OR adenoid

2. Tubal tonsils (TT)

3. Palatine tonsils (PT)

4. Lingual tonsils (LT)

entrance to the digestive & respiratory tracts

Immunological role:early recognition of antigen

initiation of an immune response.

Play a role in the immune function

1. Reticular crypt of epithelium

2. The extrafolicular area

3. The mantle zone of lymphoid

follicles

4. The follicular germinal centres

Lymphoid compartments of palatine tonsilReticulated crypt epithelium

Extrafollicularregion

Lymphoid follicle

Surface epithelium

Mantle zoneSecondary lymphoid follicle

B cellHEV

T cell

Germinal centre

capsule

Lymph vessel

Reticulated crypt epithelium

Extrafollicular region Lymphoid follicle

•M cells•B cells•T cells (CD8 > CD4), •T cells •Plasma cells•Macrophages•Interdigitating dendritic cells•Mast cells

• T cells (CD4 > CD8)–Memory & naïve CD4

•Interdigitating dendritic cells•B cells •Plasma cells•Macrophages•HEV

•Germinal center•B cells

–Naïve B cells–Centrocytes–Centroblasts

•Plasma cells•Follicular dendritic cells•T cells (memory CD4)

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

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

1. Transportation of antigen by M cells or dendritic cells (DC) to the extrafollicular areas

2. Activation of T cells in the extrafollicular areaAPC: Interdigitating DC

(IDC)

circulation

TONSIL

HEV

lymphatic

Only few immunocompetent cells are available in normal tonsil

Lymphocytes migrate continuously from the blood to tonsils

3. Stimulation of naïve 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

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 Join the systemic immune

DOGMA:Decreased J-chain expression by

tonsilar B cells reduce sIg A levels in saliva

Age (years)

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: 413-16Lenander-Lumikari et al., Pediatr Dent 1992; 14: 86-91

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

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

Ikinciogullari et al,. Int. J. Pediatr. Otolaryngol 2002. 66:251-257

In young adultsA slight reduction of total IgM and salivary IgG antibodies to Streptococcus mutans and EBV

Kritila et al., Clin Immunol 1996: 80: 110-5

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