IMMUNOLOGICAL ASPECT OF THE

TONSILS

Dr. Dony Hartanto. SpTHT -KL, MKes.

ENT-HNS, RSUD Sukoharjo/ UMS School of Medicine
 +
MANAGEMENT?
EFFECT OF TONSILLECTOMY ON IMMUNE
SYSTEM?
OUTLINE

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

WELDEYER’S 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. Reticular crypt of epithelium

2. The extrafolicular area

3. The mantle zone of lymphoid follicles

4. 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 Lymphoid

follicle
capsule

Lymph vessel
CELLS IN TONSIL

Reticulated crypt Extrafollicular region Lymphoid follicle

epithelium
•M cells • T cells (CD4 > CD8) •Germinal center
•B cells –Memory & naïve CD4 •B cells
•T cells (CD8 > CD4), •Interdigitating –Naïve B cells
•T cells  dendritic cells –Centrocytes
•B cells –Centroblasts
•Plasma cells
•Plasma cells •Plasma cells
•Macrophages
•Macrophages •Follicular dendritic
•Interdigitating cells
dendritic cells •HEV
•T cells (memory CD4)
•Mast cells
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

2. Activation of T cells in
the extrafollicular area
APC: Interdigitating
DC
(IDC)
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 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
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
 Join the systemic immune
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

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

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