The palatine tonsils are unique lymphoepithelial organs positioned at the entrance of the respiratory and gastrointestinal tracts. Although there have been many reports about them, their exact functions are still not completely known. Recently, rapid progress has been made in the understanding of the molecular interactions that result in adhesion. Adhesion and other signals from cell adhesion molecules probably affect the behavior of cells in many organs. So the adhesion of cells is critical to many biological processes, including not only maintenance of tissue integrity, but also embryonal development, wound healing and cellular migrations. Cell adhesion molecules play a contributory role in immune systems and may be related to the structure and function of human tonsils.
Palmoplantar pustulosis (PPP) has been accepted as one of the secondary diseases caused by tonsillar focal infection ; however, the pathogenesis is still unknown. In this study, the expression of adhesion molecules on the palmar and plantar skin of eight patients with PPP and three healthy volunteers with normal skin were examined immunohistochemically. In normal skin, only CD44 was expressed on the epidermis. In the macroscopically normal region of PPP skin, intercellular adhesion molecule-1 (ICAM-1) was demonstrated on the endothelial cells in the dermis. In the erythema stage and the pustule stage, CD3, CD4, and lymphocyte function-associated antigen-1 (LFA-1) were expressed on the cells infiltrating the dermis. ICAM-1 was detected immunohistochemically on the endothelial cells, keratinocytes and infiltrating cells in PPP skins. Moreover, endothelial cell-leukocyte adhesion molecule-1 (ELAM-1) was expressed on vessels in the dermis in these two stages. These findings suggest that the interaction between LFA-1 and ICAM-1 plays an important role in T cell infiltration into PPP skin and that the continuity of ICAM-1 expression is related to the chronicity of PPP.
The expression of cell adhesion molecules on the endothelial cells of lymphoid organs influences the progression of immunological and inflammatory events. We investigated immunohistochemically the localization of ICAM-1, E-selectin and P-selectin in palatine tonsils to analyze the relationship between the expression of these molecules and the progressive events of focal infection. The expression of these three molecules on the capillary lumen was examined only in tonsils with focal infection, and not in hypertrophic tonsils without focal infection. Our findings suggest that the expression of these molecules in the tonsils is a significant feature of focal infection.
We examined 135 patients with tonsillar focal infections both before and after tonsillectomy and evaluated the results of the tonsillar negation test. 1) The tonsillar negation test was positive in 40 to 50% of the patients. 2) Almost all the patients with pustulosis palmaris et plantaris who had positive tonsillar negation tests improved after tonsillectomy. 3) The tonsillar negation test was correct more often than the tonsillar provocation test, but not often enough to be used alone. 4) The combined use of the tonsillar negation test and the tonsillar provocation test provided a higher percentage of correct diagnoses.
We studied 20 patients over 18 years of age who were referred during the past 5 years because of was diagnosed low grade fever. Tonsillar focal infection was performed tonsillectomy of there were 7 men and 13 women, with an average age 28.6 years. Most of the new patients were examined more than 2 months of after onset. Nine patients with a positive response to provocation tests were cured of after tonsillectomy. The overall results were; 15 cured, 2 inproved and 3 unchanged. Low grade fever disappeared in most cases within 3 months.
We evaluated the clinical usefulness of tonsillar provocation by indirect irradiation with ultra-micro waves as a diagnostic test of tonsillar focal infection. A long-term follow up observation was conducted in 241 patients treated with tonsillectomy and 165 treated medically. Secondary diseases in these patients with tonsillar focal infection were chronic low grade fever, skin diseases, kidney diseases and diseases of bones and joints. Improvement of secondary diseases occurred in 66.8% of the operated patients and in 63.4% of the non-operated patients. The parameters of the tonsillar provocation test by ultra-micro waves were body temperature, erythrocyte sedimentation rate (ESR), urinary findings, white blood cell count (WBC) and changes in skin eruption and arthralgia. Statistical analysis of each parameter showed no significant differences between the improved group and the unchanged group in most parameters. The tonsillar provocation test using indirect irradiation with ultra-micro waves has questionable value as an aid in deciding the indications for tonsillectomy. A better diagnostic method for demonstrating tonsillar focal infection must be developed.
It has been regarded that the palatine tonsils play an important role as a primary focus of infection for a variety of secondary diseases. Several tonsillar provocation tests have been developed, but they do not yet lead to an accurate diagnosis. It is well known that inflamed human palatine tonsils have many surface crypts showing characteristic lymphoepithelial symbiosis, which is important in immune responses. We have devised a new provocation test of intensive and direct ultra-microwave irradiation with cryptomassage and cryptoscope to observe the inside of crypts, as previously reported. Using the cryptomassage and the cryptoscope, we examined patients with palmoplantar pustulosis. 1. Patiens with palmoplantar pustulosis were examined by cryptomassage (314 cases) and cryptoscope (85 cases). 2. Positive results of cryptomassage were recorded in 36.8%: WBC 28.3%, skin eruptin 14.6%, elevated temperature 8.9% and increased ESR 4.7% according to the Nosaka's criteria. 3. The diagnostic efficacy rate reached 58.6% (49.6% in tonsillectomized and 72.3% in non-tonsillectomized patients), and the false negative rate was very high. 4. Cryptoscope revealed that horseshoe-type vessels were predoninant in the group with little improvement.
Numerous attempts have been made to show the relationship between focal infecton and the tonsils. We have usually diagnosed focal infection in the tonsils by a provocation test with ultra microwave irradiation and a negation test using Impletol injection. However, these diagnostic methods have not revealed the relationship between positive tests and the effect of therapy. Therefore, we used a low power laser irradiation tonsillar provocation test in patients with focal disease. 1) The provocation test by indirect irradiation under the jaw for 5 minutes was positive in 35.7%, and for 10 minutes in 53.8% of patients. 2) With direct irradiation of the tonsils for 5 minutes the test was pasitive in 54.2%. 3) Tonsillectomy was effective in 83.3% of the patients with a positive laser provocation test.
Epstein-Barr virus (EBV) is a ubiquitous herpes virus latently infecting the majority of all populations. It is known to be associated with two human malignant diseases, nasopharyngeal carcinoma (NPC) and endemic Burkitt's lymphoma. Recently, it has also been reported to be associated with B-cell lymphoma in immunosuppressed patients, nasal T-cell lymphoma, Hodgkin's disease and other lymphoproliferative diseases. In this study, we investigated the association of EBV with NPC and malignant lymphomas of head and neck origin by the Southern blot hybridization technique. We also studied the prevalence of EBV in mouth washings of patients with various tonsillar diseases by the polymerase chain reaction (PCR) method. With PCR, we detected EBV in 23% (21/91) of healthy seropositive donors, 53% (9/17) of patients with acute tonsillitis, 31% (6/19) of those with chronic tonsillitis, 53% (18/34) of those with tonsillar focal infection with palmoplantar pustulosis, and 44% (4/9) of those with tonsillar focal infection with IgA nephropathy. The EBV genome was detected in 76% (13/17) of NPC tumor tissues by Southern blot hybridization. Histologically, all tumor tissues of non-keratinizing and undifferentiated carcinomas contained EBV DNA (4 and 8 cases, respectively). On the other hand, EBV genome was detected in 1 of 5 cases (20%) of squamous cell carcinoma. The EBV genome was detected in 6 of 28 (21%) patients with malignant lymphomas of head and neck origin in 4 of 5 with nasal lymphomas and in 2 of 13 with Waldeyer's ring lymphomas. It was not detected in lymphomas of cervical lymph node and of parotid origin. The EBV-containing nasal lymphomas were considered to be of T-cell origin, and Waldeyer's ring lymphomas were of B-cell origin. In the EBV-induced B cell focus-regression assay, 4 patients with EBV-positive NPC and 1 with 2 EBV-positive lymphoma were found to have much greater impairment of long-term T cell immunity to EBV than patients with other types of cancers, including EBV-negative NPC and lymphoma. In conclusion, EBV reactivation may occur in patients with acute tonsillitis or tonsillar focal infection, and EBV is thought to be closely assosiated with the pathogenesis of NPC, nasal T-cell lymphoma and some cases of Waldeyer's ring B-cell lymphoma.
Symptoms and signs of STD are often observed in the oropharyngeal area, but the diagnosis of STD is extremely difficult in this area, where individual symptoms vary and identifying characteristics are few. It may not be an exaggeration to say that a patient is suspected of having an STD after the first visit. Since 1988, our institution has been actively involved in the diagnosis and treatment of STD. The following report will focus on syphilis and AIDS. Herpes and chlamydia, as well as critical factors after suspecting the infection of STD will also be discussed.
Radiation therapy of cancer of the head and neck region often causes salivary dysfunction .Salivary flow rates were significantly lower in patients with salivary gland irradiation than in non-irradiated controls. The secretory IgA (sIgA), IgG, IgM, lactoferrin and lysozyme in saliva were measured to investigate the changes of the immune barriers in the oral and pharyngeal mucosa. The rate of local secretion of sIgA was significantly reduced after salivary gland irradiation because of the reduction of the rate of salivary flow. The reduction of sIgA was observed both acutely and chronically after irradiation. Lactoferrin and lysozyme were also reduced in these patients. However, the rate of local secretion of IgG rose after salivary gland irradiation. Thus, irradiation of the salivary gland not only reduced salivary flow but also modified of the functional immune barriers of the mucosa .These changes were irreversible. Therefore, it was suspected that these changes of immune barriers might also affect the immune system in patients treated with salivary gland irradiation, even at terminal stages.
It is important to localize a lesion to one fascially-defined space because the components of each space are fairly specific, for example, the parotid space contains mainly the parotid gland, and the carotid space mainly several blood vessels and nerves. Therefore, specific tumors tend to originate in specific spaces. The CT and MRI appearance of 30 parapharyngeal tumors (12 males and 18 females; average age 50.5 years) treated at Tokyo university Branch Hospital and several affiliated hospitals were reviewed. Deviated pattern of internal carotid artery (ICA), parapharyngeal space fat (FAT), styloid process (SP) and muscles attached to the SP were compared between parotid space tumors and carotid space tumors. In most parotid space tumors, ICA was displaced posteriorly or not displaced, FAT was displaced medially, and SP was located posterior to the tumor in axial views. On the other hand, in most carotid space tumors, anterior displacement of ICA and FAT and anterior location of SP were seen in axial views. In coronal views of parotid space tumors, ICA was displaced medially or not displaced, and FAT was located between the parotid gland and the tumor. In carotid space tumors ICA was displaced in various directions, and FAT was located between the parotid gland and the tumor. The pattern of displacement of salivary gland tumors was correlated well with that of parotid space tumors, and that of neurogenic tumors correlated well with that of carotid space tumors. Thus, analysis of the displacement pattern seen in CT or MRI contributes to the diagnosis of the pathologic nature of parapharyngeal tumors
The parapharyngeal space is clinically very important because it is adjacent to the great vessels of the neck, deep cervical lymphnodes, the last four cranial nerves and the sympathetic trunk. Neoplasms in this region can be demonstrated clearly by CT and MRI. On the other hand, ultrasonic observation of parapharyngeal space tumors has been considered to be very difficult because of anatomical restrictions. From 1986 to 1993, 17 patients with parapharyngeal tumors were examined ultrasoni-cally in our department. The main ultrasonic scanners used were color doppler types, SSA-270A and EUB-565A. For a wider view through the narrow acoustic window between the bones, convex or sector-scanning probes were used. Transpharyngeal scanning with a finger tip type probe was also performed in some of the patients. We could demonstrate the normal anatomy of the parapharyngeal region and many lesions, such as neurilemmomas, salivary gland tumors and vascular tumors. The internal and external carotid arteries and the internal jugular vein could be differentiated easily by color doppler flow imaging. The adhesiveness or invasion of the tumors to the surrounding structures could be demonstrated by manual examination under ultrasonic guidance. When adhesions between the tumor and carotid artery were confirmed, indications for carotid resection and vascular reconstruction could be determined by performing the color dopper guided Matas test to evaluate the collateral circulation through the circle of Willis. In conclusion, real time and dynamic ultrasonic examination of the parapharyngeal region provides useful and very unique information about the character of a tumor and the relationship between the lesion and the surrounding tissues.
Thirteen patients with parapharyngeal abscess treated at Oita Medical University during the 12 years from 1981 to 1993 are reviewed. The mean age was 42 years (range; 12 to 81 years). In 10 patients of this series, upper respiratory infection was the cause and was complicated with peritonsillar abscess in 4 of them. Although odontogenic infection and cervical infection due to satellite ganglion block were thought to be the cause in one each, no apparent cause could be found in one. Two patients had an episode of steroid therapy for rheumatoid arthritis and diabetes mellitus. Ten patients underwent open surgical drainage of the abscess through a cervical incision, while in two cases combined with peritonsillar abscess, only tonsillectomy was perfomed. Although one patient refued surgical treatment and was treated conservatively with antibiotics, all patients recovered without any severe complications. Bacteriological results showed anaerobic micro-organism infection in two cases and aerobic infection in 10 caces. No causative micro-organisms were found in the other three. We reviewed 125 reported cases of this disease, including ours, in the litteratures and described clinical features and surgical treatment of parapharyngeal abscess.
Benign lymphoepithelial lesions of the salivary glands associated with Sjögren's syndrome are characterized by extensive infiltration of lymphoid cells, atrophy of acini and the presence of epimyoepithelial islands. This report describes our three dimensional reconstructive study of epimyoepithelial islands using computer graphics. Ultrastructural and immunohistochemical studies were also performed with several antibodies: KL-1, actin, PanB and PanT. The monoclonal antibody KL-1 intensely stained duct cells of the normal parotid gland. Most of the cells composing epimyoepithelial islands were positive for KL-1, but they were negative for actin. PanB-positive cells were dominant among the lymphoid cells of the stroma and were scattered in the epimyoepithelial islands. The reconstructive study proved that epimyoepithelial islands are continuous duct-like structures rather than isolated cell clusters. Ultrastructural examination showed that epimyoepithelial islands are composed mainly of epithelial cells containing intermediate filaments. Myoepithelium-like cells containing myofilaments were rarely found in the peripheral portion of the islands. These results suggest that epimyoepithelial islands are derived from proliferating duct epithelial cells.
A 61-year-old woman was found to have an extramedullary plasmacytoma of the epipharynx. The tumor was removed by the transpalatal method with the use of CO2 LASER. The patient received postoperative radiotherapy. Immnohistochemical examination showed the cells of the tumor produced a monoclonal κ-type light chain. There has been no local recurrence or development to multiple myeloma one year after surgery.
A 51-year-old male complaining of nasal obstruction and snoring was, sent to our hospital for further examination of a pharyngeal deformity. Examinations including CTscan, MRI, carotid artery angiography and fine needle aspiration biopsy led to a diagnosis of giant tumor in the left parapharyngeal space. Under general anesthesia, the tumor was removed through a cervical. approach without mandibulotomy. The tumor had a nodular surface with a fibrous capsule, and its cut surface was milkywhite. It was 63×35×28mm in size and weighed 63g. Histopathological study revealed a carcinoma in pleomorphic adenoma. Postoperatively, there were no noticeable complications except slight paresis of the left soft palate. CTscan, MRI, and carotid artery angiography are considered to be useful in the preoperative diagnosis of parapharyngeal tumor as well as in the selection of the best surgical approach.
Forty patients with squamous cell carcinoma of the mouth or pharynx were treated by Neoadjuvant chemotherapy (NAC) with THP-ADM, CDDP and tegafur. The carcinoma was in the epipharynx in 8 patients, in the mesopharynx in 11, in thehypopharynx in 9, in the oral cavity in 7, and in the tongue in 5. The tumor was stage I in1 patients, stage II in 6, stage III in 11 and stage IV in 22. Therapy achieved effectiveness was complete response (CR) in 18 patients, partialresponse (PR) in 10 and no change (NC) in 12. The response rate was 70% and CR rate was45%. Carcinoma in the epipharynx and mesopharynx responded well to NAC, but that in thehypopharynx, oral cavity or tongue did not respond. The CR rate decreased as the stageadvanced. There was no clear difference between DNA diploidy and aneuploidy. There were no severe side effects. The outcome was better in the CR than in the PR patients. In 5 patients, surgery was avoided; because the primary legion was in the mesopharynx;after NAC, they were treated by radiotherapy. All 5 have survived and are tumor free. Therefore, we think that it is possibile to avoid surgery in selected cases treated with NAC.
We performed Müller's maneuver and dynamic cephalometry in 66 adult American patients with OSAS. We measured such conventional parameters as distance and angle in cephalometry and the lateral areas of the soft palate, oral cavity, tongue, and pharynx to evaluate the preoperative predictability and usefulness of UPPP and MLG, and we repeated the measurements postoperatively. Almost all of the UPPP-responder group had type Ha OSAS, and about 50% of the UPPP non-responders had type IIb OSAS, demonstrated by Müller's maneuver. The areas of the soft palate, the whole tongue, and the lower half of the tongue were significantly larger in the apnea group than in the snoring group.In this study, MPH, SPL and PNS-H were longer in the apnea group than in the snoring group.Our preoperative measurements revealed that in the apnea group the whole tongue was larger and the pharyngeal area smaller in the UPPP non-responder subgroup than in the responder subgroup.In the UPPP non-responder subgroup, the area of the soft palate and SPL became smaller, but the pharyngeal area and PUA did not increase after surgery. In the MLG cases, the oral cavity and pharyngeal areas increased, while the area of the upper half of the tongue decreased.
Salivary gland function was evaluated quantitatively by 99m Tc-pertechnetate scintigraphy in 24 subjects with various oral symptoms. Twenty-four patients (19 female), with ages ranging from 48 to 83 years (median 60.2 years), had symptoms including tongue pain (9 cases), recurrent stomatitis (3 cases), sore throat (3 cases), cough (3 cases), sticky mouth (4 cases), and problems with taste (2 cases). Seven of 9 patients with tongue pain were diagnosed with salivary gland dysfunction, especially submandibular gland dysfunction . Each group with other oral symptoms included some cases of salivary gland dysfunction . Many patients had xerogenic diseases (i.e., Sjogren's disease, thyroid gland dysfunction, anemia, etc.) and had received xerogenic medications (i.e., antihypertensive drugs, antidepressant drugs, etc.) for a long time. In this study, salivary gland dysfunction was found to cause various oral symptoms. In patients with various oral symptoms, especially middle aged females, salivary gland function should be investigated.
Although plain X-ray films are usually used for the observation of lingual tonsils, we examined the shape and size of lingual tonsils by magnetic resonance image (MRI), which provides accurate information, and the results were correlated with level of abnormal feelings in the throat and the habits of smoking and drinking by means of a questionnaire survey. The size of the tonsil was determined by its distance from the epiglottis, and its shape as broad based or triangular. The subjects were 157 males and 106 females, with a mean age of 47.8 years. The following age-related changes in size were observed: degree O, in which the tongue root and lingual tonsil were not visible, was lease common in the third decade, and became more common with aging, reaching 100% by 80 years of age. Swelling of degree 3, in which there was no space between the lingual tonsil and the epiglottis, showed two peaks, then decreased to 0% by 80 years of age. The broad shaped base was more common on the whole, and seemed to be correlated with the shape of the epiglottis. The questionnaire survey showed an increase in the incidence of abnormal feeling in the throat with progress of the swelling, but it was not significant. Some differences were observed in marked swelling depending on the presence or absence of smoking and drinking, but the general association with swelling was unclear.
The relationship between the results of the tonsillar provocation test by tonsil massage and the postoperative prognosis of tonsillectomy in patients with IgA nephropathy wereexamined. 1) In 70% (24/34) of patients with IgA nephropathy, the tonsillar provocation test by tonsil massage was positive. 2) Within one week after tonsillectomy, urine test results were worse in 5/24 of the patients with positive results and 1/10 of those with negative results of the provocation test. 3) Six months after tonsillectomy, proteinuria and hematuria were reduced in 68% and 32% respectively, of the 34 patients. 4) The tonsillar provocation test was effective in 71% for proteinuria and in 62% for hematuria. 5) Of the abnormal findings, hematuria was changed most, followed in order by pro-teinuria, number of leukocytes, ESR and fever. 6) The size, core of the abscess and redness of the tonsil were not related to the rate of improvement.
A 71-year-old male had a tumor in the epipharynx which was treated by surgical resection. Histological examination showed dysplastic plasma cells. However, the ABC method showed no production of monoclonal γ -globulin. Therefore, it was difficult to differentiate it from a plasma cell type of Castleman's lymphoma. We decided not to give him postoperative radiotherapy, because 1- The tumor was single and pedunculated. 2- There were no abnormal findings in serum protein or urine protein. 3- We were uncertain that the tumor was Castleman's lymphoma. The patient was followed, and no local recurrence or evidence of multiple myeloma has been noted for 2 years.
We tried the tonsillar provocation test in 42 patients with the low power laser irradiation and compared the results with those of indirect irradiation with ultra-micro waver. The laser used in this study was a He-Ne laser with a 632.8 nm wavelength and 8.5 mw power (Model PDT, Senko Medical Instrument Co, Tokyo). The tonsillar provocation test by indirect irradiation with ultra-micro waves was positive in 52.4%, and that by low power laser irradiation was positive in 42.9%. We conclude that low power laser irradiation can be used as a new tonsillar provocation test.
A study was made of the bacterial flora in the oral cavity before and after treatment of six groups of patients with diseases of the ear, nose and throat. Those in groups 1, 2 and 3 had benign disease and were treated with surgery and antibiotics. Group 1 consisted of 30 patients with nasal and paranasal diseases, Group 2 was 30 patients with diseases of the ear, and Group 3 was 20 with diseases of the oral cavity. Group 4 consisted of 20 patients with sudden deafness who were treated with steroid hormones. Those in groups 5 and 6 had malignant diseases, Group 5 was 17 patients treated with radiation, and Group 6 was 8 patients treated with chemotherapy. Bacteria were cultured from the oral cavity before and after treatment. The number of bacteria in the oral cavity increased in Groups 1 and 5, but decreased in Group 3. The counts of fungi in the oral cavity increased in Groups 1, 3 and 5. In contrast, in the patients in Groups 4 and 6 there was little change.