Recurrences in chronic tonsillitis substained by tonsillar biofilm-producing bacteria in children. Relationship with the grade of tonsillar hyperplasy

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Abstract

Objectives

It has been suggested that bacterial biofilms are involved in chronic tonsillar disease, but there is a lack of strong evidence concerning their etiopathogenic role in childhood chronic tonsillar infections. The aim of this study was to assess the presence of biofilm-producing bacteria (BPB) in tonsillar bioptic specimens taken from children with recurrent exacerbations of chronic hyperplastic tonsillitis, and to evaluate the possible relationship between them and the patients’ demographic and clinical characteristics.

Methods

22 children (68.2% males; median age 6.5 years, range 3–13) with recurrent exacerbations of chronic hyperplastic tonsillitis were included. The presence of tonsillar BPB was assessed by means of the spectrophotometric analysis of tonsillar bioptic specimens taken during tonsillectomy between episodes of tonsillar infection.

Results

BPB were found in 50.0% of the 44 tonsillar specimens, and Staphylococcus aureus was the most frequent pathogen (81.8%). There was a significant relationship (p = 0.02) between the grade of tonsillar hyperplasy (GTH) and the presence of tonsillar BPB, with an increased relative risk (RR = 4.27, standard error = 2.57, p < 0.01) of tonsillar BPB development in children with GTH scores of >2.

Conclusions

The findings of this study: (1) confirm the presence of tonsillar BPB in children with recurrent exacerbations of chronic tonsillar infections; (2) suggest that GTH is an important indicator of the presence of tonsillar BPB; and (3) raise the question as to whether tonsillar biofilm is a causative factor or just a consequence of recurrent exacerbations of chronic hyperplastic tonsillitis.

Introduction

It is known that bacterial biofilms are involved in the chronicity of infections and resistance to antibiotic treatments, and therefore have a considerable negative impact on the patients’ quality of life and a significant effect on public health [1], [2]. Bacterial biofilms may play a role in various recurrent/chronic upper respiratory tract infections, including acute and chronic middle ear diseases [3], [4], chronic adenoiditis [5], and rhinosinusitis [6], and a few studies of limited case-series of patients have recently suggested that they are also involved in chronic tonsillar disease [7], [8], [9]. They have been found in the tonsillar tissue of children with chronic infections [7], [8], [9] and children with chronic tonsillar hyperplasia [7], but are more prevalent in the former. In 2009, Stoodley et al. [10] suggested that the tonsilloliths often associated with tonsillar inflammation [11] were actually polymicrobial biofilms that are structurally heterogeneous at confocal microscopy.

However, there are few published studies of biofilm formation on tonsillar surfaces, and a lack of any strong evidence concerning the etiopathogenic role of tonsillar biofilm in childhood chronic tonsillar infections. The aim of this study was to assess the presence of biofilm-producing bacteria (BPB) in tonsillar bioptic specimens taken from children with recurrent exacerbations of chronic hyperplastic tonsillitis during tonsillectomy between episodes of tonsillar infections, and evaluate the possible relationship between their presence and the patients’ demographic and clinical characteristics.

Section snippets

Study design

A longitudinal study at a tertiary hospital.

Study setting

The study was carried out at the Department of Clinical Sciences and Community Health and at the Department of Pathophysiology and Transplantation of Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico (Milan, Italy). The protocol was approved by our local Ethics Committee, and written informed consent was obtained from the children's parents or legal guardians.

Study subjects

Between March 2008 and February 2009, we recruited outpatients aged 3–13 years who

Results

BPB were detected in 50.0% of the 44 tonsillar specimens taken from the 22 enrolled children (68.2% males; median age 6.5 years, range 3–13 months). The main pathogen was Staphylococcus aureus, which was detected in 18 samples (81.8%). Table 1 shows the main demographic and clinical data.

Table 2 shows the microbiological results by GTH. The presence of tonsillar BPB did not correlated with gender, age, or the number of reported tonsillar infections in the previous 12 months, but there was a

Discussion

Our findings documented the presence of BPB in 50% of tonsillar bioptic specimens taken during tonsillectomy from children with recurrent exacerbations of chronic hyperplastic tonsillar infections. This confirms previous findings [7], [8], [9] and seems to be in line with the reported prevalence of tonsillar biofilm (41–85%) in limited case-series of patients with recurrent or chronic tonsillar disease [7], [8], [9]. Involvement of bacterial biofilm in a consistent proportion of children with

Financial disclosure

The authors have no sponsorships or competing interests to disclose in relation to this article.

Conflict of interest

None.

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