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0THE IMPACT OF BILATERAL TONSILLECTOMY ON THE COURSE OF TIC HYPERKINESIS IN CHILDREN
Egamberdieva Z.D.
Tashkent Pediatric Medical Institute https://doi.org/10.5281/zenodo.13169200
Abstract. The article presents the results of observation ofpatients with chronic tonsillitis, occurring with tic hyperkinesis, who underwent bilateral tonsillectomy under general anesthesia. The group of patients consisted of 20 people; 20 patients were included in the comparison group. All patients had their complaints, anamnesis data, pharyngoscopic picture, clinical blood test, EEG, intraoperative features, as well as the postoperative period carefully analyzed before and after the operation. During the study, it was revealed that bilateral tonsillectomy, which was carried out for the purpose of sanitation of the focus of chronic infection in patients with tic hyperkinesis, leads to an improvement in the neurological picture manifested by tics.
Keywords: chronic tonsillitis, tonsillectomy, hyperkinesis, tics.
Chronic tonsillitis is a chronic infectious-allergic disease in which the infectious focus in the palatine tonsils occurs under the influence of decreased immunity. In this case, there is a transformation, activation and expansion of the innate natural process of limited inflammation in the crypts of the palatine tonsils, the products of this limited inflammation in a healthy person participate as an antigen in the stimulation and development of immunity in the lymphadenoid tissue of the palatine tonsils [1]. According to modern data, the prevalence of chronic tonsillitis ranges from 5-6% to 37% in adults and from 15% to 63% in children, which indicates the relevance of this problem. In the absence of treatment of chronic tonsillitis, local and general complications may occur, such as rheumatism, arthritis, vasculitis, glomerulonephritis and others [2, 3]. During a thorough study of the etiology, pathogenesis and clinical picture of chronic tonsillitis, a number of classifications were proposed. However, in recent years, the classification of B.S. Preobrajensky has become relevant, taking into account the degrees of toxic-allergic processes and the connection with associated and concomitant general diseases. According to B.S. Preobrajensky, a simple form of chronic tonsillitis and a toxic-allergic form (TAF) are distinguished, in which TAF I and TAF II are distinguished. In 96% of patients, exacerbation of CT (tonsillitis) is a pattern, but 4% of patients have a non-anginal form of CT [4,5].
The most pronounced changes in the internal organs are in the decompensated form of chronic tonsillitis. They are due to the impact of neuroreflex, bacteremic, toxicemic and allergic factors.
The imbalance in the immune status is also determined - redistribution in the content of Tand B-lymphocytes and their subpopulations, the presence of circulating immune complexes, sensitization of granulocytes to bacterial allergens.
Circulating immune complexes antigen-antibody have chemotoxic activity and increase the proteolytic capacity of macrophage enzymes, which leads to lysis of tonsil tissue, denaturation of tissue proteins, which as a result acquire antigenic properties. Getting into the blood, they cause the formation of autoantibodies. Thus, the palatine tonsils become a place of permanent delayed-type sensitization to antigens of streptococcus and staphylococcus - microflora, most often vegetating in the lacunae of the palatine tonsils.
The neuroreflex mechanism of the influence of chronic tonsillitis on the formation of associated pathology is also described. A.M. Monaenkov was the first to discover and study the afferent connections of the palatine tonsils with the most important subcortical formations, in particular with the structures of the posterior part of the hypothalamic subthalamic region. These nerve structures are involved in the regulation of natural active immunity, which determines the central determination of immunological reactivity disorders in chronic tonsillitis.
It has been established that under the influence of the flow of afferent signals from the tonsillar region, the functional state of the nuclei of the hypothalamic region is disrupted, and adrenergic receptors of neurons are excited. This serves as a trigger for the development of a breakdown in vegetative synergism and a sequential chain disorganization of other nerve structures. Such disorders of neurodynamic processes in certain subcortical and cortical parts of the brain are called "tonsilogenic" neurodystrophic process and are assessed as an obligatory component in the pathogenesis of any metatonsillar lesions. Based on information about the observed activity of this disease after an upper respiratory tract infection, doctors often resort to the practice of using tonsillectomy as a method of treatment in patients with tic hyperkinesis.
The frequent occurrence of recurrent tonsillitis and tics in patients gave rise to the first hypothesis that tonsillitis may contribute to the progression of tic hyperkinesis in children, since the tonsils can produce glycosylated IgA. In recent years, more and more reports in the literature, there are reports of post-streptococcal autoimmune diseases of the central nervous system [8]. The spectrum of post-streptococcal diseases of the central nervous system includes movement disorders (chorea, tics, dystonia, parkinsonism), mental disorders (especially emotional) and sleep disorders [9]. These diseases are especially common in childhood, and are therefore classified into a special group PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections) [10]. The epithelium of the NM is located in the lacunae and crypts and is larger in area than the intestinal epithelium, and also contains a system of specialized channels containing specific immune cells (M cells). These cells accept antigens into vesicles and transport them to the extrafollicular zone or lymphoid follicles of the LMW.
The lymphoepithelial pharyngeal ring is part of MALT (Mucosal Associated Lymphoid Tissue) - lymphoid tissue associated with the mucous membrane, which consists of NALT (Nasal Associated Lymphoid Tissue), BALT (Bronchus Associated Lymphoid Tissue), GULT (Gut Associated Lymphoid Tissue). MALT includes lymphoid and plasma cells scattered on the surface of the mucous membranes and involved in the formation of antibodies. MALT has direct contact with the external environment, the integumentary epithelium is involved in the induction of the immune response. According to modern concepts, the NM is not an independent anatomical unit, but a part of MALT or, in a broader sense, a part of the immune system. Germinal centres of the NM follicles represent the B-zone, participate in the training of B-clones of lymphocytes that produce immunoglobulins of classes A and M. T-lymphocytes are concentrated in extrafollicular zones.
The aim of the study was to evaluate the effect of bilateral tonsillectomy in patients with tic hyperkinesis on the course of the disease.
Materials and methods
At the Department of Otolaryngology at the Happy Life Clinic, a study is currently underway to evaluate the characteristics of the course of chronic tonsillitis and the effect of
bilateral tonsillectomy in patients with tic hyperkinesis. A total of 40 patients with chronic tonsillitis who were prescribed tonsillectomy were examined. The first group (20 people) included patients with chronic tonsillitis and tics, including 12 boys and 8 girls. The second group included 20 patients with chronic tonsillitis without concomitant pathology, including 9 boys and 11 girls. The study included children under 18 years of age with tic hyperkinesis who underwent bilateral tonsillectomy. A group with CT with tics and CT without tic hyperkinesis was distinguished, the postoperative condition and remote results were assessed. It was found that the size of the palatine tonsils does not significantly depend on the severity of tics, and the duration of clinical remission of the disease was statistically significant. Thus, this observation indicates the need for a more thorough examination of the palatine tonsils in this category of patients and a timely surgical approach [9].
All patients underwent bilateral tonsillectomy under general anesthesia by one operating team. All patients had their complaints, anamnesis data, pharyngoscopic picture, clinical blood test, intraoperative features, and postoperative period carefully analyzed. Patients noted their complaints on a scale from 0 to 3 before surgery. Among the complaints, the following were separately identified: sore throat, caseous plugs in the tonsils, subfibrillation, general weakness, and a feeling of bad breath. Based on these complaints, an analysis of the total clinical score was performed on a scale from 0 to 3, which revealed that in patients with chronic tonsillitis and tic hyperkinesis, symptoms of general intoxication were more pronounced than in patients without concomitant pathology. However, local complaints (sore throat, caseous plugs on the surface of the tonsils, bad breath) are more pronounced in patients without concomitant pathology (Table 1). Using a questionnaire and calculating the total clinical score, we analyzed the previous medical history of patients, paying special attention to the frequency of exacerbations of chronic tonsillitis, the presence of local complications of tonsillitis in the medical history, as well as an increase in the level of ASLO. Patients with tics suffered from tonsillitis less often and local complications of tonsillitis occurred only in the group of patients without concomitant pathology (Table 2). We assessed the pharyngoscopic picture using a scale from 0 to 3, where, for example, the presence of caseous plugs was assessed as 3 if a large number of plugs were detected on the surface of the tonsil during examination, 2 — single caseous masses, 1 — were detected only when pressing a spatula on the tonsil, 0 — no plugs. In patients with tic hyperkinesis, in most cases, the increase did not exceed the first degree, but there was a significant difference in the presence of adhesive changes in the tonsil tissue, which indirectly indicate long-term chronic inflammation of the palatine tonsils (Table 3).
It was noted that intraoperatively, patients with tic hyperkinesis had more intense diffuse bleeding; a more pronounced adhesive process between the tonsil capsule and surrounding tissues than in patients without concomitant pathology. The exception were patients without tics, but with a history of peritonsillar abscesses.
In the early postoperative period, patients with tics generally felt better. On the third day after surgery, patients with hyperkinesis had a less pronounced pain syndrome (pain was assessed using VAS in the morning before waking up and the mandatory 12-hour abstinence from analgesics), and body temperature normalized faster than in patients with chronic tonsillitis without concomitant pathology. All patients were examined 1 month after surgery. There were no differences in complaints or pharyngoscopic findings between the groups. Patients with tic hyperkinesis had their ASLO levels assessed. It was found that all patients with tics who underwent
bilateral tonsillectomy to sanitize the source of infection had a decrease in ASLO. According to the Wilcoxon test, the changes in the indicators were statistically significant (p<0.05).
Table 1
Complaints of patients with chronic tonsillitis with hyperkinesia (tics) and without
concomitant pathology
Group 1 Group 2
Sore throat 1,77 ± 0,5 1,87 ± 0,92 p>0.05
Presence of caseous plugs in the 0,62 ± 0,7 1,95 ± 0,8 p<0.05
tonsils
Subfibrillation 1,23 ± 0,5 0,43 ± 0,5 p<0.05
General weakness 1,77 ± 0,5 1,1 ± 0,85 p<0.05
Feeling of bad breath 0,85 ± 0,8 1,65 ± 0,94 p<0.05
Table 2
Anamnesis of patients with chronic tonsillitis with hyperkinesia (tics) a n d without
concomitant pathology
Group 1 Group 2
Frequency of tonsillitis 1,3± 0,4 1,9± 0,5 p<0.05
Local complications of tonsillitis 0 0,35 0,8 p>0.05
ASLO 0,15± 0,5 0,67± 0,8 p>0.05
Table 3
Pharyngoscopic data of patients with chronic tonsillitis with hyperkinesia (tics) and
without concomitant pathology
Group 1 Group 2
Hypertrophy of the palatine tonsils 1,1 ± 0,8 1,84± 0,6 p<0.05
Caseous plugs on the tonsils 0,92± 0,6 1,95± 0,7 p<0.05
Hyperemia of the palatine arches 1,46± 0,5 1,74± 0,7 p>0.05
Adhesive changes in the tonsils 2,3± 0,3 1,37± 0,4 p<0.05
Table 4
Clinical data of the early post-operativeperiod in patients with hyperkinesia (tics) chronic tonsillitis and without concomitant pathology, 3 days after the operation
Group 1 Group 2
Pain syndrome (VAS) 3-5 points 3-8 points
Body temperature within t returned to normal in 55.6% of t returned to normal in
3 days patients 32.0% of patients
ASLO within 3 days ASLO 5.6% (1 patient), decrease
in ASLO level from the initial Norm
level in 22.2% (4 people)
Conclusion
Performing bilateral tonsillectomy in patients with tic hyperkinesis in order to sanitize the
source of chronic infection leads to an improvement in the course of the underlying disease. It was
revealed that all patients with tics who underwent bilateral tonsillectomy in order to sanitize the
source of infection showed a decrease in ASLO
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