title: Selection of indicators for tonsillectomy in adults with recurrent tonsillitis.
abstract: BACKGROUND
  We aimed to find some new indicators for tonsillectomy (TE) in adults with recurrent tonsillitis (RT) by exploring whether the frequency of tonsillitis episodes and the length of morbidity period are associated with the macroscopic signs of sclerotic process in tonsils and microbiological data assessed by culture, molecular (PCR) and transmission electron microscopy (EM) methods.
  
  
  METHODS
  The study involved 62 RT patients admitted for TE (age range 15-35, median 22 years) and 54 healthy volunteers (age range 18-24, median 20 years). The index of tonsillitis (IT) was calculated by multiplying the number of tonsillitis episodes per year by the morbidity period in years. On oropharyngeal examination the presence or absence of three sclerotic signs was evaluated: tonsillar sclerosis, obstruction of tonsillar crypts and scar tissue on the tonsils. The occurrence of Streptococcus pyogenes was assessed by culture and PCR methods in 24 tonsillar core specimens. The samples for EM investigation of crypt epithelium were taken from 10 removed tonsils.
  
  
  RESULTS
  The IT values were in positive correlation with the number of sclerotic signs on oropharyngeal examination (r = 0.325, P = 0.010). Based on the IT values and the presence or absence of tonsillar sclerosis and obstruction of tonsillar crypts the receiver-operating curve (ROC) was constructed. It revealed that an IT score of 36 is an optimal cut-off value for prediction of sclerotic type tonsils. S. pyogenes was never found by culture, but its presence by PCR in nearly one third (29%) of diseased tonsillar tissue specimens was tightly associated with longer morbidity. EM revealed coccoid forms of intracellular bacteria in the crypt epithelium, which was accompanied with the damage of tight junctions between epithelial cells.
  
  
  CONCLUSIONS
  The index of tonsillitis > or = 36, being a combination between the frequency of tonsillitis and the length of morbidity period, predicts the sclerotic process in recurrently inflamed tonsils. Therefore, the high IT values could serve as an indicator for TE in adults. The correlation between the longer morbidity period and the presence of S. pyogenes by PCR suggests that persistent infection may have a role in maintenance of recurrent inflammation in tonsils.
authors.affiliation: Department of Microbiology, Tartu University, Ravila St. 19, Tartu 50411, Estonia. priit.kasenomm@kliinikum.ee
authors.forename: Priit
authors.initials: P
authors.lastname: Kasenõmm
authors.forename: Andres
authors.initials: A
authors.lastname: Piirsoo
authors.forename: Mart
authors.initials: M
authors.lastname: Kull
authors.forename: Mart
authors.initials: M
authors.lastname: Kull
authors.forename: Marika
authors.initials: M
authors.lastname: Mikelsaar