切替一郎著、野村恭也編：新耳鼻咽喉科学（改訂10版）、南山堂、2004.
Brodsky L.
Modern assessment of tonsils and adenoids.
Pediatr Clin North Am. 1989 Dec;36(6):1551-69. doi: 10.1016/s0031-3955(16)36806-7.
Abstract/Text
Modern assessment of the tonsils and adenoids is based on an appreciation of new concepts pertaining to the pathogenesis of tonsil and adenoid disease. Recognition of the emergence of beta-lactamase-producing and encapsulated anaerobic bacteria in the tonsils and adenoids should lead to a reconsideration of present therapeutic recommendations for antibiotic therapy in infectious tonsil and adenoid disease. The performance of a precise history, use of a standardized physical examination, and judicious use of laboratory evaluation are all necessary for appropriate patient management and improved communication between the pediatrician and otolaryngologist. Thus, appropriate recommendation for tonsillectomy and adenoidectomy will enhance their benefits, and the result will be happier and healthier children.
小泉敏夫: レ線高圧撮影による咽頭扁桃の観察（第2報—アデノトミー前後のレ線像の変化について）. 耳喉 30: 637-641, 1958.
Parikh SR, Coronel M, Lee JJ, Brown SM.
Validation of a new grading system for endoscopic examination of adenoid hypertrophy.
Otolaryngol Head Neck Surg. 2006 Nov;135(5):684-7. doi: 10.1016/j.otohns.2006.05.003.
Abstract/Text
OBJECTIVE: To propose and validate a new subjective grading system of adenoid size with flexible fiberoptic evaluation.
STUDY DESIGN AND SETTING: Digital video clips of 24 flexible fiberoptic nasopharyngeal exams were presented to 24 examiners (otolaryngology resident and consultant physicians) at a tertiary care institution. Examiners were asked to use the proposed grading system to rate adenoid hypertrophy. Kappa statistical analysis was used to evaluate the degree of intergrader agreement or disagreement.
RESULTS: Statistical analysis of intergrader agreement demonstrated an overall Kappa score of 0.71 suggesting a "substantial" strength of agreement. The Kappa strength of agreement was found to be 0.83 (almost perfect) among consultant physicians and 0.62 (substantial) among resident physicians.
CONCLUSIONS: The proposed adenoid staging system is a reliable and consistent method of staging adenoid tissue size.
SIGNIFICANCE: This new validated grading system may be a useful standard for reporting adenoid size in future clinical outcome studies.
Black NA, Sanderson CF, Freeland AP, Vessey MP.
A randomised controlled trial of surgery for glue ear.
BMJ. 1990 Jun 16;300(6739):1551-6. doi: 10.1136/bmj.300.6739.1551.
Abstract/Text
OBJECTIVE: To assess the effect of five different surgical treatments for glue ear (secretory otitis media) on improvement in hearing and, assuming one or more treatments to be effective, to identify the appropriate indications for surgery.
DESIGN: Randomised controlled trial of children receiving (a) adenoidectomy, bilateral myringotomy, and insertion of a unilateral grommet; (b) adenoidectomy, unilateral myringotomy, and insertion of a unilateral grommet; (c) bilateral myringotomy and insertion of a unilateral grommet; and (d) unilateral myringotomy and insertion of a grommet. Children were followed up at seven weeks, six months, 12 months, and 24 months by symptom history and clinical investigations.
SETTING: Otolaryngology department in an urban hospital.
PATIENTS: 149 Children aged 4-9 years who were admitted for surgery for glue ear and who had no history of previous operations on tonsils, adenoids, or ears and no evidence of sensorineural deafness. Inadequate follow up information on levels of hearing and on middle ear function was obtained from 22.
MAIN OUTCOME MEASURES: Mean hearing loss (dB) of the three worst heard frequencies between 250 and 4000 Hz, results of impedance tympanometry, and parental views on their child's progress.
RESULTS: In the 127 children for whom adequate information was available ears in which a grommet had been inserted performed better in the short term (for at least six months) than those in which no grommet had been inserted, irrespective of any accompanying procedure. Most of the benefit had disappeared by 12 months. Adenoidectomy produced a slight improvement that was not significant, though was sustained for at least two years. The ears of children who had had an adenoidectomy with myringotomy and grommet insertion, however, continued to improve so that two years after surgery about 50% had abnormal tympanometry compared with 83% of those who had had only myringotomy and grommet insertion, and 93% of the group that had had no treatment. Logistic regression analyses identified preoperative hearing level as the single best predictor of good outcome from surgery. Other variables contributed little additional predictive power.
CONCLUSIONS: If the principal objective of surgery for glue ear is to restore hearing then our study shows that insertion of grommets is the treatment of choice. The addition of an adenoidectomy will increase the likelihood of restoration of normal function of the middle ear but will not improve hearing. When deciding appropriate indications for surgery, a balance has to be made between performing unnecessary operations and failing to treat patients who might benefit from surgical intervention. Preoperative audiometry scores might be the best predictor in helping to make this decision.
Maw R, Bawden R.
Spontaneous resolution of severe chronic glue ear in children and the effect of adenoidectomy, tonsillectomy, and insertion of ventilation tubes (grommets).
BMJ. 1993 Mar 20;306(6880):756-60. doi: 10.1136/bmj.306.6880.756.
Abstract/Text
OBJECTIVE: To measure the time to spontaneous resolution of severe chronic otitis media with effusion (glue ear) in children and study the effects of adenoidectomy, adenotonsillectomy, and ventilation tubes (grommets).
DESIGN: Randomised controlled study over 12 years.
SETTING: Paediatric otorhinolaryngology clinics and in-patient unit.
SUBJECTS: 228 children aged 2-9 years with pronounced hearing loss from glue ear and persistent bilateral middle ear effusions confirmed on three occasions over three months.
INTERVENTIONS: Children were randomly allocated to adenotonsillectomy, adenoidectomy, or neither procedure. In all groups a Shepard type ventilation tube was inserted in one randomly chosen ear. Follow up was annually for five years and then less often for up to seven years four months. For analysis the two operated groups were combined.
MAIN OUTCOME MEASURES: Otoscopic clearance of fluid, change in tympanogram, and improvement in mean audiometric hearing threshold.
RESULTS: Survival analysis showed appreciable otoscopic and tympanometric resolution of fluid with ventilation tubes alone and adenoidectomy alone compared with no surgery. Further improvement was seen after combination of both treatments. Mean audiometric hearing thresholds improved with fluid resolution. Resolution was delayed in younger children and in those whose parents smoked, irrespective of treatment. Whereas a single insertion of a Shepard tube resolved the glue for a mean (SD) period of 9.5 (5.2) months, the effect of adenoidectomy was sustained throughout follow up.
CONCLUSIONS: Treatment of glue ear considerably shortened the time to fluid resolution, combined adenoidectomy and tube insertion being better than either procedure alone. Resolution was longer in younger children and those whose parent(s) smoked, irrespective of treatment.
Maw AR, Bawden R.
The long term outcome of secretory otitis media in children and the effects of surgical treatment: a ten year study.
Acta Otorhinolaryngol Belg. 1994;48(4):317-24.
Abstract/Text
Two hundred and twenty two children with bilateral secretory otitis media were allocated at random for adenoidectomy, adenotonsillectomy or for neither procedure. In all cases only a unilateral grommet was inserted. The contralateral unoperated ear was examined during a ten year period to show otoscopic clearance, change in tympanometric status and improvement in mean hearing threshold. Adenoidectomy or insertion of a grommet alone produces similar improvement but in combination are more effective than either procedure in isolation. The unoperated ear in cases not receiving either procedure reflects the natural history of the condition. It shows a steady improvement in all outcome measures as time passes.
Ogra PL.
Effect of tonsillectomy and adenoidectomy on nasopharyngeal antibody response to poliovirus.
N Engl J Med. 1971 Jan 14;284(2):59-64. doi: 10.1056/NEJM197101142840201.
Abstract/Text
Böck A, Popp W, Herkner KR.
Tonsillectomy and the immune system: a long-term follow up comparison between tonsillectomized and non-tonsillectomized children.
Eur Arch Otorhinolaryngol. 1994;251(7):423-7. doi: 10.1007/BF00181969.
Abstract/Text
Immunological functions of the tonsils and possible effects of their removal are still controversial. One reason for this is the lack of long-term follow-up investigations after tonsillectomy. In the present study selected parameters of the cellular and humoral immune systems of 160 children 0.5-11 years after tonsillectomy (mean 6.6 +/- 2.1 years) were compared to those of 302 age-matched non-tonsillectomized children. In tonsillectomized children the incidence of infections of the upper respiratory tract was not increased compared to the non-tonsillectomized control group. Slightly increased percentages of CD 21 + cells, raised counts of CD4+ cells, absolute and relative increases in DR+ cells and a raised CD4+ DR count was found mainly in tonsillectomized boys, while lymphocyte subpopulations of tonsillectomized girls remained unaffected. Tonsillectomized children had lower IgA levels, but the complement system was not altered in either sex. These findings show that while tonsillectomy may lead to certain changes in the cellular and humoral immune systems, these alterations are clinically insignificant and no increased frequency of immunomodulated diseases should be expected.
van den Akker EH, Sanders EA, van Staaij BK, Rijkers GT, Rovers MM, Hoes AW, Schilder AG.
Long-term effects of pediatric adenotonsillectomy on serum immunoglobulin levels: results of a randomized controlled trial.
Ann Allergy Asthma Immunol. 2006 Aug;97(2):251-6. doi: 10.1016/S1081-1206(10)60022-1.
Abstract/Text
BACKGROUND: It remains controversial whether pediatric adenotonsillectomy ultimately results in decreased serum immunoglobulin levels and if so whether such a decrease is associated with increased susceptibility to upper respiratory tract infections (URIs).
OBJECTIVE: To evaluate changes in serum immunoglobulin levels in relation to occurrence of URIs in children participating in a randomized controlled trial on the effectiveness of adenotonsillectomy.
METHODS: A total of 300 children aged 2 to 8 years, with symptoms of recurrent throat infections or tonsillar hypertrophy, were randomly assigned to either adenotonsillectomy or watchful waiting (WW). Serum samples were collected at baseline and at 1-year follow-up. Occurrence of throat infections and other URIs during first-year follow-up was recorded in a diary by the child's parents.
RESULTS: Paired serum samples were available for 123 children (63 in the adenotonsillectomy group and 60 in the WW group). IgG1 and IgG2 levels decreased but remained within the reference range for age in both study arms. IgM and IgA levels decreased as well but remained elevated. The IgA level in the adenotonsillectomy group decreased in significantly greater degree compared with the WW group, but this difference disappeared in cases where children experienced frequent URIs. In general, no relation between immunoglobulin levels and the number of throat infections or URIs at 1-year follow-up was found.
CONCLUSIONS: Immunoglobulin levels of children undergoing adenotonsillectomy decreased from elevated to slightly elevated or reference values for age during 1-year follow-up irrespective of treatment (adenotonsillectomy or WW). IgA showed a greater decrease in the adenotonsillectomy group but rose to levels comparable with the WW group in cases of frequent URIs. This finding indicates that the remaining mucosa-associated lymphoid tissue can compensate for the loss of tonsil and adenoid tissue.
Sainz M, Gutierrez F, Moreno PM, Muñoz C, Ciges M.
Changes in immunologic response in tonsillectomized children. I. Immunosuppression in recurrent tonsillitis.
Clin Otolaryngol Allied Sci. 1992 Oct;17(5):376-9. doi: 10.1111/j.1365-2273.1992.tb01677.x.
Abstract/Text
The possible immunoregulatory role of the tonsils was studied by determining immunoglobulins IgG, A, M, E and factors C'3, C'4 and PFB of the complement system before and after tonsillectomy. The synthesis in vitro of IgG and IgM by lymphocytes stimulated with pokeweed mitogen was also measured. There were statistically significant differences between pre and post-operative levels of serum IgG, IgA and IgM, which decreased after surgery. Practically no change in the mean values of IgE and no significant differences in the levels of serum C'3, C'4, and PFB, were found. The in-vitro synthesis of both immunoglobulins (IgG, IgM) by lymphocytes increased significantly after tonsillectomy. Our results suggest that not only does tonsillectomy have no counterproductive effect on the immune system, but that, on the contrary, it seems to improve the immune response, since it appears to unblock the suppression to which the immune system was subject.
Sennaroglu L, Onerci M, Hascelik G.
The effect of tonsillectomy and adenoidectomy on neutrophil chemotaxis.
Laryngoscope. 1993 Dec;103(12):1349-51. doi: 10.1288/00005537-199312000-00005.
Abstract/Text
Although tonsillectomy and adenoidectomy are common surgical procedures, the effects of these operations on the immune system have not been thoroughly determined. Our data on neutrophil chemotaxic functions in a group of 17 patients with chronic tonsillitis and adenoid hypertrophy show that chronic tonsillitis and adenoid hypertrophy impair neutrophil chemotaxic functions and that there is a subsequent normalization of these values following tonsillectomy and adenoidectomy.
Brouillette RT, Fernbach SK, Hunt CE.
Obstructive sleep apnea in infants and children.
J Pediatr. 1982 Jan;100(1):31-40. doi: 10.1016/s0022-3476(82)80231-x.
Abstract/Text
Twenty-two infants and children were found to have clinically significant obstructive sleep apnea. A history suggesting complete or partial airway obstruction during sleep was obtained on all patients, and physical examination of the sleeping patient revealed snoring, retractions, or OSA in 21 patients. Nevertheless, the mean delay in referral for 20 patients first seen after the neonatal period was 23 +15 (+ SD) months. Sixteen of 22 patients (73%) developed serious sequelae: cor pulmonale in 12 (55%), failure to thrive in six (27%), permanent neurologic damage in two (9%), and behavioral disturbances, hypersomnolence, or developmental delays in five (23%). Clinical and radiologic evaluations revealed anatomic abnormalities which narrowed the upper airway in 21 patients; enlarged tonsils and/or adenoids in 14, micrognathia in three,generalized facial abnormalities in three, and cleft palate repair/tonsillar hypertrophy in one. In five patients, upper airway fluoroscopy was performed and was helpful in establishing the site and mechanism of obstruction. Polygraphic monitoring was utilized to quantify the frequency and duration of OSA. Prolonged partial airway obstruction during sleep resulted in significant hypercarbia in 11 patients and hypoxemia in five. Twenty patients improved after surgery which relieved or bypassed the pharyngeal airway obstruction; two cases are pending. Increased awareness of OSA and examination of the sleeping patient should result in earlier treatment and less morbidity for infants and children with OSA.
Leach J, Olson J, Hermann J, Manning S.
Polysomnographic and clinical findings in children with obstructive sleep apnea.
Arch Otolaryngol Head Neck Surg. 1992 Jul;118(7):741-4. doi: 10.1001/archotol.1992.01880070071013.
Abstract/Text
A retrospective study was conducted to determine which types of children might have polysomnographic findings that are most compatible with obstructive sleep apnea (OSA). The charts of 93 patients who were aged 18 months to 12 years were examined. All 93 patients had symptoms that were initially suggestive of OSA, and they underwent polysomnography. The types of presenting symptoms and associated illnesses were noted. Physical findings, including height, weight, and tonsil size, were examined. Of 93 patients with symptoms that were suggestive of OSA, 34 met sleep study criteria for OSA. In 44 patients, OSA was not demonstrated, and 15 patients had other results. On the basis of age, sex, and symptoms, no significant differences could be found between the group with OSA and the group with normal polysomnographic findings. Cor pulmonale, tonsil hypertrophy, and failure to thrive were associated with OSA. Surprisingly, obesity was not significantly associated with OSA.
Richardson MA, Seid AB, Cotton RT, Benton C, Kramer M.
Evaluation of tonsils and adenoids in Sleep Apnea syndrome.
Laryngoscope. 1980 Jul;90(7 Pt 1):1106-10. doi: 10.1288/00005537-198007000-00005.
Abstract/Text
Peripheral Sleep Apnea syndrome has been associated with enlarged tonsils and adenoids as well as other abnormalities which may cause upper airway obstruction in children. A multidisciplinary approach is used at the Step Disorder Center of Cincinnati General Hospital to evaluate the role of tonsils and adenoids in sleep apnea. Polysomnographic techniques combined with cine sleep studies of the upper airway document the degree, site and type of obstruction. This presentation highlights the entity of obstructive sleep apnea and provides a rational clinical approach in the management of these patients.
American Academy of Sleep Medicine: The International classification of sleep disorders; 3rd ed, Academy of Sleep Medicine, Darien IL, 2014.
