Pathogenesis and Microbiology

Microbiologically, patients suffering from adenoiditis harbor an abnormal NP and oropharyngeal microflora. Typically, this flora is characterized by the persistent presence of two to five bacterial species that are frequently associated with clinical infections of the head and neck: GABHS, S. aureus, H. influenzae, Streptococcus pneumoniae, Candida albicans, enteric gramnegative aerobes and AGNB. The viruses often present are adenoviruses and Epstein-Barr virus (85,86).

The adenoids are believed to play a role in several infectious and noninfectious upper airway illnesses. They may be implicated in the etiology of otitis media (87-91), rhinosinusitis (92,93), adenotonsillitis (94), and chronic nasal obstruction due their hypertrophy (95,96).

Establishing the unique microbiology of the adenoids in patients with a variety of pathologic conditions is of importance, as it can assist in their management. Several studies have explored the aerobic bacteria microbiology of the adenoids (87,96).

Brook (97) compared the aerobic and anaerobic bacteria recovered from the core of adenoids obtained from 18 children with chronic adenotonsillitis (group A) and those of 12 children with adenoid hypertrophy and persistent middle ear effusion (group B) (Tables 4 and 5). Mixed aerobic and anaerobic flora was obtained from all patients, yielding an average of 7.8 isolates (4.6 anaerobes and 3.2 aerobes) per specimen. There were 97 anaerobes isolated. The predominant isolates in both groups were AGNB (including Prevotella and Porphyromonas spp.),

TABLE 4 Aerobic and Facultative Organisms Isolated from Excised Adenoids from 18 Children with Chronic Adenotonsillitis (Group A) and 12 with Adenoid Hypertrophy (Group B)

Group A Group B Total number

Isolates (18 patients) (12 patients) (30 patients)

Gram-positive cocci

TABLE 4 Aerobic and Facultative Organisms Isolated from Excised Adenoids from 18 Children with Chronic Adenotonsillitis (Group A) and 12 with Adenoid Hypertrophy (Group B)

Gram-positive cocci

Streptococcus pneumoniae

5

4

9

Alpha-hemolytic streptococci

14

9

23

Gamma-hemolytic streptococci

7

5

12

Group A, beta-hemolytic streptococci

6

4

10

Group B, beta-hemolytic streptococci

2

1

3

Group C, beta-hemolytic streptococci

1

1

Group F, beta-hemolytic streptococci

1

2

3

Staphylococcus aureus

9 (9a)

2 (2a)

ii (iia:

Gram-negative cocci

Neisseria spp.

15

12

27

Gram-positive bacilli

Lactobacillus spp.

2

3

5

Diphtheroids

7

3

10

Gram-negative bacilli

Haemophilus influenzae type b

7 (2a)

1

8 (2a)

Haemophilus parainfluenzae

3

1

4

Eikenella corrodens

2

1

3

Pseudomonas aeruginosa

2

2

Escherichia coli

3

3

Yeast

Candida albicans

3

1

4

Total number of aerobes and facultatives

88 (11a)

50 (2a)

138 (13a)

a Number of beta-lactamase-producing organisms. Source: From Ref. 97.

Fusobacterium spp., gram-positive anaerobic cocci, and Veillonella spp. There were 138 aerobic isolates. The predominant isolates in both groups were alpha- and gamma-hemolytic streptococci, beta-hemolytic streptococci (groups A, B, C, and F), S. aureus, S. pneumoniae, Haemophilus spp. H. influenzae type b and S. aureus were more frequently isolated in group A. B. fragilis was

TABLE 5 Anaerobic Organisms Isolated in Excised Adenoids from 18 Children with Chronic Adenotonsillitis (Group A) and 12 with Adenoid Hypertrophy (Group B)

Group A Group B Total number

Isolates (18 patients) (12 patients) (30 patients)

TABLE 5 Anaerobic Organisms Isolated in Excised Adenoids from 18 Children with Chronic Adenotonsillitis (Group A) and 12 with Adenoid Hypertrophy (Group B)

Gram-positive cocci

Peptostreptococcus spp.

12

7

19

Gram-negative cocci

Veillonella parvula

3

2

5

Gram-positive bacilli

Bifidobacterium adolescentis

1

1

Eubacterium spp.

2

2

4

Actinomyces spp.

2

1

3

Gram-negative bacilli

Fusobacterium spp.

2

1

3

Fusobacterium nucleatum

10

6

16

Bacteroides spp.

4

1

5

Pigmented Prevotella and Porphyromonas spp.

13 (7a)

9 (1a)

22 (8a)

Prevotella oralis

6 (3a)

5 (1a)

11 (4a)

Prevotella oris-buccae

4

2

6

Bacteroides fragilis group

2 (2a)

2 (2a)

Total number of anaerobes

61 (12a)

36 (2a)

97 (14a;

Total number of aerobes, facultatives, and anaerobes

149 (23a)

86 (4a)

235 (27a;

a Number of beta-lactamase-producing organisms. Source: From Ref. 97.

recovered only in group A. There were 27 BLPB isolated from 18 patients. Fifteen (83%) of these patients belonged to group A, while three (25%) were members of group B.

Brook et al. (98) determined the qualitative and quantitative microbiology of core adenoid tissue obtained from four groups of 15 children each: with recurrent otitis media (ROM), RAT, obstructive adenoid hypertrophy (OAH), and occlusion or speech abnormalities (controls).

Polymicrobial aerobic-anaerobic flora was present in all instances. A total of 89 organisms were isolated from controls, 146 from ROM, 142 from RAT, and 149 from OAH. The predominant aerobes in all groups were alpha- and gamma-hemolytic streptococci, H. influenzae, S. aureus, GABHS, and M. catarrhalis. The prominent anaerobes were Peptostreptococcus, Prevotella, and Fusobacterium spp. The number and distribution of types of most organisms did not vary among the three groups of diseased adenoids. However, the number of all organisms, those that are potential pathogens and BLPB, was lower in the control than the diseased adenoids (p < 0.001). The study highlights the importance of the bacterial load in the adenoids in contributing to the etiology of ROM, RAT, and OAH.

H. influenzae is more commonly recovered in patients with chronic adenotonsillitis when compared with those with adenoid hypertrophy (87,88,97). Another striking difference is the presence of BLPB in 83% of patients with chronic adenotonsillitis when compared with 25% in those with adenoid hypertrophy (98). Of particular interest is the higher prevalence of B. fragilis and the beta-lactamase-producing pigmented Prevotella and Porphyromonas and B. oralis. This could be due to the selective pressure of repeated antimicrobial therapy administered to these patients, which could select these BLPB.

The existence of BLPB, many of them anaerobic, within the core of the adenoids may explain the persistence of many pathogens in that area, where they may be shielded from the activity of the penicillins. The chronically infected adenoid tissue may also be a factor in the recurrence of middle ear disease by causing Eustachian tube dysfunction and serving as a source for pathogenic organisms (88).

Similarity and differences exist in individuals between the bacteriology of recurrently inflamed adenoids and tonsils. A recent study investigated the microbiology of the adenoids and tonsils electively removed from 25 children with a history of recurrent GABHS adenotonsillitis (99). Mixed flora was present in all instances with an average of 9.1 isolates/ specimen. The predominant aerobes were Streptococcus spp., H. influenzae, GABHS, and the prevalent anaerobes were Peptostreptococcus, Prevotella, and Fusobacterium spp. BLPB were detected in 75 isolates recovered from 22 (88%) tonsils and 74 from 21 (84%) adenoids. Discrepancies in the recovery of organisms were found between the tonsils and adenoids. Of the aerobic isolates, 18% were only isolated in tonsils and 18% only in adenoids. Of the anaerobes, 20% were found only in tonsils and 26% only in adenoids. This study demonstrates the similar polymicrobial aerobic-anaerobic flora in both adenoids and tonsils, and the discrepancies in recovery of pathogens. The adenoids may serve as a potential source of tonsillitis due to this organism.

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