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Rajabov Askarjon Hamroqulovich, PhD Head of Congenital and Acquired ENT diseases Department, Republican Specialized Scientific Practical Medical Center of Pediatrics, Republic of Uzbekistan Inoyatova Flora Ilyasovna, professor Head of Hepatology Department, Republican Specialized Scientific Practical Medical Center of Pediatrics, Republic of Uzbekistan Amonov Shavkat Ergashevich, professor Head of ENT, pediatric ENT and dentistry Department, Tashkent Pediatric Medical Institute, Republic of Uzbekistan
E-mail: [email protected]
Clinical course of chronic tonsillitis in children with chronic hepatitis B
Abstract: In the course of our study was investigated the clinical course of chronic tonsillitis in children patients in combination with chronic hepatitis B. There were 120 children patients aged 3 to 18 years under our supervision. Our study showed that chronic tonsillitis with chronic hepatitis B occurs with frequent exacerbations, which contributes to the development of severe forms of chronic hepatitis B and affects the rate of disease progression and the frequency of adverse outcomes.
Keywords: tonsils, chronic tonsillitis, chronic hepatitis.
General medical value of tonsil's pathology caused by that described more than 100 diseases associated or combined with chronic tonsillitis can affect to the function of remote organs and chronic tonsillitis, which also includes liver diseases [4; 7]. systems. Chronic inflammation of tonsils is the direct or indirect Connection of pharyngeal lymphoid ring diseases with abnor-
cause of many pathological states in children, as well, as factor malities of the liver and biliary system is shown in the few research which deteriorates a course of various diseases [3]. Currently, it is works [1; 6]. A number of studies concerning the relationship of
Clinical course of chronic tonsillitis in children with chronic hepatitis B
the liver pathology with pathology of the tonsils mainly described the effect of focal infection of the tonsils to the functional state of the liver, as well as the influence of the late one to the course of acute viral hepatitis in adults [2; 5]. A pathogenetic mutual chronic tonsillitis and chronic hepatitis B (HBV) in children currently have remained almost unexplored. So far, there is no clear answer to the question, how does tonsil infection affect to the state of the liver, and in which clinical forms this relationship is shown.
Based on the above said, our aim was to identify the clinical manifestations of two different diseases in combination. That is why, it was interested to study the features of the clinical course of comorbidity in order to increase the representation of both mutual influence and interdependence.
Materials and methods. During study was supervised 120 children aged 3 to 18 years. 60 children from them with chronic tonsillitis in combination with chronic hepatitis B (basic group). For a comparative analysis of monopathology and comorbidity, it has taken the following two groups: 30 patients with chronic tonsillitis (first comparative group) and 30 children with chronic hepatitis B (second comparative group).
Methodology of survey included the following: a detailed study of the complaints and medical history of patients, the general ENT examination and pharyngoscopy with squeezing gaps content, X-ray of the paranasal sinuses in the nasomandibular position. The diagnosis of chronic hepatitis B was set on the basis of medical history,
A significant role in the diagnosis of chronic tonsillitis is given to the results of the physical examination of the pharynx, i. e., pharyngoscope which are presented in comparative aspect in Table 1.
During survey of all patients were found significant changes in the status of palatine tonsils and palatine arches. Hypertrophy of palatine tonsils at pharyngoscopy was found in 86,7±4,4% children in main group ofpatients, but in the group with chronic tonsillitis was found -63,3±8,8% (P<0,05) children.
Important in the diagnosis of CT, is to define the gaps content ofpalatine tonsils. Content in the gaps defined pressing by two spatula on front palatine arches, liquid purulent secret revealed at 86.7 ± 4.4% of patients the main group, and in children with CT 43.3 ± 9.0% (p < 0.001).
A similar pattern was observed in sign of edema upper sections of the front and rear arches (p < 0.001). Tuberoses, loosening and
clinical examination, a series ofbiochemical, serological and instrumental studies.
Results. In all patients manifestations of chronic tonsillitis and HBV had recurrent tonsillitis, symptoms of tonsillogenic intoxication, dyspepsia, increasing and sealing of the liver, as well as signs of discomfort in the gastrointestinal tract. On admission in stationary treatment patients, who observed by us, complained to throat disease in 38 (63.4%) — were indications of typical angina, occurs with an increase in body temperature to 38-39°, great pain in the throat when swallowing, and severe symptoms of intoxication. In 15 (25.0%) patients exacerbations preceded on the background of subfebrile temperature, insignificant sore throat and general intoxication. In 7 (11.6%) patients noted impermanent sore throat with varying intensity of pain on the background of normal body temperature and no violation of the general condition.
Along with this, these contingents noted pain in the heart and joints during and after acute chronic tonsillitis. They were prone to frequent acute respiratory viral infections.
The study of children anamnesis, which was under our supervision, let to identify groups of patients depending on the frequency and nature of the exacerbations. All the sick children — 60 (100%) stated a few chronic tonsillitis exacerbations as banal angina within one year. 32 (53.3%) patients chronic tonsillitis exacerbations ranged from 3 to 5 times a year, 8 (13.3%) — up to 3 times, in 20 (33.4%) — more than five times a year.
surface roughness of palatine tonsils are marked in the main group at 76.7 ± 5.5% of patients. The consistency of the tonsils was dense cause of scarring tissue changes, while this symptom in children comparison group amounted to 63.3 ± 8.8% (p < 0.05). In 4 (6, 7%) patients with co-infection have established the presence of suppuration follicles as cold abscesses, and in patients Chronic tonsillitis this symptom is not detected (p < 0.05). Enhanced vascular pattern of the mucous membrane of the palatine arches marked at 66.7 ± 6.1% of patients (p < 0.001).
Changes of palatine arches, expressed hyperemia and infiltration, installed at 50 (83.3%) a main group of patients against 46.7 ± 9.1% (p < 0.001) group CT, the presence of adhesions between tonsils and arches 73.3 ± 5.7% against 26.7 ± 8.1% (p < 0.001). By palpation at 42 (70.0%) patients noted an increase and moderate pain of regional submandibular lymph nodes (p < 0.01).
Table 1. - Local symptoms of chronic tonsillitis in patients with chronic hepatitis B
Sign Chronic tonsillitis Chronic tonsillitis + Chronic Hepatitis B P
Number of patients n=30 Number of patients n=30
abs % ± m abs % ± m
Liquid pus in the gaps 13 43,3±9,0 52 86,7±4,4 <0,001
Purulent cheesy plugs 17 56,7±9,0 8 13,3±4,4 <0,001
Hyperemia of palatal arches 14 46,7±9,1 50 83,3±4,8 <0,001
Swelling of the upper sections of the front and rear arches 13 43,3±9,0 52 86,7±4,4 <0,001
Hypertrophy of tonsils 19 63,3±8,8 52 86,7±4,4 <0,05
Loosening of the surface of the tonsils 18 60,0±8,9 46 76,7±5,5 >0,05
Scar adhesions tonsils with arches 8 26,7±8,1 44 73,3±5,7 <0,001
Festering follicles in the form of «cold» abscesses 0 0 4 6,7±3,2 <0,05
Reinforced vascular pattern mucosa palatine arches 0 0 40 66,7±6,1 <0,001
Yellowness of the mucous membrane of the palatine and arches 0 0 36 60,0±6,3 <0,001
The increase of regional lymph nodes 12 40,0±8,9 42 70,0±5,9 <0,01
Footnote: *- differences between data of chronic tonsillitis and chronic tonsillitis + chronic hepatitis B are statistically significantly (*- P<0.05).
Hypertrophy of the palatine tonsils was observed in 52 (86.7%) of 60 patients, of whom 22 (42.3%) patients — II degrees, 12 (23, 1%) — III degree, and 18 (34.6%) — I degree. In patients with hypertrophy of palatine tonsils II — III degree were also complaints about the violation of breathing during sleep, which was accompanied by snoring and nocturnal attacks of breathlessness.
It should be noted that 52 (86.7%) observed patients revealed the simultaneous combination of two or more clinical signs of local chronic tonsillitis. In addition, patients parallel complained of to the pathology of the liver. So, weakness, lethargy and fatigue observed in the majority of patients and lasted an average of 1215 days on the background of acute chronic tonsillitis. Decreas-
ing of appetite had all patients, pale and dry skin in 57 (95.0%) patients (Table. 2).
Headaches were observed in 43 (71.6%), irritability observed in 52 (86.7%), abdominal pain were 54 (90.0%), nausea — in 26 (43.4%), slight yellowness of skin in 57 (95.0%) patients.
More than half of the patients had extra hepatic signs: palmar erythema in 45 patients (75.0%), capillary network — 36 (60.0%), spider veins — in 29 patients (48.3%). All patients were observed enlarged liver, which appeared from under the costal arch from 1 to 3 cm. The consistency of the liver had an average surface density. Increasing of the spleen size was observed in 14 (23.4%) children in the main group.
Table 2. - Clinical symptoms of chronic hepatitis B in patients with chronic tonsillitis
Sign Chronic hepatitis B Chronic tonsillitis + Chronic hepatitis B P
Number of patients n=30 Number of patients n=60
abs % ± m abs % ± m
Paleness and dryness of skin 16 53,3±9,1 57 95,0±2,8 <0,001
Decreasing of appetite 23 76,7±7,7 60 100,0 <0,01
Pain in belly 16 53,3±9,1 54 90,0±3,9 <0,001
Irritability 8 26,7±8,1 52 86,7±4,4 <0,001
Weakness 17 56,7±9,0 48 80,0±5,2 <0,01
Flatulence, nausea 9 30,0±8,4 26 43,4±9,9 >0,05
feeling of heaviness in the right upper quadrant 12 40,0±8,9 56 93,3±3,2 <0,001
Slight yellowness of sclera 13 43,3±9,0 36 60,0±6,3 >0,05
Palmar eritema 10 33,3±8,6 45 75,0±5,5 <0,001
Telangiectasia on the trunk 3 10,0±5,5 29 48,3±6,5 <0,001
Increasing of the liver 18 60,0±8,9 60 100,0 <0,001
Increasing of the spleen 7 23,3±7,7 14 23,4±11,7 >0,05
Footnote: *- differences between data of Chronic tonsillitis and Chronic tonsillitis + Chronic hepatitis B are statistically significantly (* - P<0.05)
In almost all patients were observed intoxication in different degrees. Most patients had signs of discomfort from the gastrointestinal tract in the form ofweakness 48 (80.0%), nausea and flatulence noted in 26 (43.4%), a feeling of heaviness in the epigastria region and the right upper quadrant in 56 (93 3%) patients. Localization of telangiectasia 29 (48.3%) patients were diverse, but more often they are seen on the face, neck and palms of the hands.
Conclusions. Chronic tonsillitis with chronic hepatitis B in children proceeds harder than usual isolated form, manifested severe local and general clinical symptoms.
The clinical significance of chronic tonsillitis children patients by chronic hepatitis B is defined by its role in the development of severe forms of the course; influence the rate of progression of the underlying disease and the incidence of adverse outcomes. Wherein the major clinical syndromes of chronic hepatitis B were astheno-vegetative, dyspeptic, and enlarged liver and spleen.
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