Effect of Tonsillectomy on Antistreptolysin O (ASO) Titer

R ecurrent attacks of tonsillitis are a common worldwide problem and the best treatment of choice after failure of medical therapy is a tonsillectomy. The large numbers of patients that presented with recurrent attacks of tonsillitis and associated with high antistreptolysin O (ASO) titer level due to group A beta hemolytic streptococcal (GABHS) tonsillitis will have serious complications as glomerulonephritis and rheumatic fever. The aim of study: to evaluate the effect of tonsillectomy on elevated ASO titer. Patients and methods : Prospective non-randomized clinical study was performed at Al-Jumhory teaching hospital, Mosul, Iraq; for the period from January 2021 to January 2022. that included seventy patients for whom tonsillectomy was indicated. There were 45 females and 25 males, the age range from 3 to15 years old and the mean age was7.63 year. Positive throat swab for group A beta hemolytic streptococcal (GABHS) and elevated ASO titer level (≥200 IU/ml). Postoperative follow up of the patients were processed for six months. Results: seventy patients included in the study, presented with recurrent attacks of tonsillitis, with positive throat swab for GABHS and elevated ASO titer level (≥200 IU/ml), age between 3 to 15 years old .Follow up of the patients for six months after tonsillectomy had been shown that there is a significant decrease in ASO titer level in comparison to preoperative level measures (p <0.001 ) Conclusion: The most important conclusion from the result of


INTRODUCTION
Tonsillectomy, is the palatine tonsils removal surgically, is advised to patients suffer from tonsillar hypertrophy or recurrent tonsillitis, because such diseases can lead to repeated use of antibiotic, chronic pain, and obstruction of the airway like secondary otitis media, or speech impairment. and obstructive sleep apnea (OSA) [1] One of the few surgical procedures is tonsillectomy that raised from ancient times and is still carried out till now. The tonsillectomy incidence in the United States reaches 2 million in 1940s, commonly done for recurrent tonsillitis but also for many other conditions like failure to gain weight because of poor feeding, enuresis, and overbite. Tonsillectomy continued to be a trend in the1960s and, about two million of tonsillectomies and being adenoidectomies carried out yearly in the United States. Nowadays, still tonsillectomy is one of the predominantly carried out, with around 400,000 surgeries carried out yearly. The reduction in the tonsillectomy number is may be associated with clinical trials that concluded in clear tonsillectomy indications. [2] ASO titer group A beta-hemolytic streptococci (GABHS) is responsible for production of 2 hemolysins, streptolysin O (a cytolytic toxin) only the latter is antigenic and streptolysin S. Streptolysin O biologic properties composed of erythrocytes hemolysis and other eukaryotic cells; and also lead to leukocytes damage. There will be a host production of antibody against this toxin, and the commonly used, available and standardized group A streptococcal antibody tests is the Anti-streptolysin O (ASO). But unfortunately this antibody does not give host protection role [3]. The ASO is an antibody formed against streptolysin O which is oxygen-labile hemolytic toxin, and immunogenic that formed by most strains of group A and most strains of group C and G Streptococci . [4] Reasons behind ASO titer increment  Infections by S. pyogenes or GABHS  pyoderma  toxic shock syndrome  scarlet fever  rheumatic fever  erysipelas  Cellulitis  necrotizing fasciitis  puerperal fever  bacteremia and sepsis [4]  multiple myeloma  high rheumatoid factor and hypergammaglobulinemia [3]  Tuberculosis  hepatic disorders may cause false positive titer of ASO [3] Causes of low ASO titer The low ASO values could be explained purely on lack of streptococcal antigenic stimulus which stimulate the antibody, though we would expect all these children to have experienced infections with haemolytic streptococci of groups C or G, which have low stimulation of this antibody. [5] GABHS infection in the human body produces several toxins; the one with antigenic nature is Streptolysin O. ASO is detected in the serum beyond infection with Group A Streptococcal as it is a normal immunological response. An elevation of ASO titer is probable beyond infection with Group A Streptococcal in any part of the body. [6] an increment of ASO above 200 IU/ml is considered as a raised level and represent an alarm of probable of rheumatic fever development. It obviously known that at every attack of rheumatic fever is related with an increment of ASO titer and an increased ASO titer level is one of the criteria for rheumatic fever diagnosis based on the modified Johnes criteria [7] Aim of the study This study aims at evaluation of the tonsillectomy effect of on ASO titer elevation.

Laboratory investigations
Hematological investigations Routine blood and virology screening tests (HBV,HCV,HIV). Lab examination of blood in terms of total number of white cell and differential count, haemoglobin, Erythrocytes sedimentation rate (ESR) bleeding time (BT) general urine examination (GUE) prothrompin time(PT) activated partial thrompoplastin time (APTT) blood group and rhesus group,covid19 test by polymerase chain reaction (PCR) Throat swab Swab from Throat was taken from tonsil mucosal surface through a sticks of sterile swab and then sent for culture to identify the organism.

ASO titeration
Sample of blood was taken and sent for laboratory to be examined for ASO titer before surgery, 2.5ml of fresh blood are used. Tonsillectomy Tonsillectomy under general anaesthesia performed for all patients with maintenance of the airway using either cuffed or uncuffed orotracheal tube. The tube is fixed carefully by use of the plaster to one side or in the centor of the phayrnx when we use doughty tongue blade and care is taken not to be encroached between the tongue and mouth gag. Put the patient in a rose position (patient in supine position with neck extention). Good exposure of the tonsils done by opening the mouth is usually performed with a Boyle Davis mouth gag, with extended head, elevated mouth gag and with Mayo stand connection on that the instruments to carry out the tonsillectomy are put and it is important that wet gauze put into hypopharynx not to allow the oxygen escape and escape of the agent of anaesthetic drug from the endotracheal tube through the operation and also prevent the blood from escape to the stomach during procedure. Cold steel dissection technique was performed in all patients; Before starting the procedure, the palpation of the hard and soft palate was performed for submucous cleft palate exclusion because this that may increase the risk of velopharyngeal insufficiency postoperatively. Once the mouth gag blade in a position and tongue are centered. An opening of the mouth gag is done, an examination carefully done ensure perfect the following; protection of the tube, not entrapping the upper lip, coverage of the base of the tongue by the tongue blade. The procedure of tonsillectomy is begin with an incision at anterior pillar just lateral to the mucosal reflection of the surface of the tonsil. This become easy by use of Dennis Browne tonsil holding forceps to catch the tonsil and pulling it medially with slight inferiorly to place the mucosa of the anterior pillar under tension. The tonsil is retracted inferiorly, when the capsule of the superior pole of the tonsil has been determined. This step usually helped by tonsil repositioning by a holding forceps. The tonsil can be removed easily by using snare, if the lower pole of the tonsil has been reached.
After the completion of this procedure, normal saline solution irrigation of the pharynx was carried out. To ensure that bleeding is not being controlled merely by mouth gag compression, the mouth gag closed and opened once or twice. After the end of operation the patient is shifted to the ward after awakening from anaesthesia and confirming that there was no bleeding. In day zero postoperatively the patient checked for presence any bleeding and recommended to have cold soft diet and fluids, with a course of antibiotics (amoxil vial 500mg each 8hours for 3 days or azithromycin syurp 10mg/kg once dialy) and analgesia was given for one week duration postoperatively for all patients. Parents or relatives of the patient are recommended to return to hospital if there is any bleeding or inability to swallow due to severe pain or any other problems for re-evaluation and emergency intervention once, required. Most of the patients were day case ,so, we discharge the patients to home after about 5 to 6 hours later. Follow up of the patients after tonsillectomy Estimation of ASO titer level was performed after first month, third months and sixth months after tonsillectomy.

Statistical analysis
The statistical package for social sciences (SPSS) version 22 for windows is used for processing and analysing study data statistically. The data were Described statistically in terms of mean+/-standard deviation (SD) and frequencies as percentages-tables test was use for continuous variables. Correlation was assessed using the Pearson(R correlation coefficient), the statistically significance of data considered when P-value of <0.05.

Results
Tonsillectomy was performed for 70 patients with positive ASO titer ≥ 200 IU/ml. and positive throat culture for GABHS. Their age ranging from 3 to 15 years old. The mean was 7.63 years; the (±SD) was 3.27±. Around one third of the sample 32.9% aged 6-8 years and one third of the sample 35.7% were males and Around one third of the sample 31.4 was rural area. The means of ASO titer measured,first,third,sixth month postoperatively were significantly less than the mean ASO titer 421.86 measured preoperatively p < 0.001.

Discussion
Rheumatic fever and glomerulonephritis are serious non suppurtive complications of streptococcal tonsillitis due to the underestimation of the value of precocious determination of throat infection with streptococcal and early efficient therapeutic interference. ASO titer test is the most widely used test. It is more popular because of its availability in our country, less cost and reasonable sensitivity. [3] The study was performed on 70 patients between 3 to15 years old presented with recurrent attacks of tonsillitis, high ASO titer level (≥200 IU/ml) and positive throat swab for GABHS for whom tonsillectomy was performed.  [10] found that about 53.3% of family history of tonsillitis having positive history of recurrent attacks of tonsillitis. Bakir S.S.at 2017 [9] found positive family history of tonsillitis about 51%, and this agree with our study. Conclusion: The most important conclusion from the result of our study is that tonsillectomy lead to significant reduction in ASO titer level.