The lymphoid tissues of Waldeyer's ring play a key role in initiating immune responses against inhaled and ingested pathogens. The tonsils are responsible for the recognition and processing of antigens presented to the pharynx. The size of the tonsils is directly proportional to the amount of lymphoid tissue, which increases during antigen challenge. The reactive lymphoid hyperpla-sia of the palatine tonsils is often simply referred to as "tonsillitis" and in the case of the pharyngeal tonsil as

"(hyperplastic) adenoids". Tonsillar hypertrophy is associated with normal childhood development, mostly due to viral challenge or can be secondary to specific bacterial or viral infections. Childhood hypertrophy of the pharyngeal tonsil begins at approximately 2 years of age or during infancy and usually regresses by 8 years of age. Palatine tonsils hypertrophy at the end of the first decade, somewhat later than the pharyngeal tonsil. They regress by puberty and are atrophied in adults. The lingual tonsil enlarges at the time of puberty and regresses very little during adult life [41]. Tonsillar hypertrophy is usually symmetrical and diffuse, but can be papillary and unilateral.

The normal flora of the naso- and oropharynx includes anaerobic bacteria such as gram-positive Actinomyces and Proprionibacterium, and gram-negative bacteria such as Bacteroides, Fusobacterium and Vibrio [202]. Actinomyces israelii is a common nosocomial saprophyte in the oro-/nasopharyngeal cavity. The true incidence of tonsillar manifestations of actinomyces is unknown, but has been reported to be as high as 40% [57, 120]. Occasionally, actinomyces form small sulphur granules that can be seen as small yellow dots on the tonsillar surface. Larger aggregates of actinomyces may produce a tumour-like mass [172]. The tangled masses of gram-positive branching mycelial-like bacteria lie within the crypts or are attached to the surface epithelium of normal tonsils. Tonsillectomies for hypertrophied tonsils or adenoids are one of the most common surgical procedures, but the term "tonsillitis" is still poorly defined. Surgical resection specimens may demonstrate only hyperplastic lymphoid tissue and lymph follicles with enlarged germinal centres or no pathology at all [91].

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