Transcript for Ep 134 Tonsils: Underestimated and underappreciated

This is exactly right.

It sounds just awful, awful, awful. I'm so sorry.

Off the Furnged y'all wall. Oh, it's on my gosh.

I used suggested tonsils and I was like, what? And then immediately it was like, yeah, let's do it. I have no idea how this is going to go or what we're going to talk about, but like, why not?

Oh, I thought you were going to say like in your oral fairings. Oh, that was true.

Oh my God. Okay, so when I told my parents that we were gonna be doing tonsils, it's been hilarious to tell people that we're doing this episode. My mom was like, oh, I still have mine, but a lot of people don't. A lot of people my age and then she turns to my dad and she goes, do you still have your tonsils and he goes, yeah, I got mine. But everyone wanted to get theirs out. And I was like, what? And he goes, Well, you got ice cream.

In Madeline, was it her tonsils or her appendix? I don't know.

But first, but first, it's quarantine time.

In the spirit of tons of like dummies, we're drinking the cut throat.

It is a multi chocolate milk beverage that will make sense later. I promise. Multid milk powder and vanilla ice cream, chocolate sauce, some whiskey in there. Oh, it's just fantastic.

Our website, this podcast, okay, you.com. It's a pretty incredible website. If you haven't been there yet, check it out. We've got transcripts from all of our episodes. We've got sources from this episode and every one of our episodes. We've got links to blood mobile for music. We've got our good reads account, our, um, oh, I'm flailing here. We've got Patreon. We've got us there. Check it out. You're good. You're good. We got it. Okay, are we ready for the biology? Let's do it right out of this break. Okay. tonsils. Tonsils. I now I wish that I had written something really like clever to start this off with, but I didn't.

I know, you don't mean that screenshot of all the things they 92% rhyme with.

It's not even good. So first of all, what most of us think of when we think of our tonsils are in fact only one of four different tonsils in our buds.

So the set of two tonsils, it's a paired set of tonsils that sit at the back of our throat, the ones that get swollen when we get strep throat or any other infection, those are called our palatine tonsils. But we have three more. We have tonsils at the very base of our tongue, like where our tongue connects back in the base, that are appropriately named our lingual tonsils. We have a set that's like in the wall of our nasal pharynx way back up near the opening to our use station tubes. That's our ear tubes. And those are called our tubal tonsils. They're little. And then we have another one that sits at the top rear of our pallet in our nasopharynx, like above and behind our soft pallet, right in the midline, where our nose kind of connects to the back of our throat. And this particular tonsil, which is called our pharyngeal tonsil, is also called our adenoid. Ah, okay. So when you hear adenoids and tonsils, those are the same things they're just talking about two different sets of tonsils. Yeah. And everyone always says adenoids, but it's just one. Like it's one structure. It's not a paired set. It's a one. I mean, it's like JC pennies or Myers or sorry, you say JC pennies, plural?

I forgot about that. Yeah. Showing our Midwest. Anyways, anyways. Our adenoids and our tonsils. meaning our forageal tonsil and our palletine tonsils are the two that we all think of the most when we think of our tonsils because these are the ones that get big and swollen and oftentimes painful when we get an infection. So these are the two that will focus on kind of, but really when I'm talking about tonsils, it means all of these different things. So what are these things anyway? Like what the heck are tonsils?

Well, let me tell you, all of these tonsils are a type of tissue that are called mucosal-associated lymphoid tissue or malt. Oh yeah, okay. All of these tonsils together form a ring at the back of our throat, which is essentially at the opening of both our digestive and our respiratory systems, right? And this ring is sometimes called wall diers ring. Oh, I named after a guy. I don't know. I'm sure. But the function of all of these tissues, all of this ring of tonsular tissue, essentially, is in short to protect us against infection. the end. Our tonsils are part of our immune system.

Oh, great question. No. Our tonsils are by no mean the only forms of malt, mucosyl associated lymphoid tissue that exist. In fact, they are a small part of a large network of malt throughout our bodies. Basically, all of malt are these immune-related tissues that exist specifically on our mucosal surfaces. In our guts, we often call this galt gut associated lymphoid tissue. So we've gut tonsils? Yeah, pretty much. They're called pires patches. In our guts, we also have like isolated lymphoid follicles that just kind of scatter throughout our guts. And we have wait for it, an appendix. Uh-huh. Of course. Also lymphoid tissue. There's also bronchial malt, which is sometimes called bald. Although, not all humans have this. I don't know. It's probably really interesting. I didn't get into it. What? Rodents don't have tonsils, but they do have not, which is nasopharyngeal associated lymphoid tissue.

Well, let me bring it under your head again, because is that appropriate? Sure. I love it. So the question that we want to understand is like these globs of tissue that are associated with our immune system. Like, what does that actually mean? Like, what does it even mean to be a part of our immune system? What are they doing? What are they composed of? If we remember way, way, way back to our vaccines episode.

20 major throwback. In that episode, we talked about the very specifics of the ways that our immune system responds to antigens, basically responds to the stuff viruses bacteria dust proteins, the crud that we're exposed to all the time. And I won't make you go back and listen to that, but if anyone wants to, it's a great episode. But I'll summarize what we talked about really briefly so that we can understand tonsils. In that episode, I split the immune system into a four-act play focusing specifically on our adaptive immune system. The summary is basically that our bodies mostly via things like our nose and our mouth, but also our guts and our skin and our eyes are constantly exposed to hundreds of thousands of stuff. every day. And we call this stuff anagines. And our immune systems job is to identify all of this stuff and decide what belongs and what doesn't, what's a part of us and what is not supposed to be there and how to deal with it. And one of the major ways that we do this is that we have cells in our body called macrophages. These cells go along in either our bloodstream or our lymphatics. And they gobble up this crud, these antigens, wherever they're exposed to them, and bring them to our T cells, who then bring that crud to our lymph nodes, which we also touched on in our lymphatic polarized episode. And lymph nodes are where our B cells hang out, and our B cells are what make antibodies. Right. That will then be very specific to be able to find, neutralize, and destroy the crud, the antigens. It turns out that that part is accurate, but leaves out part of the story of our immune system, and that story is malt.

I just makes me think of malted milk. I mean, appropriate. Okay, so malt. The composition of malt tissue is very similar to our lymph nodes themselves. Except that it is not connected to our lymphatic system.

It gets cooler because the stuff that malt is sampling, the stuff that it's going to decide whether or not for our B cells to mount a response to, is being sampled directly from the mucosa itself, rather than going through macrophages traveling through the lymphatics and then making its way to the lymph nodes. So it's like first line. Exactly. It is first line. That is what malt is. It is first line immune system.

Anyway, it would be really interesting. Histologically, malt is very similar to lymph nodes, except that it doesn't tend to have a capsule. and again, they don't have any lymphatic drainage. But the outer cells of malt tissue, including our tonsils, have these cells called M cells, which are depending on the source called membrane cells or microfold cells. But these are cells that are essentially just really good at uptaking the stuff that our mucosa or nose or mouth are guts are constantly exposed to floating across our mucosa. These M cells take them up and then shuttle them into the core of these tonsils, or other maltissue, but we'll focus on tonsils for this episode. Our tonsils have these crypts, these like deep crypts. And so these structures are covered with this epithelial tissue, and then these M cells just like, swoop stuff into the inner bits, where are housed, B cells, and T cells? And these B and T cells do exactly what they do everywhere else in our body. They sample antigens, and then they make antibodies. And it gets even cooler, because I can see your face being like, what is this? Yeah, absolutely. Our multitudes, especially our tonsils and our pires patches in our gut. They make and secrete a kind of specialized type of antibody called IGA, which is different than other antibodies like IGM and IGG. And it's probably beyond the scope of this episode to get into the nitty gritty on all these different types of antibodies. But IGA is a really important type of antibody that really does function as a first line defense. on these new coastal surfaces. And it's being secreted from things like our tonsils and adenoids and in our guts and things like that.

It really is. It really is. Wow.

They essentially are what are like funneling and shuddling things in, in, in, in, in, in, in, in, in, in, in, in, in, in, in, in, in, in, in, in, in, in, in, in, in, in, in, in, in, in, in, in, in, in, in, in, in, And our tonsils, especially our Palatine tonsils, and our Adinoid or Fringeal tonsils, and the other ones as well, they are especially important in this role because they form this ring around the entrance to two of our most important systems that interact with the outside world, our digestive system, and our respiratory system. So our tonsils are being constantly exposed to everything all the time. So that's what they do, that's what they're for. They are a hugely important part of the development of our antibody mediated immune response, especially for things like respiratory viruses and bacteria.

Great question. The ones that you think of as tonsils, your palatine tonsils, the two that sit in the back of your throat, are the biggest, like physically, they're the big hunkers that you see. The tubular tonsils near you, station tubes, are really quite small. You're at an oide up in your nasal pharynx can get large and we'll talk about it. But it is just a single tonsil and is a little smaller than the others. And then your lingo tonsils back in the back of your tongue are actually a whole series of a bunch of really little things. Okay. like little little cell areas and nuggets. Okay. I'm doing things at my hand. Like patchy.

Patchy panties. Patchy vets.

Yeah, there's a lot of stuff. There was a lot where I was like, I don't know where to go from here. Like, that's what a console is. Like, now what? So let's start with Where can things go wrong? If these are something that is so great, then why don't we talk about when things are less great? I eat tonsillitis. Shall we?

So tonsillitis literally just means inflammation,itis in your tonsils. And again, at this point, when I'm talking about tonsils, I am primarily now only talking about the two big ones, the fringial tonsil that is your adinoids, and primarily the palatine tonsils that are commonly referred to as tonsils, right? So tonsilitis turns out it's not actually like a very specific thing because sore throat in general is really common. It's one of the most common symptoms. It's associated with so many viral infections. The flu, the common cold, covid, mono, so many bacterial infections, strep throat, many more. Not all sore throats will necessarily cause inflammation in the tonsils themselves. And sometimes a sore throat is just called like acute pharyngitis, which just means sore throat in medical terms, inflammation in the pharynx or whatever. But often there is some degree of tonsillitis, especially depending on the age of the person and the infectious agent, that happens when there is sore throat. There's a few different reasons why our palletine tonsils, the two in the back of your throat, are so very prone to this. Partly, it's because like I already said, they are constantly being exposed to and sampling all of the viruses and bacteria that we're exposed to and that just like live and hang out in our throats.

Yes, that's what it is. That's what happens. The crypts just get trapped sometimes. Stuff gets stuck in the aisles of Costco in our tonsils.

But then they can begin to proliferate before we've managed to mount a sufficient immune response, right? And that's going to cause some degree of blood flow inflammation to the area. Pain receptors, cytokines are going to be sent out, which are going to tell us that there's pain. There's also, I have a really interesting paper on like the actual pathophysiology of the pain of a sore throat that's like really fascinating and interesting. Um, but there's like a lot of open nerve endings that exist in that region, which is part of it. It's like, why? It's so painful. It's so painful, I know. But anyways, on top of that, a lot of the respiratory pathogens that cause sore throat, especially like all of the millions of rhinovirus serivars are really well adapted to the cells of our tonsils. So they are actually really good at not just being sampled by, but getting into and replicating within the cells of our consoles. So our tonsils cells, while there's like this trade-off, right? They're really good at sampling all of this material, but they're also really prone to infection because they sit at some of the most commonly infected sites in our upper airways. Right. On top of that, the people who get the most infections in their tonsils and the most severe infections in their tonsils are kids, especially school age kids. And part of that is because our tonsils, which are present from birth, actually grow during early childhood and they reach their peak in size in kids ages like four to eight and then they start to regress as we get older. Interesting. On top of that, comparative to body size, the tonsils are the largest in very young kids. So rather than like school age and like teenage years, when the tonsils are still kind of growing, when they're very young, like three, four, compared to the size of their throat, tonsils are really big. even though they're going to continue to grow. Does that make sense?

Yes. So that is where this type of inflammation can cause real problems. This infection and inflammation can either just be very recurrent, especially in like school aged kids from like five to 15. It can cause really recurrent infections, which can end up with a lot of miss school. or just a lot of pain, a lot of exposure to antibiotics, as we heard in our first hand account, which was not even during a school age. This kind of hypertrophy can also put kids at increased risk of things like recurrent ear infections, because hypertrophy of various tonsular tissue can also then compress the use station tubes where our ears are supposed to drain, which is what can increase the risk of ear infections. And of course, if tonsils and especially adenoids, which sit at the top back of our nasopharynx, become severely enlarged and hypertrophy, It can cause problems with breathing. Both in the acute form where an acute infection can be a real risk of respiratory distress or just over time, it can cause obstructive sleep apnea in kids. There is also a phenomenon that you may have heard of called peritonsular abscess.

Abscess in tonsils. And it's not really in tonsils, really. This is a complication that happens when an infection kind of spreads beyond the tonsils. It can also happen in absence of tonsils, even after a tonsilectomy, for example. But it's essentially just a group of deep space neck infections. So abscesses either right next to the tonsils or in the back of the tonsils or in the retroferendial or paraphringial space. Essentially our neck is very complicated with a whole bunch of things in it in a really small amount of space. So we have a lot of like, facial layers separating these all. And if infection spreads beyond some of those facial planes, it can become very severe and lead to airway compromise really easily. That makes sense. So these type of infections can be really serious because they can, you know, cause a lot of swelling and make it so that people can't breathe.

Anything can do it. Bacterial infections are going to be much more likely to cause an abscess than anything like a viral infection. And streptococchi, like your group A streptrop throat, is a really common one, but by no means the only pathogen that can cause these types of infections. Okay. Yeah. And then there are tonsils stones. Yay, I'm so glad you're talking about these.

Tons of stones are just collections of schmuts, really. It's unsatisfying, I feel. I know. It's just schmuts that get stuck in those little crypts in the tonsils. And what our body tends to do to schmuts anywhere in our body is kind of calcify it. To be like, let's wall this off and package it up so that it doesn't cause any more problems. And in so-doing, it can sometimes cause problems.

I don't know because I don't know what it means because I'm probably not smart enough.

No. Anyways, tonsils, stones, shmuts in your tonsils. These can also happen in your salary glands. Like, they can happen in a lot of other places. That's not, that's all I really have for that. It's not all that exciting. But those are the kind of ways in which tonsils can become a problem. And why someone might need to undergo a toncelectomy and or an adenoidctomy?

Yeah, so there's risks associated with surgery, right? So most of the complications that we see are in that acute phase where you have risk of things like bleeding, you have risk of infection as a result of surgery, bleeding is really the big one. And in really severe cases, people can end up dying as a result of complications from surgery. Very rare, but surgery is surgery and so complications can happen. Beyond that surgical complication time frame, we don't really have a lot of data to say that there are negative effects in the long term from not having tonsils. And when it's indicated, like in the case of really recurrent infections, or even in the case of obstructive sleep apnea in young kids, there is some data that there is benefit to tonsil removal in those cases. because it can significantly reduce the rate of recurrent infection and in kids with obstructive sleep it can improve their sleep even if it's only in the short term and we'll get more into that later. But it's fascinating that something that would appear as integral as a major source of antibodies and a major source of sampling of our environment to protect against infection can be removed with relatively little consequence. To me, what I think makes that so fascinating is it kind of shows how many redundancies we have in our bodies.

And it is, right? Because whenever tonsils are being removed, it's not all of them. You still have your language tonsils. You still have those tubal tonsils. Nobody's removing those. It's just the Palatine tonsils and sometimes the adenoids, sometimes both, but sometimes just like one or the other, right? So first of all, we have redundancy just within that. There's also additional, like, malt-like tissue throughout other parts of our mucosa that just isn't as well organized as the actual tonsils themselves. And then, of course, there's the rest of our entire immune system, which is doing all the same stuff. It's just doing it in a slightly different way than this mucosal lymphoid tissue is doing. So cool. It is. And there's a lot more that we could do in talking about malt and galt because. Yeah, like celiac, for example, is associated with discrepancies in galt and IGA secretion and things like that. Like it's, it's really cool.

It is. So that's tonsils. Aaron, they're amazing. They're so cool. Except from their problem. And then it's cool that you can take them out. So tell me, Aaron, where did we get to hear from? Is that?

Stop it. Oh, yeah. I don't want a millennia to go anyone cutting anything out of me. I gotta be honest with you. Well, listen to enough episodes of this podcast.

And quote, oh my goodness. Yeah. I can picture every piece of that that you just described like very clearly. And I don't like it.

Can you just imagine how much that would hurt because you're talking about an acutely inflamed angry organ and using a fingernail.

Also, someone is holding their hand. Yeah.

Wow, that is complicated.

Okay, yeah.

Sorry, I'm also really wondering why they were taking out people's euvielas?

We should, I guess.

I cannot. They're actual fingers. Yes. It's gruesome. Yeah. I also just like, I'm thinking about tonsils. Doesn't seem easy.

I can't wait to my nose.

No one wants a one-liner, Erin. No, they don't.

Like if they thought it was great, then it was great kind of a thing.

Uh-huh. Or you just don't see them anymore because there's nothing for you to search rice. Exactly.

I wonder how much of it could have been the bias of seeing only the abnormal that you see, right? Like if you only see the kids who are coming to you because their tonsils are giant and swollen and their causing problems, take them out, you're fixing people, but you're not seeing all of the people who's not having any problems with their tonsils and who are living just fine, right? But it's like, you only are seeing these so they're only a problem. I don't know, but I don't know. I don't know.

Oh gosh, with numbers like that, it's no wonder that it's part of our collective consciousness.

The statistics. Making things less fun for everyone, just kidding.

Not usually. Not usually air. Not usually. Like, it happens every day.

Oh, Erin, this is one of my favorite things because it's something I think about literally all the time at my other job, too.

It's, it's so long, Erin. Like, in the 1920s, it was probably even longer. And even today with the internet, it's still long.

Yeah, okay, let me tell you, right out to this break. Honestly, it was very difficult pretty much impossible to get any kind of data on incidents, prevalence of tonsillitis, or recurrent tonsillitis, or fair and dreadest, like, come on. We can't do that. It's too common. It's so common. It's everyone everywhere all the time. I had to start through yesterday, okay? It's nearly always self-limited. It's not an infection that we can track. But that doesn't mean I have no data for you. I found a very interesting paper out of the UK. It's a few years old now. But it was very interesting, what it looked at specifically was the incidence of toncelectomy and the proportion of these toncelectamies that were based on what they considered to be truly evidence-based criteria versus the proportion of toncelectamies that were not fitting with evidence-based criteria. This was from 2005 to 2016, so like a little old, but like that's super old, so like, kind enough. What's fascinating about this study is that what they found overall in conclusion is that in the UK, in the population that they looked at, it wasn't every kid in the UK, but it was several hundred thousand kids about four in one thousand children. And this, again, was all in children. Four in a thousand met evidence-based criteria for Tonselectomy. So first of all, we can talk about what does that actually look like? Like what today is considered guideline approval evidence-based for Tonselectomy? Yeah. The major criteria is what are called the paradise criteria. I don't know why, don't ask why. And this is pretty Like hardcore criteria, it is seven documented episodes of severe sore throat or tonsillitis in one single year. Seven. And part of it is that this is documented as severe sore throat, meaning that a sore throat that's not bad where someone doesn't go to the doctor wouldn't count because those episodes are considered to be less severe. Could you argue about access to health care, et cetera? Yes, definitely this is in the UK. They at least have a national health care system. Okay. So it's seven episodes of severe sore throat in one year or five per year for two years in a row or three per year for three years in a row. Okay. Those are the most common criteria, the paradise criteria. The other criteria that they considered in this paper to be evidence-based was a tonsiller tumor, which makes sense. Yep. And a condition called PFAPA, which stands for periodic fever. Apthus, stomatitis, pharyngeitis, and adenitis. That's a lot of ituses. It's a lot of ituses. And what this actually is is like a genetic condition that results in these periodic fevers, these ulcers in the mouth, and a sore throat, and swollen, tonsils, adenoids, and lymph nodes, and things like that. Okay. It's not super common. It's a genetic disorder. We could probably do a whole episode on it. But those are the three things that they considered as evidence-based criteria for taunt's electomy. Four in a thousand kids in this study met criteria. Like that was the overall prevalence. But less than one in seven of those kids had a taunt's electomy. Between two to three kids per 1,000 each year had a taunts elect me, but less than one in eight of the kids who had taunts elect me actually had an evidence-based indication. Whoa. Yeah. So like lots of kids met criteria for Tons Electomy for what they considered evidence-based criteria for Tons Electomy. Did not have a Tons Electomy? Uh-huh. And many, many more kids did not meet criteria for Tons Electomy and yet had a Tons Electomy. So their overall conclusion was that of the 37,000 Tons Electomies that were performed in the UK in this time, in this population each year, 32,000 of them were quote unnecessary.

Here's part of what's going on. A large proportion of the kids who underwent tons of electing me in this study had one, two, or three, or sometimes four, or five, episodes of tons of latest. So they had severe sore throat, they had evidence of tons of infection, but not enough per year to meet this evidence-based criteria. Okay. That's a big one. The other one is sleep apnea or obstructive sleep disorder breathing.

So in this paper, in the UK, it's not considered an evidence-based indication. But the number of kids who have been having and who have been recommended for taunt select me and really add annoyed act to me, especially, and sometimes not both, sometimes just add annoyed act to me. who were referred for tonsilectimese over that time period for obstructive sleep disorder breathing or obstructive sleep apnea increased over this time period and It's really interesting because in this paper, in the UK, it was not considered an evidence-based indication, but what they did mention is that there is data that shows that adenoyantectomy specifically, so removal of just that pharyngeal console. Does reduce snoring and can show short-term improvements in the quality of life on a few different metrics for kids ages five to nine who have obstructive sleep disorder breathing or obstructive sleep apnea and who undergo adenoidctomy? But there isn't a lot of long-term data on its effectiveness, and there is not necessarily data that it improves all possible outcomes or all possible complications associated with sleep disorder breathing. Okay. So according to this paper, that was not enough evidence to consider it an evidence-based indication. Does that make sense? Yes. It doesn't necessarily mean there's no utility in it or that it can't be beneficial. It just means according to this, there wasn't enough data. So I think that that's an interesting part because part of the story of the number of ton selectamies is like, how bad does it have to be? To consider ton selectamies evidence-based versus not, right? Like, what outcomes are we looking at? How much data do we have to prove that? Like, what are we going off of? So that was in the UK. What's interesting is that that paper highlighted that the rates of tonsillectomy vary really widely across the globe. That paper specifically just mentioned that rates in Belgium, Finland, and Norway are about twice as high as in the UK, whereas Spain, Italy, and Poland significantly lower than the UK. And then in the US, rates tend to be about three times as high as in the UK. So let's think about the U.S. for a quick moment here. Yeah, love to. According to the American Academy of Otolaringology and had an extraordinary foundation, and this was data that was in a 2019 update on their guidelines, but I think the data is older than that. There are about 289,000 tons of electimese performed each year just on kids under age 15. It's really hard to get data on tons of electimese in adults because it's a much, much less common procedure. Which, what's interesting about that number 289,000 is that Erin, you said that that was the number at the end of the 80s. So like, yeah, it just hasn't really changed, which I find really interesting.

The most recent update that I could find was 2019, but those had been updated again in 2011. And so it's not that infrequent that this society seems to be updating their guidelines. And what's interesting about the American Academy of Oterlingology's guidelines is that obstructive sleep disorder breathing is an indication for which they do recommend. I don't know you'd act to me. But they also say that the evidence is not as strong for this indication as it is for those paradise criteria indication really. And the newest guidelines have a strong recommendation. So like whenever you look at guidelines, it's always like low quality, moderate quality, high quality in terms of the evidence behind it. And then what is the recommendation? Is it like a think about it or like a week kind of recommend it or we strongly recommend it? That's like how guidelines are worded. So they updated their guidelines to strongly recommend holding off, watchful waiting unless a kid has had at least seven, unless a kid meets these criteria, essentially the paradise criteria. So it seems like the guidelines are really in terms of recurrent infections, moving more towards pause, wait, treat with antibiotics. Let's really wait and see if this kid truly needs a tonsillectomy. But in the case of sleep disorder breathing, maybe the numbers are going up as we get more evidence for it. Yeah, okay. At this point, we still don't have a ton of evidence for it, especially in the long term, but there is evidence for short-term improvements in sleep outcomes, as well as behavioral parameters, like school performance and things like that, because not being able to sleep affects a lot of your life. Yeah. We're not being able to breathe while you're asleep. I should say it for you. I mean, yeah. So that's kind of where we stand with tonsillitis and tonsillate activities. And when it comes to what I wanted to talk about with the future of tonsillitis, I really didn't know where I wanted to go. There seemed like so many possibilities, but luckily I found this fascinating paper took me to a place I never expected. In 2021, you're ready for this area. It's pretty exciting. I don't know. A better be. In 2021, there was a paper published in Nature Medicine by someone named Wagar at all, I think. Sorry if I pronounced it wrong. Here's what they did, Aaron. They took tonsil tissue, like tissue from discarded tonsils after a tonsilidectomy, I presume, and grew it in cell culture. Cool. And what this tonsil tissue did was re-aggregate it itself into little organoids, little baby tonsils on your own cell culture plate. And then what they did was they exposed these tiny baby little tonsils. Two things like, for example, alive, attenuated flu vaccine, which is something that we know a lot about how these flu vaccines work in our bodies and what kind of an immune response it generates. And they did this to study the immune response in these little baby organoid tonsils on a cell culture plate. What they were doing is creating a new type of model system to be able to study the human immune response. And specifically, our antibody mediated immune response, which, again, our tonsils are particularly good at, especially for things like respiratory infections.

That is so cool. It's so cool. They went beyond. They also tested it with like SARS-CoV-2 infection and vaccines. And then there was another study that I'll also link to that like just really specifically looked at using this as a model for SARS infection for SARS-CoV-2 infection. It is a fascinating, amazing tool to be able to study things like future vaccine development, to be able to test things and see what kind of an immune response is generated in a very realistic human model rather than just animal models which are far from perfect because animal immune systems are not the same as ours. Really cool, really exciting. I have a couple of fun papers for people to read. tonsils amazing. I know. If people want to read more, boy, have we got something for you?

I have a few tons of papers that I want to shout out, three of them. One by Cooper at all, Mucosa associated lymphoid tissues is the title, and it was, again, about all malt, and it was really a great read. Bathala at all from 2013 was a review on the mechanism of sore throat and tonsillitis. Super fascinating and really gets at why ice cream. Why ice cream cold inhibits the release of a lot of these cytokines and it can also like inhibit the actual pain receptors. So like cold is what you want in your throat when it hurts. Oh my gosh, there's more there. You can love about it. Okay. And then another one by Arambula at all from 2021 that was Anatomy and Physiology of the Palatine Tonsils, Adinoids and Lingual Tonsils. And then, of course, I have links to those recent papers about tonsil organoids and using them to study our immune response. You can find the list of sources from this episode, and every single one of our episodes on our website, under the Episodes tab.

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