1. Introduction
Actinomyces is a genus of Gram-positive, slow-growing, non-spore-forming, and non-acid-resistant anaerobic bacteria with a branched filamentous shape [
1,
2,
3,
4,
5].
Actinomyces is a part of the physiological flora of the oral cavity, throat, intestines, genital tract, and skin in humans [
5,
6,
7]. However, these bacteria can sometimes be an etiological factor in the development of infections [
5]. They can penetrate soft tissues, leading to infection which is favored by hypoxia associated with inflammation resulting from trauma, surgery, cancer, or another infectious disease [
2,
7,
8,
9,
10]. Actinomycosis can involve all tissues and organs [
11]. The disease process is most often related to the cervicofacial region (55%), the abdominopelvic region (25%), and the pleural-thoracic region (15%), with 5% of cases involving another location [
2,
9,
12,
13,
14]. The symptoms of actinomycosis are site-specific. The most predominant clinical features include abscesses, poorly healing fistulas, nodular lesions, and granulomatous fibrous inflammatory infiltrates. In the most common cervicofacial manifestation, the disease process primarily involves the soft tissues and the mandibular region, and less frequently affects the oral cavity, tongue, or pharynx. In all cases, actinomycosis should be differentiated from a neoplastic process [
13].
Actinomyces israeli is the most commonly isolated species of
Actinomyces [
2,
5,
6,
11,
15]. In the oral cavity,
Actinomyces has been found in carious dentin, dental plaque, on the gingival surface, and in tonsillar crypts [
5,
16,
17,
18]. The presence of tonsillar
Actinomyces is confirmed by the assessment of histopathological samples of filamentous clusters of basophilic microorganisms arranged in a radial pattern (“ray-fungus”) or bacterial cultures [
4,
5,
19]. Hematoxylin and eosin staining is considered an effective method for identifying these bacteria (
Figure 1) [
1,
14].
According to the literature, reports on the role of
Actinomyces in palatine tonsil diseases are inconclusive [
1,
2,
3,
4,
18,
19,
20,
21,
22,
23,
24]. Some studies have found that they are commensals, fortuitously detected during postoperative histopathological examination, and their presence is not indicative of active disease. Other studies stressed their significant role in the development of tonsillar pathology. Treatment of some conditions could primarily rely on pharmacotherapy, thus reducing the frequency of tonsillectomies associated with elevated postoperative pain and the risk of bleeding. Additionally, if proven, an association between
Actinomyces bacteria and the occurrence of postoperative complications, along with increased postoperative pain, could lead to the implementation of appropriate perioperative antibiotic prophylaxis to decrease the incidence of these complications. The disparities in research findings and the potential benefits of determining the role of
Actinomyces were the reasons for conducting this study.
The primary aim of the study was to determine the importance of bacteria of the genus Actinomyces in the pathology of the palatine tonsils, such as chronic tonsillitis, hypertrophy, asymmetry, and formation of tonsilloliths. In addition, an attempt was made to determine whether the presence of Actinomyces could be associated with obstructive sleep apnea syndrome (OSAS) and halitosis.
2. Materials and Methods
The study was conducted between 2019 and 2022. It consisted of a retrospective component and a survey. The study group comprised 481 patients (aged 3 to 82 years) who underwent surgery in the Department of Otorhinolaryngology and Laryngological Oncology in Zabrze, Medical University of Silesia, Katowice from January 2017 to the end of December 2019. All patients underwent bilateral tonsillectomy due to chronic tonsillitis (n = 405) or OSAS (n = 76). The study included 89 children and 392 adults (205 women, 276 men). A retrospective analysis of data on the study group was performed and a telephone survey was conducted among a randomly selected group of 100 patients.
The inclusion criteria were as follows: bilateral tonsillectomy due to chronic tonsillitis or OSAS and availability of histopathological results in the medical records. The exclusion criteria were as follows: lack of informed written consent to participate in the study, lack of histopathological findings in the medical history, and tonsillectomy due to oncological indications.
The palatine tonsils were removed by different surgeons, always following the same steps performing the cold steel tonsillectomy. Next, the samples in formalin were transferred to the histopathology laboratory. Histological samples were collected from the removed tissue. Hematoxylin and eosin were used to stain the histological sections. The presence of Actinomyces in the samples was assessed qualitatively. We compared the group of patients who presented the bacteria in the palatine tonsils with the group of patients in whom the bacteria were not found upon histopathological examination. We analyzed the dependence of the presence of tonsillar Actinomyces in the specimens on factors such as age, sex, weight, OSAS/chronic tonsillitis, and the variables included in the telephone survey.
The size of the palatine tonsils was given In cm3, and the result was obtained by multiplying the length, height, and width of the palatine tonsils. In each patient, the average size of the palatine tonsil from both removed tonsils was taken unless asymmetry was found. The prevalence of tonsillar asymmetry in each group was analyzed according to the presence of Actinomyces (a subdivision into the detailed groups is included in the “results”).
The survey section was based on a telephone questionnaire that involved 100 respondents who were randomly selected from the group of adult patients included in the retrospective part of the study. The survey was conducted on a subpopulation of adults due to the previously estimated higher prevalence of Actinomyces in this group of patients. The questions were related to the co-occurrence of bronchial asthma, tobacco smoking, halitosis, tonsilloliths, postoperative complications, such as bleeding or infection of the surgical site, and the severity of postoperative pain assessed using the Visual Analog Scale (VAS).
The limitations of the study were as follows: variables, such as smoking and the presence of Actinomyces, were assessed qualitatively, and the presence of halitosis was assessed based on the subjective patient evaluation. Antibiotic therapy in the postoperative period was considered to be due to a surgical site infection.
All analyses and data transformations were performed using the R statistical environment 4.0.5 [
25]. A
p-value of 0.05 was used as the basis for rejection of the null hypothesis for a given test. Hypotheses were tested using the following procedures: in the case of logistic regressions, the model fit was tested in relation to simpler models (with fewer explanatory variables) using the log-likelihood ratio test. The values of the χ
2 statistic and the
p-statistic were reported. Logistic regressions were fitted using the glm() function. In the case of the logistic models with quantitative explanatory variables, tests were performed to assess the fit of the models to the data as suggested by Hosmer, Lemeshow, and Sturdivant using the gof() function (LogisticDX) [
26,
27]. The ordinal regression model was fitted using the ordinal package [
28]. It was assumed that the assigned category of pain was based on unmeasurable pain, which could approximate the normal distribution. Ordinal models were also compared using the log-likelihood ratio test. The comparison of the means was done using the Welch’s
t-test. Variable independence tests were performed using Pearson’s χ
2 statistic.
For statistical purposes, data regarding names and contact details were made confidential. Therefore, patient identification was impossible.
3. Results
In the entire study population (n = 481), Actinomyces occurred in 31.4% of patients. We performed the analyses involving 477 patients to determine the prevalence of the bacteria depending on age, sex, BMI, and disease status.
First, the probability of the occurrence of Actinomyces was estimated based on age (<18 years of age or ≥18 years). The logistic regression model was fitted with age (explanatory variable) and occurrence of Actinomyces colonies (explained variable).
Actinomyces was significantly more prevalent in patients above 18 years of age (37.8%) compared with those below 18 years of age (3.4%). The model with the explanatory variable was significantly better than the null model, in which the explanatory variable was not included (χ
2 = 51.98,
p < 0.001). The effect was statistically significant. Patients aged 18 and older had a higher probability of presenting
Actinomyces. The estimated probabilities are shown in
Figure 2.
Eighty-eight patients younger than 18 years of age at the time of the study were excluded from further analysis.
Table 1 shows descriptive statistics of age for patients with and without
Actinomyces.
Actinomyces was more prevalent in men than women (32.2% vs. 30.20%). In patients with OSAS, Actinomyces was found in 43.4% of study subjects and in 29.1% of patients with chronic palatine tonsillitis. After excluding children from the analysis, the prevalence of Actinomyces was 43% (OSAS group) compared to 36.6% (chronic tonsillitis group).
The regression model fitting proposed by Hosmer, Lemeshow, and Sturdivant was applied. In the first step, we checked which explanatory variables influenced the occurrence of
Actinomyces in individual models. Variables for which
p < 0.2 were considered potentially influential. The result of Pearson’s χ
2 test was χ
2 = 0.002 (
p = 0.963) for sex and χ
2 = 1.156 (
p = 0.282) for disease status. However, the differences were not statistically significant. Next, the model was tested with respect to age and categorized BMI, the latter of which was found to be statistically non-significant (χ
2 = 1.85,
p = 0.397). A statistically significant effect of age on the prevalence of
Actinomyces was determined. The estimated odds ratio for the occurrence of
Actinomyces per year of age was 1.023 [1.007, 1.041].
Figure 3 shows the estimated probability of the occurrence of
Actinomyces according to age.
Further variables were tested using logistic regression models. Smoking had no effect on the presence of Actinomyces in tonsils (χ2 = 0.01, p = 0.922, n = 145). The estimated probability of postoperative bleeding was not significantly associated with the presence of Actinomyces in the histopathological samples (χ2 = 0.08, p = 0.778, n = 100). Complications in the form of surgical site infection were not related to the presence of the bacteria in the postoperative samples (χ2 = 0.55, p = 0.458, n = 98). No significant relationship was found between the co-occurrence of bronchial asthma and tonsillar Actinomyces (χ2 = 0.42, p = 0.516, n = 118).
To determine the effect of
Actinomyces on tonsillar size and the occurrence of tonsillar asymmetry, the comparison of the means of the size of tonsils was performed using Welch’s t-test depending on the presence of
Actinomyces. The analysis was performed in 419 patients for whom data regarding the tonsil size were available. Due to the right-skewed distribution of the variable according to the groups, a logarithmic transformation was performed before the analysis. The presence of
Actinomyces in the palatine tonsil samples was not associated with tonsillar hypertrophy. The mean size of tonsils was smaller in the group of patients with
Actinomyces. Logarithmic mean tonsil size was 2.27 for patients with
Actinomyces and 2.39 for those without
Actinomyces (
Table 2 and
Figure 4).
We calculated the absolute value from the difference between the sizes of the tonsils to determine the effect of Actinomyces on the occurrence of asymmetry. The variable was divided into four approximately equal intervals, which can be interpreted as follows:
No or negligible asymmetry (0–0.5);
Slight asymmetry (0.5–2.25);
Moderate asymmetry (2.25–5.07);
High asymmetry (>5.07).
Figure 5 shows the distribution of all values of the variable according to groups with the edges of the intervals.
The test of independence of variables was performed using Pearson’s χ2 statistic. However, the results were not statistically significant. Therefore, the null hypothesis of independence of the variables could not be rejected. Based on the data obtained from 100 patients participating in the survey, no significant relationship was observed between the presence of tonsilloliths and Actinomyces colonies (χ2 = 0.01, p = 1). No statistically significant association was found between halitosis and the presence of Actinomyces colonies in tonsil samples (χ2 = 3.66, p = 0.064).
The ordinal regression model was fitted to the data to assess the effect of Actinomyces on the severity of postoperative pain. The analysis involved 99 patients who provided information on the severity of postoperative pain. The highest number of respondents (45.5%) reported experiencing severe pain after tonsillectomy (VAS 7–9), 14.1% described the pain as unbearable (VAS 10), and only 7.1% reported mild pain (VAS 1–3). The remaining respondents described the severity of pain as moderate (VAS 4–6). No significant differences were noted in the severity of pain after palatine tonsillectomy depending on the presence of Actinomyces in the postoperative samples (χ2 = 0.245, p = 0.117).
4. Discussion
The influence of
Actinomyces on the occurrence of pathological processes in the palatine tonsils has been analyzed for many years [
1,
2,
3,
4,
8,
18,
19,
20,
21,
22,
23,
24]. Confirmation of the relationship between the presence of tonsillar
Actinomyces and the prevalence of postoperative bleeding, increased postoperative pain, or the need for postoperative antibiotic therapy associated with surgical site infection could allow the implementation of appropriate prophylactic measures. Demonstrating a positive correlation between palatine tonsillar hypertrophy and the occurrence of
Actinomyces could change the approach to the treatment of patients whose main problem is related to obstruction of the upper respiratory tract associated with hypertrophy of the pharyngeal lymphoid tissue.
In our study,
Actinomyces was found in 31.4% of patients. In the literature, the prevalence of
Actinomyces colonies in palatine tonsils removed due to recurrent tonsilitis and OSAS ranges from 0.8% to 61.6% [
2,
14,
16,
29,
30,
31,
32]. In their study on a large cohort of patients, Aydin et al. found that this percentage was 6.7% for the entire study population, including children (
n = 1252) and adults (
n = 568) [
31]. On the other hand, Toh et al. obtained results similar to our findings. They examined 834 patients (72 patients aged 1–16 years, 762 patients aged 17–68 years), with
Actinomyces found in 35.6% of samples [
17]. This disproportion may be due to the fact that Aydin et al. assessed a significant group of children, while in the study of Toh et al. adults were predominant. Similarly, the adult population was predominant in our study. The analyzed data included 391 adults and 89 children. The mean age of the study population was 30.82 ± 15.7 years. The study showed a statistically significant effect of age on the prevalence of
Actinomyces, which is in line with many study findings [
2,
4,
14,
19,
24,
30,
32]. Only Gaffney et al. obtained results that indicated that
Actinomyces was more prevalent in patients under 15 years of age [
33]. Higher prevalence of
Actinomyces in adults may be explained by poor oral hygiene and prolonged exposure to microinjuries of the oral and pharyngeal mucosa. The above factors promote colonization and penetration of
Actinomyces into the tonsillar tissue [
9,
12,
34].
We also investigated the prevalence of
Actinomyces depending on sex. Our study found that tonsillar
Actinomyces was present in 30.2% of women and 32.2% of men. However, the difference was not statistically significant. The results for this variable are in line with the results obtained by other authors [
2,
3,
4,
17,
19,
32,
33,
35].
The composition of the oral microbiome is influenced by many factors, including diet, body weight, and smoking habits. Considering the above, we decided to investigate the relationship between the occurrence of tonsillar Actinomyces and the above factors. We found that Actinomyces was more prevalent in the palatine tonsils of overweight or obese patients. To the best of our knowledge, no studies have assessed such a relationship. Furthermore, smoking did not seem to affect the prevalence of Actinomyces. In smokers, these bacteria were present in 37.7% of patients, while 36.9% of non-smokers presented the bacteria.
Much attention has been paid to the question of whether the presence of
Actinomyces could lead to palatine tonsil hypertrophy [
10,
32]. The concept according to which tonsil colonization by
Actinomyces could play an essential role in the hypertrophy of the tonsillar lymphoid tissue was first presented by Lord, who suggested that
Actinomyces produced toxins that could lead to tonsillar hypertrophy [
29,
33,
36]. However, it was not clearly confirmed. Many findings linking
Actinomyces to tonsillar hypertrophy can be found in the literature. However, the mechanism that could result in tonsillar hypertrophy has not been clearly demonstrated yet. Many researchers have attempted to prove a link between the presence of
Actinomyces and the hypertrophy of the pharyngeal lymphoid tissue [
2,
3,
4,
10,
17,
18,
19,
29,
30,
32,
35].
Hari et al. found that 98% of patients with tonsillar
Actinomyces presented with lymphoid hyperplasia compared to 77% without the bacteria. They emphasized that
Actinomyces almost always led to tonsillar hyperplasia [
29].
A significant effect of
Actinomyces on tonsillar volume was demonstrated by Kutluhan and colleagues. The mean tonsillar volume was significantly higher in tonsils with
Actinomyces than those without.
Actinomyces was 5.71 times greater in hypertrophied tonsils than in recurrent tonsillitis. Kutluhan et al. uncovered a strong association between
Actinomyces and tonsillar hypertrophy. However, the pathomechanism of these changes was not fully elucidated [
3].
The role of
Actinomyces in the etiology of tonsillar hypertrophy was also investigated by Daneshmandan and colleagues. The tonsil size was significantly greater in specimens positive for Actinomycosis compared to specimens negative for
Actinomyces (8.65 ± 1.5 mL vs. 4.38 ± 0.22 mL,
p < 0.001) [
35]. Kansu also showed a statistically significant correlation between prevalence of
Actinomyces and tonsils with higher volume [
18]. Bhargava et al. showed a significant association between
Actinomyces and tonsillar hypertrophy. Actinomycosis was present in 56.8% of patients with tonsillar hypertrophy compared to 10.3% of patients with recurrent tonsillitis without tonsillar hypertrophy [
32]. According to Riffat and Walker, tonsillar hypertrophy associated with the presence of
Actinomyces was related to lymphoid hyperplasia due to an antigen–antibody reaction or a cell-mediated phenomenon [
23]. Pransky et al. also observed an association between tonsillar
Actinomyces colonization and their hypertrophy [
10].
In light of the above data, our results may be surprising. The mean tonsil size was smaller in the group of patients with
Actinomyces. This difference was not statistically significant. However, these findings do not lead us to believe that
Actinomyces causes tonsillar hypertrophy. Therefore, it can be suspected that the presence of tonsillar
Actinomyces does not correlate with their size. Our results are different from the findings of many studies. Some authors, however, are of the opinion that the presence of tonsillar
Actinomyces does not translate into tonsil increased size [
2,
4,
17,
19,
30,
37]. Our findings are in line with those obtained by Jones et al., who noted a negative correlation between tonsillar hypertrophy and tonsillar
Actinomyces colonization. The authors indicated that these microorganisms should be regarded as saprophytes that do not affect the tonsil size [
38].
In turn, a different perspective on this issue was presented by Yadav et al. in their case report. They found that
Actinomyces resulted in massive unilateral tonsillar hypertrophy mimicking a tumor. Similarly, Kaipuzha et al. and Rasić et al. found that
Actinomyces could cause unilateral tonsillar hypertrophy, thus causing tonsillar asymmetry [
8,
12,
39].
Therefore, we also decided to investigate the relationship between the presence of Actinomyces and the occurrence of tonsillar asymmetry. However, the results did not confirm such a relationship.
Another broadly discussed issue is whether Actinomyces is more prevalent in patients with OSAS or chronic tonsillitis. In our study, Actinomyces was found in 43.4% of patients who underwent tonsillectomy for OSAS and in 29.1% of patients who underwent surgery for chronic tonsillitis.
After excluding children from the analysis, the prevalence of
Actinomyces in these two groups was 43% (OSAS) vs. 36.6% (chronic tonsillitis). The differences were not statistically significant. There are significant differences in data from many studies. The most similar results to our findings were obtained by Toh et al., who found
Actinomyces in 44.1% of patients with OSAS and 33.3% of patients with recurrent tonsillitis [
17]. As in our study, these differences were not statistically significant.
Some studies found no significant association or differences in the prevalence of
Actinomyces depending on the diagnosis (chronic tonsillitis vs. OSAS) [
19,
31,
33,
35]. Melgarejo et al. and Gaffney et al. stressed that
Actinomyces should be considered a saprophyte that does not contribute to the above conditions [
24,
33]. In their histopathological study of tonsillectomy specimens, Sujatha et al. found that the presence of
Actinomyces colonies was associated with the presence of a positive tissue reaction. They stressed that the etiological role of
Actinomyces was significant in chronic tonsillitis, especially in antibiotic-resistant tonsillitis [
14]. According to Daneshmandan et al., the presence of
Actinomyces could be the reason for long-term problems with antibiotic-resistant tonsillar symptoms [
35]. Ashraf et al. found a higher prevalence of
Actinomyces colonies in patients with recurrent tonsillitis (43.9%) compared to those with OSAS (26.3%); however, the difference was not statistically significant. As opposed to Sujatha et al., Ashraf et al. found that the presence of
Actinomyces in tonsil specimens did not indicate any active disease [
4]. Gunizi et al. and Jones et al. also observed a higher prevalence of
Actinomyces in patients who underwent surgery for recurrent palatine tonsillitis [
30,
38]. Additionally, many researchers showed that
Actinomyces was found more commonly in specimens of tonsils removed due to OSAS than in those removed because of recurrent inflammation [
3,
10,
17,
20,
22,
23,
32,
37]. In a study on a large group of patients (n = 1213), Riffat and Walker found that
Actinomyces was statistically more common in patients with obstructive symptoms [
23]. These authors did not exclude its pathological role in the development of sleep-disordered breathing. According to them, one possible explanation for the difference between the sleep-disordered breathing group and the recurrent tonsillitis group was that children with recurrent tonsillitis had been often treated with multiple courses of broad-spectrum antibiotics and this could have an effect on the eradication of
Actinomyces. They also showed that the involvement of
Actinomyces in the pathogenesis of OSAS should be considered in further studies. They stressed that
Actinomyces could not be dismissed as passive saprophytes [
23].
Bhargava et al. expressed a similar opinion and suggested that
Actinomyces could play a potential role in the development of obstructive tonsillar hypertrophy. In their study,
Actinomyces was present in 56.8% of patients with OSAS and 10.3% of patients with recurrent tonsillitis [
32]. In the study of Kutluhan et al., this ratio was 61.5% in patients with OSAS vs. 26.6% in those with recurrent tonsillitis. This difference was statistically significant (
p < 0.001) [
3]. In their study, Ozgursoy et al. also reported a higher prevalence of
Actinomyces in patients undergoing tonsillectomy for obstructive symptoms. The presence of
Actinomyces in tonsillectomy specimens did not indicate active tissue infection. They also suggested that
Actinomyces could indirectly lead to OSAS by contributing to tonsillar hypertrophy [
37].
The role of
Actinomyces is also stressed in the context of the formation of tonsilloliths. Some studies showed that tonsillar cryptitis could be considered a histopathological indicator of Actinomycosis due to a significant correlation between the occurrence of
Actinomyces and tonsillar cryptitis [
12,
31].
Arvisais-Anhalt et al. noted a significantly higher prevalence of
Actinomyces in patients with tonsilloliths compared to those with recurrent tonsillitis. They emphasized that the prevalence of
Actinomyces in tonsillolith tonsil specimens was high. However, they also stressed that
Actinomyces routinely colonized non-tonsillolith tonsil specimens. Therefore, they questioned whether
Actinomyces played an important role in the pathogenesis of this condition. They also reported that
Actinomyces-targeted treatment of tonsilloliths failed to be effective [
16].
In our study, no significant association was found between the occurrence of tonsilloliths and the presence of Actinomyces colonies. Due to the frequent coexistence of tonsilloliths and halitosis, our patients were also asked about the presence of halitosis. The analysis for the co-occurrence of Actinomyces and halitosis showed the result was close to statistical significance (p = 0.064). However, this finding did not clearly confirm that Actinomyces was responsible for the occurrence of this symptom.
Recently, more attention has been paid to studies on the role of the microbiome in the pathogenesis of some diseases. It is suspected that there is a link between microorganisms colonizing the upper respiratory tract and the development of asthma [
32]. Zhao et al. determined that the core oropharyngeal microbiome of patients with asthma include
Prevotella,
Streptococcus,
Neisseria,
Rothia,
Haemophilus,
Fusobacterium, and
Actinomyces [
32]. Bhargava et al. found a statistically significant association (
p < 0.0001) between
Actinomyces in the palatine tonsils and bronchial asthma (
Actinomyces was more prevalent in patients with asthma). However, those authors did not provide a hypothetical explanation for this relationship [
32]. Our study found no significant relationship between the occurrence of bronchial asthma and
Actinomyces in tonsillar tissue.
We also analyzed the effect of the occurrence of
Actinomyces on the postoperative period after bilateral tonsillectomy. An interesting retrospective study related to the occurrence of postoperative bleeding was conducted by Schrock et al., who analyzed 1522 patients who underwent palatine tonsillectomy. The group of patients in whom postoperative bleeding (7.7%) was found was compared with the group of patients without such a complication. The presence of tonsillar
Actinomyces was significantly correlated with bleeding (
p = 0.02). The odds ratio, however, was low (OR 2.0). Despite a significant correlation between Actinomycosis and postoperative bleeding, Schrock et al. showed that
Actinomyces only slightly increased the risk of postoperative bleeding. Further studies are needed to determine the importance of other contributing factors [
32].
The above study was the stimulus which prompted our investigation into these relationships in our patient population. The analysis was based on the data obtained from 100 patients who were asked about the occurrence of postoperative bleeding. This complication occurred in 12 patients. The estimated probability of postoperative bleeding was not significantly associated with the presence of Actinomyces in histopathological specimens. We also assessed the influence of Actinomyces on the need for empirical postoperative antibiotic therapy due to surgical site infection.
Based on the analyses, complications in the form of surgical site infection were not associated with the presence of
Actinomyces in the postoperative specimens. To the best of our knowledge, a study evaluating similar variables has yet to been conducted. Our study analyzed the effect of
Actinomyces on the severity of postoperative pain. It is known that inflammation affects the sensory innervation of tissues and organs. Therefore, we decided to assess this relationship. Patients usually describe tonsillectomy-related pain as a pain of significant severity, which significantly reduces the quality of life in the postoperative period [
40].
Among the respondents, the largest number of patients (45.5%) reported severe pain (VAS 7–9). However, no significant differences were noted in the severity of pain after tonsillectomy depending on the presence of
Actinomyces in the postoperative specimens. The presence of tonsillar
Actinomyces does not seem to indicate active inflammation in the oropharyngeal tissues, which could translate into the course of the postoperative period. Zagólski et al. evaluated postoperative pain according to the indications for tonsillectomy. They assessed the effect of recurrent inflammation on pain severity. Patients with recurrent tonsillitis reported less severe postoperative pain than patients undergoing tonsillectomy due to other indications. Higher pain intensity in patients without a history of recurrent tonsillitis was explained by the fact that they had not expected such a severe pain. Patients with recurrent tonsillitis presented with a history of disabling sore throat episodes [
40].